New Zealand s experience of the 1918 19 influenza pandemic: a systematic review after 100 years
View Article PDF
The 1918–19 influenza pandemic was one of the most severe natural disasters in recorded human history. It occurred during the final stages of the First World War (WW1) and this particularly lethal H1N1 viral pandemic strain of influenza is estimated to have killed 50–100 million people worldwide.1 Very few localities (other than a few remote islands) escaped the deadly impact of this pandemic, and for the peoples of New Zealand, the pandemic would be described as “the worst single human disaster in recorded New Zealand history”.2
Various aspects of New Zealand’s experience of the pandemic have been documented using both historical and epidemiological methods. The knowledge of the events leading up to the pandemic, and its long-term effects, are also increasingly well documented. However, a century later, it is prudent to re-examine all the evidence from a range of sources to gain a clearer perspective of this pandemic and its impact on New Zealand. Therefore, this current paper aimed to review the literature related to the 1918–19 influenza pandemic in New Zealand and among its peoples (including New Zealand military personnel overseas) and to identify any research gaps. The latter is of importance for this country’s preparedness for inevitable influenza and other pandemics in the future.
Methods
We aimed to systematically identify all published literature related to the 1918–19 influenza pandemic either in New Zealand or among New Zealanders outside of New Zealand. The searches were conducted using the Cochrane Library, Google Scholar, Embase, PubMed, various University thesis repositories and grey literature for all studies published from 1914 to 2018 (to take into account evidence of pre-pandemic waves3,4). Search strategies used in databases and other archival/thesis catalogues are detailed in the Appendix (Appendix 1, 2 and 3). We also examined the bibliographies of all the identified literature for additional publications.
Results
The experience of the pandemic in New Zealand and among New Zealanders has been evaluated both during and since the pandemic occurred in 1918, from a variety of primary sources from the period (for example military records or personal accounts) and secondary historical/epidemiological publications. A total of 61 publications were identified which relate to the 1918–19 influenza pandemic in New Zealand or among New Zealanders as a primary focus and provide understating of the pandemic (with further details on each publication in Appendix 4). In total, we identified five books, two case-series, nine discussion/commentary pieces, 15 epidemiological studies, 24 reviews and six theses. These publications use a variety of methods and spanned different academic fields, such as social history, epidemiology, public health, health services and biostatistics.
The earliest identified publication was a case series in 1918 of New Zealand military personnel in the New Zealand Expeditionary Force (NZEF), which described post-mortem details of cases.5 In contrast, the most recent publication was published in 2018 and it reviewed mortality patterns within the Pacific region during the pandemic.6
There has been steady increase in the number of publications on the pandemic and New Zealand, with the vast majority of studies being published in the last decade. This pattern may reflect the increasing availability of records from 1918 such as the digitisation of military files for online archives and online newspaper records (Figure 1). But there has also been a growth in all medical research, including for “seasonal influenza” in the New Zealand context (eg, 63 Medline-indexed publications as of late 2018).
Figure 1: Cumulative frequency of publications related to New Zealand’s experience of the 1918–19 influenza pandemic.
The main impact of the 1918–19 influenza pandemic occurred in New Zealand during November 1918 for both civilian and military populations situated within New Zealand (Figure 2). While for New Zealand military personnel situated either at sea (on board the troopship HMNZT Tahiti) or in the Northern Hemisphere, the experience of the pandemic was rather different. Official reports of the troopship outbreak are held at Archives New Zealand7–9 and detail the course of the outbreak and the outcomes for the military personnel. These reports have been used in several epidemiological studies of the outbreak as they provide detailed description of the individuals on board.4,10,11 Those on board the Tahiti experienced one of the worst ship outbreaks worldwide during the pandemic, and the personnel in the Northern Hemisphere experienced two mortality waves, in November 1918 and in late February 1919 (much like other populations in Europe) (Figure 3).
Figure 2: Pandemic-related mortality per week among the civilian populations in the North and South Islands of New Zealand and NZEF personnel who died in New Zealand.4,12
Note: some of the civilian data include discharged NZEF personnel.
Figure 3: Pandemic-related mortality among New Zealand military personnel by location during the 1918–19 in the defined pandemic periods.4
Research domains identified in a previous review article for New Zealand as areas which needed further development included epidemiology, Māori history, social history, military history and disaster sociology/psychology.2 Given the significant increase in publications, many of these domains have been developed (Table 1), along with several studies examining the health system in New Zealand during the pandemic.
Table 1: Identified literature on the 1918–19 influenza pandemic in New Zealand categorised by major research domains.
Figure 4: Plate 1 (Coloured) Lung Case 680: ‘haemorrhagic oedema type’.
Figure 5: Plate 2 (Coloured) Trachea & Bronchi: ‘along the trachea and bronchi appear swollen lymphatic glands dotted with haemorrhages’.
Discussion
Main findings and interpretation
A century has passed since the 1918–19 influenza pandemic reached the shores of New Zealand and among the New Zealand military personnel serving in the Northern Hemisphere as part of WW1. The influenza pandemic occurred during the final stages of WW1 and no doubt spread further during Armistice celebrations resulting in the pandemic having the grim record as New Zealand’s worst human disaster. The works of Rice12,34 and one of the current author’s thesis,4 has identified 8,831 deaths as a results of the 1918–19 pandemic among New Zealanders. Rice’s34 more recent book suggests a more accurate total may be over 9,000 deaths if undocumented deaths among the Māori population are taken into account. The majority of these deaths occurred in New Zealand during a six-week period in November and December 2018. However, the first substantial numbers of New Zealanders dying during the pandemic occurred eight weeks earlier in September 1918 on board the troopship HMNZT 107 Tahiti on route to the UK carrying New Zealand military reinforcements.
Studies in the last decade have increasingly focused on the pandemic’s impact on military populations; due to access to rich and detailed medical records for large volumes of individuals. As roughly 40% of eligible male New Zealanders served in the NZEF during WW1, estimates of morbidity and mortality can be generalised to the wider population, such as the identification of increased pandemic mortality risks associated with being a young adult, being Māori or Pacific, or having had pre-pandemic respiratory admissions to hospital.
Patterns consistent with the international data
In general, the epidemiology of the pandemic in New Zealand was similar to that of other countries. A notable similarity was the w-shaped age distribution for mortality rates (albeit with some more in-depth analysis that may relate to the role of the 1890s influenza pandemic in this pattern).24 The higher mortality rate for Māori and Pacific soldiers in the New Zealand military (see Table 1), is also consistent with the higher burden for indigenous peoples from this pandemic.6 Similarly, risk factors for death identified in a New Zealand case-control study23 were often the same as those reported elsewhere (eg, co-existing chronic disease or being a recent military recruit). The spread of the pandemic via railway and shipping networks was also part of the international pattern—though rarely has it been shown in such detail as in the work of Rice for New Zealand.12 Our informal observations are that memorials to this pandemic are rare internationally—which is also the case for New Zealand.60
Unusual patterns with the New Zealand data
There were unusual patterns for pandemic impacts and response in New Zealand which contrast with other populations around the world, such as the following:
- Some novel risk factors for pandemic-related mortality were identified in a New Zealand case-control study; with males with larger chest size having an increased mortality risk (possibly related to the increased lung capacity of soldiers which might ‘increase the chance of a cytokine storm’).23
- There was an apparent lack of a socio-economic gradient in mortality rates for the New Zealand European population10,12,23 with no apparent variation by different housing districts in Auckland.45 This finding (albeit with only the two military studies using modern analytic methods), is in contrast to some of the international literature. For example, a socio-economic gradient has been described for Norway,73 Sweden74 and Chicago, US.75 The finding of no gradient in New Zealand is also in contrast with evidence for lifespan differences by male occupational class in New Zealand at this time.76
- The similar male vs female mortality rates among Māori were also somewhat unusual—in contrast to the relatively higher mortality in males vs females in the New Zealand European population.31 One of the possible reasons is Māori being exposed to greater crowding (more mixing of men and women), but possibly also the greater similarities in chronic respiratory disease burdens by sex in Māori (eg, due to greater similarities in smoking prevalence). However, this area requires further research.
- New Zealand was like most settings where there were only a few (or no) successful acts of border control or ‘protective sequestration’ (ie, there were only some successful moves in a small town26 and a few institutions.12 In contrast, some other jurisdictions successfully used maritime quarantine,58 road closures22 and measures such as school closures and public gathering bans.77
Strengths and limitations of this review
A strength of this review is that it is the first systematic review of this pandemic in the New Zealand context in the journal literature. It has also encompassed a wide variety of academic fields. However, this review also has its limitations. For example it has focused on secondary sources mostly as they provide summary accounts/data. Furthermore, there was little review of first-hand accounts, such as newspaper articles, letters or diaries (other than military sources, eg, Summers et al11). It is also conceivable that there are journal articles or theses that were published in the early part of last century which have not yet been included in the online medical databases which we searched.
Possible implications for future research
A first step is probably to consider further research around those unusual aspects of the pandemic in New Zealand that differed from the international literature as detailed above (ie, the large chest size as a risk factor for death, the apparent lack of a socio-economic gradient in mortality rates, and the similarity of male and female Māori mortality rates). For example, the use of modern biostatistical methods for additional analysis of other data relevant to socio-economic gradients, eg, by using the suburb data in Rice’s Christchurch research43 or the Auckland-based work by Bryder.45
But other apparent gaps are as follows:
- There is scope for better quantifying the extent of undocumented Māori deaths with studies that compare registered deaths with names on memorials in urupā (Māori burial sites). This type of research by a Māori researcher would also have the benefit of further building Māori research capacity.
- Modern spatial analysis could be applied to data on the spread of the pandemic (as detailed in maps on the rail and shipping networks compiled by Rice).12 This analysis could then estimate the speed of pandemic spread (eg, in kilometres per day and week).
- The relationship of the natality shocks of 1918 and 1919 in New Zealand to the pandemic have not been thoroughly analysed, although Pool provides a brief assessment of decreased fertility among Māori women.35 It is known that influenza infection is associated with fetal loss and stillbirth (as documented in Dunedin, New Zealand, during the pandemic)67 and it is likely to have been a factor in the sudden decline in New Zealand’s annual birth rate in 1918 by 9% and in 1919 by 17% (relative to 1917) [Data calculated from the 1924 Yearbook70 and based on changes in rates]. This issue only appears to have been studied in a few international settings, eg, US and Scandinavia,73,78 Taiwan,79 and Sri Lanka.80 This topic has some contemporary relevance given suboptimal vaccination of pregnant woman against influenza.81
Given the importance of learning from pandemics, there is perhaps a case for the Ministry of Health to allocate funds to the Health Research Council to specifically support research to address these knowledge gaps. Once this work was done, an updated review of the potential lessons relevant to modern pandemic planning could be conducted, eg, in terms of external border control, internal border control, health system preparedness and provision of voluntary sector nursing care to neighbours, etc.
Several studies evaluated the effect of the pandemic on the New Zealand health system both during and post-pandemic. There appears to be consensus that the health system was under immense strain, with limited resources/staffing and a crippled administration that was unable to provide clear leadership in the face of an overwhelming influenza pandemic. If anything can be learned from this experience it is that pre-pandemic planning is essential for New Zealand in order to face inevitable future pandemics. Such planning needs to include scenarios of similar intensity to the 1918 influenza pandemic and potentially more extreme events.
A greatly improved Health Act in 1920 was one of the responses to the 1918 influenza pandemic, which aimed to address the limitations of the previous legislation in terms of administrative responsibilities/duties by restructuring the health department and allowing special measures during periods of infectious disease outbreaks.44,66,82 Perhaps New Zealand could use the centennial of the 1918 pandemic as an opportunity to reflect on our readiness for the kinds of pandemics that we may face over the next 100 years and plan accordingly. One example is the need for rapid border closure to prevent entry of particularly severe pandemic diseases. Such measures could be highly cost-effective.83,84
Conclusions
In the centenary year of the 1918–19 influenza pandemic, now is the time for New Zealand to reflect on its impact on New Zealand in terms of its mortality, its long-term effects on the physical and psychological health of survivors, and indeed its role in shaping New Zealand’s health system and society. Most importantly for today’s New Zealanders, the pandemic provides insight into the nature of influenza pandemics and how societies response to such events. Despite the large body of work to date, there remain important knowledge gaps relating to this pandemic in New Zealand. Filling these gaps may contribute to improved planning for managing future pandemics.
Appendix 1: Literature search criteria
Appendix 2: Database search strategies
Cochrane Libraries
Search date: 22nd August 2018
Google Scholar
Search date: 22nd August 2018
Embase
Search date: 22nd August 2018
Embase 1974 to 2018 Week 34
Embase Classic 1947 to 1973
Global Health 1973 to 2018 Week 32
HMIC Health Management Information Consortium 1979 to May 2018
Ovid MEDLINE® Epub Ahead of Print, In-Process & Other Non_indexed Citations, Ovid MEDLINE® Daily, Ovid MedLINE and Versions®
PubMed
Search date: 22nd August 2018
Grey literature
Search date: 22nd August 2018
Grey literature – searched key words such as “1918”, “influenza”, Spanish”, and “Zealand”.
Appendix 3: PRISMA 2009 Flow Diagram87
Appendix 4: Additional detail on the publications (secondary sources) included in this systematic review
Available through external link:
http://www.nzma.org.nz/__data/assets/pdf_file/0003/86655/Appendix-4-FINAL.pdf
Summary
Abstract
Aim
The 1918-1919 influenza pandemic has been New Zealand s most severe disaster event (around 9,000 deaths). We aimed to review the literature related to this pandemic in New Zealand and among New Zealanders overseas, to identify any remaining research gaps (given ongoing risks of future influenza pandemics and from new pathogens, eg, synthetic bioweapons).
Method
Systematic literature searches and comparisons with international findings for this pandemic to facilitate identification of research gaps.
Results
A total of 61 relevant publications were identified. The epidemiological patterns reported were largely consistent with the international literature for this pandemic. These features included the w-shaped age-distribution for mortality, and the much higher mortality rates for indigenous people (ie, seven-fold for Mori vs New Zealand European). But some novel risk factors were identified (eg, large chest size as a risk factor for death in military personnel), and there was an extremely high mortality troop ship outbreak (probably related to crowding). In contrast to some international work, there was an apparent lack of a socio-economic gradient in mortality rates in two studies using modern analytical methods. New Zealand work has clearly shown how the pandemic spread via the rail network and internal shipping routes and the rarity of successful measures to prevent spread in contrast to some other jurisdictions. It has also found a marked lack of memorials to the pandemic (in contrast to war memorials). Nevertheless, some research gaps remain, including on the apparent marked reduction in birth rates in 1918-1919 and the reasons for no socio-economic gradient despite other New Zealand evidence for occupational class variation in lifespan at this time.
Conclusion
This is a relatively well-studied disaster event but there remain important research questions relating to this pandemic in New Zealand. Filling these gaps may contribute to improved planning for managing future pandemics.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
- Johnson N, Mueller J. Updating the Accounts: GLobal Mortality of the 1918–1920 ‘Spanish’ Influenza Pandemic. Bull Hist Med. 2002; 76:105–115.
- Wilson N, Baker M. Ninety Years on: what we still need to learn from the “Black November” 1918 about pandemic influenza. N Z Med J, 2008; 121(1285):136–138.
- Oxford JS, Sefton A, Jackson R, et al. Early Herald Wave Outbreaks of Influenza in 1916 prior to the Pandemic of 1918. Intl Congr Ser. 2001; 1219:155–161.
- Summers JA. The Burden and Risk Factors for Death from the 1918-19 Influenza Pandemic amongst the New Zealand Military Forces of World War One [PhD thesis]. 2013, University of Otago, Dunedin, New Zealand.
- Eyre JWH, Lowe EC. Prophylactic Vaccinations against Catarrhal affections of the respiratory tract. Lancet. 1918; 192(4963):484–487.
- Shanks GD, Wilson N, Kippen R, Brundage JF. The unusually diverse mortality patterns in the Pacific regions during the 1918–21 influenza pandemic: reflections at the pandemic’s centenary. Lancet Infect Dis., 2018: p. pii: S1473-3099(18)30178-6.
- NZ Government. “Health 40th Reinforcements, Medical Report on “Tahiti” Epidemic 1918” WA.1. Box 1/3/25. Record: 10/79. Wellington: Archives New Zealand, National Office. 1918.
- O’Neill CEJ. Court of Enquiry regarding HMNZT Transport “Tahiti”. 1918: London.
- Denniston SJE, Mitchelson E, McLaren D. Report of the Influenza Epidemic Commission. 1919, Appendix to the Journals of the House of Representatives of New Zealand.
- Summers J, Wilson N, Baker MG, Shanks G. Mortality Risk Factors for Pandemic Influenza on New Zealand Troop Ship, 1918. Emerg Infect Dis. 2010; 16(12):1931–1937.
- Summers J. Pandemic influenza outbreak on a troop ship - diary of a soldier in 1918. Emerg Infect Dis. 2012; 18(11):1900–1903.
- Rice GW. Black November: The 1918 influenza pandemic in New Zealand. 2005, Christchurch: Canterbury University Press.
- Sertsou G, Wilson N, Baker M, et al. Key transmission parameters of an institutional outbreak during the 1918 influenza pandemic estimated by mathematical modelling. Theor Biol Med Model. 2006; 3(38).
- Nishiura H, Wilson N. Transmission dynamics of the 1918 influenza pandemic in New Zealand: analyses of national and city data. N Z Med J. 2009; 122(1296):81–86.
- Eyre JWH, Lowe EC. Report upon the Autumn Influenza Epidemic (1918) as it affected the N.Z.E.F. in the United Kingdom. Lancet. 1919; 193(4988):553–560.
- McSweeny K, Coleman A, Fancourt N, et al. Was rurality protective in the 1918 influenza pandemic in New Zealand? N Z Med J. 2007; 120(1256):U2579.
- Shanks GD, MacKenzie A, Waller M, Brundage J. Low but highly variable mortality among nurses and physicians during the influenza pandemic of 1918–19. Influenza Other Respir Viruses. 2011; 5:213–219.
- Wilson N, Barnard Telfar L, Summers J, et al. Differential Mortality Rates by Ethnicity in 3 Influenza Pandemics Over a Century, New Zealand. Emerg Infect Dis. 2011; 18(1):71–77.
- Shanks GD, Summers JA, Wilson N. Large mortality differences between Australian and New Zealand soldiers during 1918–19 influenza pandemic., in 61st Annual Meeting of the American Society of Tropical Medicine and Hygiene. 2012, American Journal of Tropical Medicine and Hygiene: Atlanta, USA. p. 72.
- Wilson N, Summers J, Baker M. Injury Epidemiology and New Zealand military forces in World War One. Inj Prev., 2012. 18 (Suppl 1)(A153).
- Summers JA, Shanks GD, Baker MG, Wilson N. Severe impact of the 1918–19 pandemic influenza in a national military force. N Z Med J. 2013; 126(1378):36–47.
- Summers J, Wilson N, Baker MG, Gottfredsson M. The influenza pandemic of 1918–1919 in two remote island nations: Iceland and New Zealand. N Z Med J. 2013; 126(1373):74–80.
- Summers J, Stanley J, Baker MG, Wilson N. Risk factors for death from pandemic influenza in 1918–1919: a case–control study. Influenza Other Respir Viruses. 2014; 8(3):329–338.
- Wilson N, Oliver J, Rice G, et al. Age-specific mortality during the 1918–19 influenza pandemic and possible relationship to the 1889–92 influenza pandemic. J Infect Dis., 2014; 210(6):993–995.
- Wilson N, Boyd M, Nisa S, et al. Did exposure to a severe outbreak of pandemic influenza in 1918 impact on long-term survival? Epidemiol Infect., 2016. 144(15): p. 3166–3169.
- Wilson N, Rice G, Thomson G, Baker M. Re-evaluating a local public health control measure used in New Zealand for the pandemic influenza of 1918. N Z Med J. 2005; 118(1224):U1714.
- Summers JA, Wilson N, and Baker MG, Ethnic gradient in mortality amongst the New Zealand military personnel in World War One [poster presentation], in Australasian Epidemiological Association Annual Scientific Meeting. 2010: Sydney, Australia.
- Champtaloup S. A study of the influenza epidemic in New Zealand 1918: epidemiology, administration and bacteriology, with a report on the pathology of twenty-five fatal cases. 1920, University of Edinburgh.
- Maclean FS. Challenge for Health: A History of Public Health in New Zealand. 1964, Wellington: R.E. Owen, Government Printer.
- Wright-St Clair RE. Influenza in New Zealand and the doctors who died from it. N Z Med J. 1983; 96:765–768.
- Rice GW. Influenza in New Zealand before 1918: a preliminary report. Am J Epidemiol. 2018.
- Rice GW. ‘That Terrible Time’: Reflections on the 1918 Influenza Pandemic in New Zealand. N Z Med J. 2018; 131(1481):6–8.
- Rice GW. Black November: The 1918 Influenza Epidemic in New Zealand. 1988, Wellington: Allen and Unwin.
- Rice GW. Black Flu 1918: The story of New Zealand’s worst public health disaster. 2017, Christchurch, New Zealand: Canterbury University Press.
- Pool DI. The effects of the 1918 Pandemic of Influenza on the Maori Population of New Zealand. Bull Hist Med. 1973; 47:273–281.
- Rice GW. A disease deadlier than war. N Z Med J. 2013; 126(1378):12–14.
- Rice G. Microgeography of Historical Influenza Mortality: A New Zealand example from the 1918 Pandemic, in 1990, One Thousand Years of New Zealand Population: Heeding the Past and Planning for the Future., N.Z.D.S. Conference, Editor. 1989: University of Waikato, Hamilton, New Zealand.
- Charania NA, Turner NM. 100 years since the 1918 influenza pandemic—progress made, yet questions remain. A synopsis of the 4th New Zealand Influenza Symposium, February 2018. N Z Med J. 2018; 131(1481):50–55.
- Rice G. Maori mortality in the 1918 influenza epidemic. N Z Population Rev., 1983; 9(1):44–61.
- Bennett C. Now the War is Over, We Have Something Else to Worry Us”: New Zealand Children’s Responses to Crises, 1914–1918. J History Childhood Youth. 2014. 7(1):19–41.
- Lange KJ. “Child’s Play?”: The Role of Children in the 1918 Influenza Epidemic in New Zealand. 2015, Dickinson College.
- Rice GW. Why did Wellington suffer nearly double the death rate of Christchurch in the 1918 influenza pandemic?, in In: The 2018 Jim Gardner Memorial Lecture. 2018, Canterbury History Foundation: Christchurch, New Zealand.
- Rice GW. Christchurch in the 1918 Influenza Epidemic: a preliminary study. NZJH., 1979; 13(2):109–131.
- Bryder L. “Lessons” of the 1918 influenza epidemic in Auckland. NZ J History. 1982; 16(2):97–121.
- Bryder L. The 1918 Influenza Epidemic in Auckland. 1980, University of Auckland.
- Bulling GM. Preventable deaths?: the 1918 influenza pandemic in Nightcaps. 1991, University of Otago, Dunedin, New Zealand.
- Jamieson JPS. Notes of the recent epidemic of Influenza in Nelson. N Z Med J. 1919; 18:46–51.
- Rice G. Crisis in a country town: the 1918 epidemic in Temuka. Historical News. 1985; 51:7–13.
- Lovell Gregg J. How Coromandel kept the Influenza Epidemic at bay. N Z Med J. 1919; 18:51–53.
- Rice G. Australia and New Zealand in the 1918–19 influenza pandemic. Occas Pap Med Hist Aust. 1990; 4:67–74.
- Rice GW. Japan and New Zealand in the 1918 influenza pandemic: comparative perspectives on official responses and crisis management, in The Spanish Influenza Pandemic of 1918–19., H. Phillips and D. Killingray, Editors. 2003, Routledge: Taylor and Francis Group: London and New York.
- Richardson GM. The onset of pneumonic influenza in 1918 in relation to the wartime use of mustard gas. N Z Med J. 1948; 47(257):4–16.
- Brundage JF, Shanks GD. What really happened during the 1918 Influenza Pandemic? The importance of Bacterial Secondary Infections. J Infect Dis. 2007; 196(11):1717–1718.
http://www.nzetc.org/tm/scholarly/name-140805.html - Carbery ARD. The New Zealand Medical Service in the Great War, 1914–1918. 1924; Available from:
- Wilson N, Summers J, Baker MG. Impact of the 1918–19 influenza pandemic on the New Zealand Military and persisting lessons for pandemic control. Microbiol Aust., 2014; 35(3):138–140.
- Wilson N, Summers J, Baker M, Rice G. A bizarre case of drowning as a result of pandemic influenza (1918 pandemic). N Z Med J. 2009; 122(1302).
- McLane JR. Setting a Barricade Against the East Wind: Western Polynesia and the 1918 Influenza Pandemic. 2012, University of Otago, Dunedin, New Zealand.
- McLeod MA. Baker M, Wilson N, et al. Protective Effect of Maritime Quarantine in South Pacific Jurisdictions, 1918–19 Influenza Pandemic. Emerg Infect Dis. 2008; 14(3):468–470.
- Elliot G, Wilson T, Sefton Moorhouse WH. H-31c SAMOAN EPIDEMIC COMMISSION (REPORT OF) APPENDIX TO THE JOURNALS OF THE HOUSE OF REPRESENTATIVES, 1 JANUARY 1919. 1919, Wellington, New Zealand.
- Wilson N, Ferguson C, Rice G, et al. Remembering the 1918 influenza pandemic: national survey of memorials and scope for enhancing educational value around pandemic preparedness. N Z Med J. 2017; 130(1465):53–70.
- Edwards V. Pestilence from abroad? The 1918 influenza epidemic. N Z Med J. 1986; 99(812):809–812.
- Bradshaw W, Learning the lessons of the 1918 Spanish influenza epidemic. Nurs N Z., 2005; 11(10):22–23.
- Roddick JA. Delirium and fever in the antipodes: Nursing and the 1918 influenza epidemic in Dunedin Hospital, New Zealand. J Res Nurs. 2006; 11(4):357–370.
- Wood PJ, Managing boundaries between professional and lay nursing following the influenza pandemic, 1918–1919: insights for professional resilience today? J Clin Nurs. 2017; 26(5–6):805–812.
- Roddick JA. When the Flag Flew at Half Mast: Nursing and the 1918 Influenza Epidemic in Dunedin. 2005, Otago Polytechnic, Dunedin, New Zealand.
- Rice GW. The making of New Zealand’s 1920 Health Act. N Z Med J. 1988; 22(1):3–22.
- Fitchett F, Bowie JT, Champtaloup ST, Drennan AM. A Report on the recent “Influenza Epidemic” in Dunedin, New Zealand. N Z Med J. 1919; 18.
- Archives New Zealand, Books of Active Service Casualty Forms, New Zealand Expeditionary Force 1914–1918, in Agency: AABK Series: 519. 1914–1918.
- NZ Government, The Great War, 1914–1918 : New Zealand Expeditionary Force Roll of Honour. 1924, Government Printer: Wellington.
- New Zealand Department of Statistics, The New Zealand Official Yearbook. 1924, Wellington: Eyre and Spottiswoode.
- New Zealand Department of Statistics, The New Zealand Official Yearbook. 1920, Wellington: Eyre and Spottiswoode.
- Killick E, Financing the Influenza Epidemic. Journal of the Department of Public Health, Hospitals, and Charitable Aid. 1919. 2:6–12.
- Mamelund SE. A socially neutral disease? Individual social class, household wealth and mortality from Spanish influenza in two socially contrasting parishes in Kristiania 1918–19. Soc Sci Med. 2006; 62:923–940.
- Bengtsson T, Dribe M, Eriksson B. Social class and excess mortality in Sweden during the 1918 influenza pandemic. Am J Epidemiol. 2018.
- Grantz KH, Rane MS, Salje H, et al. Disparities in influenza mortality and transmission related to sociodemographic factors within Chicago in the pandemic of 1918. Proc Natl Acad Sci U S A. 2016; 113(48):13839–13844.
- Wilson N. Clement C, Boyd M, et al. The long history of health inequality in New Zealand: occupational class and lifespan in the late 1800s and early 1900s. Aust N Z J Public Health. 2018; 42:175–179.
- Markel H, Lipman HB, Navarro JA, et al. Nonpharmaceutical interventions implemented by US cities during the 1918–1919 influenza pandemic. JAMA. 2007; 298(6):644–654.
- Bloom-Feshbach K, Simonsen L, Viboud C, et al. Natality decline and miscarriages associated with the 1918 influenza pandemic: the Scandinavian and United States experiences. J Infect Dis. 2011; 204(8):1157–64.
- Chandra S, Yu YL. Fertility Decline and the 1918 Influenza Pandemic in Taiwan. Biodemography Soc Biol. 2015; 61(3):266–72.
- Chandra S, Sarathchandra D. The influenza pandemic of 1918–1919 in Sri Lanka: its demographic cost, timing, and propagation. Influenza Other Respir Viruses. 2014; 8(3):267–73.
- Yuen CY, Tarrant M. A comprehensive review of influenza and influenza vaccination during pregnancy. J Perinat Neonatal Nurs. 2014; 28(4):261–70.
- Dow DA. Safeguarding the Public Health: A History of the New Zealand Department of Health. 1995, Wellington: Victoria University Press.
- Boyd M, Baker MG, Mansoor OD, et al. Protecting an island nation from extreme pandemic threats: Proof-of-concept around border closure as an intervention. PLoS One. 2017; 12(6):e0178732.
- Boyd M, Mansoor OD, Baker MG, Wilson N. Economic evaluation of border closure for a generic severe pandemic threat using New Zealand Treasury methods. Aust N Z J Public Health. 2018.
http://www.archway.archives.govt.nz/ - Archives New Zealand. Archway Search Engine. 2012; Available from:
- Wellcome Library. The library at Wellcome Collection. 2017 [cited 2017 November].
- Moher D, Liberati A, Tetzlaff J, et al. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med. 2009. 6(7):e1000097.
For the PDF of this article,
contact nzmj@nzma.org.nz
New Zealand s experience of the 1918 19 influenza pandemic: a systematic review after 100 years
View Article PDF
The 1918–19 influenza pandemic was one of the most severe natural disasters in recorded human history. It occurred during the final stages of the First World War (WW1) and this particularly lethal H1N1 viral pandemic strain of influenza is estimated to have killed 50–100 million people worldwide.1 Very few localities (other than a few remote islands) escaped the deadly impact of this pandemic, and for the peoples of New Zealand, the pandemic would be described as “the worst single human disaster in recorded New Zealand history”.2
Various aspects of New Zealand’s experience of the pandemic have been documented using both historical and epidemiological methods. The knowledge of the events leading up to the pandemic, and its long-term effects, are also increasingly well documented. However, a century later, it is prudent to re-examine all the evidence from a range of sources to gain a clearer perspective of this pandemic and its impact on New Zealand. Therefore, this current paper aimed to review the literature related to the 1918–19 influenza pandemic in New Zealand and among its peoples (including New Zealand military personnel overseas) and to identify any research gaps. The latter is of importance for this country’s preparedness for inevitable influenza and other pandemics in the future.
Methods
We aimed to systematically identify all published literature related to the 1918–19 influenza pandemic either in New Zealand or among New Zealanders outside of New Zealand. The searches were conducted using the Cochrane Library, Google Scholar, Embase, PubMed, various University thesis repositories and grey literature for all studies published from 1914 to 2018 (to take into account evidence of pre-pandemic waves3,4). Search strategies used in databases and other archival/thesis catalogues are detailed in the Appendix (Appendix 1, 2 and 3). We also examined the bibliographies of all the identified literature for additional publications.
Results
The experience of the pandemic in New Zealand and among New Zealanders has been evaluated both during and since the pandemic occurred in 1918, from a variety of primary sources from the period (for example military records or personal accounts) and secondary historical/epidemiological publications. A total of 61 publications were identified which relate to the 1918–19 influenza pandemic in New Zealand or among New Zealanders as a primary focus and provide understating of the pandemic (with further details on each publication in Appendix 4). In total, we identified five books, two case-series, nine discussion/commentary pieces, 15 epidemiological studies, 24 reviews and six theses. These publications use a variety of methods and spanned different academic fields, such as social history, epidemiology, public health, health services and biostatistics.
The earliest identified publication was a case series in 1918 of New Zealand military personnel in the New Zealand Expeditionary Force (NZEF), which described post-mortem details of cases.5 In contrast, the most recent publication was published in 2018 and it reviewed mortality patterns within the Pacific region during the pandemic.6
There has been steady increase in the number of publications on the pandemic and New Zealand, with the vast majority of studies being published in the last decade. This pattern may reflect the increasing availability of records from 1918 such as the digitisation of military files for online archives and online newspaper records (Figure 1). But there has also been a growth in all medical research, including for “seasonal influenza” in the New Zealand context (eg, 63 Medline-indexed publications as of late 2018).
Figure 1: Cumulative frequency of publications related to New Zealand’s experience of the 1918–19 influenza pandemic.
The main impact of the 1918–19 influenza pandemic occurred in New Zealand during November 1918 for both civilian and military populations situated within New Zealand (Figure 2). While for New Zealand military personnel situated either at sea (on board the troopship HMNZT Tahiti) or in the Northern Hemisphere, the experience of the pandemic was rather different. Official reports of the troopship outbreak are held at Archives New Zealand7–9 and detail the course of the outbreak and the outcomes for the military personnel. These reports have been used in several epidemiological studies of the outbreak as they provide detailed description of the individuals on board.4,10,11 Those on board the Tahiti experienced one of the worst ship outbreaks worldwide during the pandemic, and the personnel in the Northern Hemisphere experienced two mortality waves, in November 1918 and in late February 1919 (much like other populations in Europe) (Figure 3).
Figure 2: Pandemic-related mortality per week among the civilian populations in the North and South Islands of New Zealand and NZEF personnel who died in New Zealand.4,12
Note: some of the civilian data include discharged NZEF personnel.
Figure 3: Pandemic-related mortality among New Zealand military personnel by location during the 1918–19 in the defined pandemic periods.4
Research domains identified in a previous review article for New Zealand as areas which needed further development included epidemiology, Māori history, social history, military history and disaster sociology/psychology.2 Given the significant increase in publications, many of these domains have been developed (Table 1), along with several studies examining the health system in New Zealand during the pandemic.
Table 1: Identified literature on the 1918–19 influenza pandemic in New Zealand categorised by major research domains.
Figure 4: Plate 1 (Coloured) Lung Case 680: ‘haemorrhagic oedema type’.
Figure 5: Plate 2 (Coloured) Trachea & Bronchi: ‘along the trachea and bronchi appear swollen lymphatic glands dotted with haemorrhages’.
Discussion
Main findings and interpretation
A century has passed since the 1918–19 influenza pandemic reached the shores of New Zealand and among the New Zealand military personnel serving in the Northern Hemisphere as part of WW1. The influenza pandemic occurred during the final stages of WW1 and no doubt spread further during Armistice celebrations resulting in the pandemic having the grim record as New Zealand’s worst human disaster. The works of Rice12,34 and one of the current author’s thesis,4 has identified 8,831 deaths as a results of the 1918–19 pandemic among New Zealanders. Rice’s34 more recent book suggests a more accurate total may be over 9,000 deaths if undocumented deaths among the Māori population are taken into account. The majority of these deaths occurred in New Zealand during a six-week period in November and December 2018. However, the first substantial numbers of New Zealanders dying during the pandemic occurred eight weeks earlier in September 1918 on board the troopship HMNZT 107 Tahiti on route to the UK carrying New Zealand military reinforcements.
Studies in the last decade have increasingly focused on the pandemic’s impact on military populations; due to access to rich and detailed medical records for large volumes of individuals. As roughly 40% of eligible male New Zealanders served in the NZEF during WW1, estimates of morbidity and mortality can be generalised to the wider population, such as the identification of increased pandemic mortality risks associated with being a young adult, being Māori or Pacific, or having had pre-pandemic respiratory admissions to hospital.
Patterns consistent with the international data
In general, the epidemiology of the pandemic in New Zealand was similar to that of other countries. A notable similarity was the w-shaped age distribution for mortality rates (albeit with some more in-depth analysis that may relate to the role of the 1890s influenza pandemic in this pattern).24 The higher mortality rate for Māori and Pacific soldiers in the New Zealand military (see Table 1), is also consistent with the higher burden for indigenous peoples from this pandemic.6 Similarly, risk factors for death identified in a New Zealand case-control study23 were often the same as those reported elsewhere (eg, co-existing chronic disease or being a recent military recruit). The spread of the pandemic via railway and shipping networks was also part of the international pattern—though rarely has it been shown in such detail as in the work of Rice for New Zealand.12 Our informal observations are that memorials to this pandemic are rare internationally—which is also the case for New Zealand.60
Unusual patterns with the New Zealand data
There were unusual patterns for pandemic impacts and response in New Zealand which contrast with other populations around the world, such as the following:
- Some novel risk factors for pandemic-related mortality were identified in a New Zealand case-control study; with males with larger chest size having an increased mortality risk (possibly related to the increased lung capacity of soldiers which might ‘increase the chance of a cytokine storm’).23
- There was an apparent lack of a socio-economic gradient in mortality rates for the New Zealand European population10,12,23 with no apparent variation by different housing districts in Auckland.45 This finding (albeit with only the two military studies using modern analytic methods), is in contrast to some of the international literature. For example, a socio-economic gradient has been described for Norway,73 Sweden74 and Chicago, US.75 The finding of no gradient in New Zealand is also in contrast with evidence for lifespan differences by male occupational class in New Zealand at this time.76
- The similar male vs female mortality rates among Māori were also somewhat unusual—in contrast to the relatively higher mortality in males vs females in the New Zealand European population.31 One of the possible reasons is Māori being exposed to greater crowding (more mixing of men and women), but possibly also the greater similarities in chronic respiratory disease burdens by sex in Māori (eg, due to greater similarities in smoking prevalence). However, this area requires further research.
- New Zealand was like most settings where there were only a few (or no) successful acts of border control or ‘protective sequestration’ (ie, there were only some successful moves in a small town26 and a few institutions.12 In contrast, some other jurisdictions successfully used maritime quarantine,58 road closures22 and measures such as school closures and public gathering bans.77
Strengths and limitations of this review
A strength of this review is that it is the first systematic review of this pandemic in the New Zealand context in the journal literature. It has also encompassed a wide variety of academic fields. However, this review also has its limitations. For example it has focused on secondary sources mostly as they provide summary accounts/data. Furthermore, there was little review of first-hand accounts, such as newspaper articles, letters or diaries (other than military sources, eg, Summers et al11). It is also conceivable that there are journal articles or theses that were published in the early part of last century which have not yet been included in the online medical databases which we searched.
Possible implications for future research
A first step is probably to consider further research around those unusual aspects of the pandemic in New Zealand that differed from the international literature as detailed above (ie, the large chest size as a risk factor for death, the apparent lack of a socio-economic gradient in mortality rates, and the similarity of male and female Māori mortality rates). For example, the use of modern biostatistical methods for additional analysis of other data relevant to socio-economic gradients, eg, by using the suburb data in Rice’s Christchurch research43 or the Auckland-based work by Bryder.45
But other apparent gaps are as follows:
- There is scope for better quantifying the extent of undocumented Māori deaths with studies that compare registered deaths with names on memorials in urupā (Māori burial sites). This type of research by a Māori researcher would also have the benefit of further building Māori research capacity.
- Modern spatial analysis could be applied to data on the spread of the pandemic (as detailed in maps on the rail and shipping networks compiled by Rice).12 This analysis could then estimate the speed of pandemic spread (eg, in kilometres per day and week).
- The relationship of the natality shocks of 1918 and 1919 in New Zealand to the pandemic have not been thoroughly analysed, although Pool provides a brief assessment of decreased fertility among Māori women.35 It is known that influenza infection is associated with fetal loss and stillbirth (as documented in Dunedin, New Zealand, during the pandemic)67 and it is likely to have been a factor in the sudden decline in New Zealand’s annual birth rate in 1918 by 9% and in 1919 by 17% (relative to 1917) [Data calculated from the 1924 Yearbook70 and based on changes in rates]. This issue only appears to have been studied in a few international settings, eg, US and Scandinavia,73,78 Taiwan,79 and Sri Lanka.80 This topic has some contemporary relevance given suboptimal vaccination of pregnant woman against influenza.81
Given the importance of learning from pandemics, there is perhaps a case for the Ministry of Health to allocate funds to the Health Research Council to specifically support research to address these knowledge gaps. Once this work was done, an updated review of the potential lessons relevant to modern pandemic planning could be conducted, eg, in terms of external border control, internal border control, health system preparedness and provision of voluntary sector nursing care to neighbours, etc.
Several studies evaluated the effect of the pandemic on the New Zealand health system both during and post-pandemic. There appears to be consensus that the health system was under immense strain, with limited resources/staffing and a crippled administration that was unable to provide clear leadership in the face of an overwhelming influenza pandemic. If anything can be learned from this experience it is that pre-pandemic planning is essential for New Zealand in order to face inevitable future pandemics. Such planning needs to include scenarios of similar intensity to the 1918 influenza pandemic and potentially more extreme events.
A greatly improved Health Act in 1920 was one of the responses to the 1918 influenza pandemic, which aimed to address the limitations of the previous legislation in terms of administrative responsibilities/duties by restructuring the health department and allowing special measures during periods of infectious disease outbreaks.44,66,82 Perhaps New Zealand could use the centennial of the 1918 pandemic as an opportunity to reflect on our readiness for the kinds of pandemics that we may face over the next 100 years and plan accordingly. One example is the need for rapid border closure to prevent entry of particularly severe pandemic diseases. Such measures could be highly cost-effective.83,84
Conclusions
In the centenary year of the 1918–19 influenza pandemic, now is the time for New Zealand to reflect on its impact on New Zealand in terms of its mortality, its long-term effects on the physical and psychological health of survivors, and indeed its role in shaping New Zealand’s health system and society. Most importantly for today’s New Zealanders, the pandemic provides insight into the nature of influenza pandemics and how societies response to such events. Despite the large body of work to date, there remain important knowledge gaps relating to this pandemic in New Zealand. Filling these gaps may contribute to improved planning for managing future pandemics.
Appendix 1: Literature search criteria
Appendix 2: Database search strategies
Cochrane Libraries
Search date: 22nd August 2018
Google Scholar
Search date: 22nd August 2018
Embase
Search date: 22nd August 2018
Embase 1974 to 2018 Week 34
Embase Classic 1947 to 1973
Global Health 1973 to 2018 Week 32
HMIC Health Management Information Consortium 1979 to May 2018
Ovid MEDLINE® Epub Ahead of Print, In-Process & Other Non_indexed Citations, Ovid MEDLINE® Daily, Ovid MedLINE and Versions®
PubMed
Search date: 22nd August 2018
Grey literature
Search date: 22nd August 2018
Grey literature – searched key words such as “1918”, “influenza”, Spanish”, and “Zealand”.
Appendix 3: PRISMA 2009 Flow Diagram87
Appendix 4: Additional detail on the publications (secondary sources) included in this systematic review
Available through external link:
http://www.nzma.org.nz/__data/assets/pdf_file/0003/86655/Appendix-4-FINAL.pdf
Summary
Abstract
Aim
The 1918-1919 influenza pandemic has been New Zealand s most severe disaster event (around 9,000 deaths). We aimed to review the literature related to this pandemic in New Zealand and among New Zealanders overseas, to identify any remaining research gaps (given ongoing risks of future influenza pandemics and from new pathogens, eg, synthetic bioweapons).
Method
Systematic literature searches and comparisons with international findings for this pandemic to facilitate identification of research gaps.
Results
A total of 61 relevant publications were identified. The epidemiological patterns reported were largely consistent with the international literature for this pandemic. These features included the w-shaped age-distribution for mortality, and the much higher mortality rates for indigenous people (ie, seven-fold for Mori vs New Zealand European). But some novel risk factors were identified (eg, large chest size as a risk factor for death in military personnel), and there was an extremely high mortality troop ship outbreak (probably related to crowding). In contrast to some international work, there was an apparent lack of a socio-economic gradient in mortality rates in two studies using modern analytical methods. New Zealand work has clearly shown how the pandemic spread via the rail network and internal shipping routes and the rarity of successful measures to prevent spread in contrast to some other jurisdictions. It has also found a marked lack of memorials to the pandemic (in contrast to war memorials). Nevertheless, some research gaps remain, including on the apparent marked reduction in birth rates in 1918-1919 and the reasons for no socio-economic gradient despite other New Zealand evidence for occupational class variation in lifespan at this time.
Conclusion
This is a relatively well-studied disaster event but there remain important research questions relating to this pandemic in New Zealand. Filling these gaps may contribute to improved planning for managing future pandemics.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
- Johnson N, Mueller J. Updating the Accounts: GLobal Mortality of the 1918–1920 ‘Spanish’ Influenza Pandemic. Bull Hist Med. 2002; 76:105–115.
- Wilson N, Baker M. Ninety Years on: what we still need to learn from the “Black November” 1918 about pandemic influenza. N Z Med J, 2008; 121(1285):136–138.
- Oxford JS, Sefton A, Jackson R, et al. Early Herald Wave Outbreaks of Influenza in 1916 prior to the Pandemic of 1918. Intl Congr Ser. 2001; 1219:155–161.
- Summers JA. The Burden and Risk Factors for Death from the 1918-19 Influenza Pandemic amongst the New Zealand Military Forces of World War One [PhD thesis]. 2013, University of Otago, Dunedin, New Zealand.
- Eyre JWH, Lowe EC. Prophylactic Vaccinations against Catarrhal affections of the respiratory tract. Lancet. 1918; 192(4963):484–487.
- Shanks GD, Wilson N, Kippen R, Brundage JF. The unusually diverse mortality patterns in the Pacific regions during the 1918–21 influenza pandemic: reflections at the pandemic’s centenary. Lancet Infect Dis., 2018: p. pii: S1473-3099(18)30178-6.
- NZ Government. “Health 40th Reinforcements, Medical Report on “Tahiti” Epidemic 1918” WA.1. Box 1/3/25. Record: 10/79. Wellington: Archives New Zealand, National Office. 1918.
- O’Neill CEJ. Court of Enquiry regarding HMNZT Transport “Tahiti”. 1918: London.
- Denniston SJE, Mitchelson E, McLaren D. Report of the Influenza Epidemic Commission. 1919, Appendix to the Journals of the House of Representatives of New Zealand.
- Summers J, Wilson N, Baker MG, Shanks G. Mortality Risk Factors for Pandemic Influenza on New Zealand Troop Ship, 1918. Emerg Infect Dis. 2010; 16(12):1931–1937.
- Summers J. Pandemic influenza outbreak on a troop ship - diary of a soldier in 1918. Emerg Infect Dis. 2012; 18(11):1900–1903.
- Rice GW. Black November: The 1918 influenza pandemic in New Zealand. 2005, Christchurch: Canterbury University Press.
- Sertsou G, Wilson N, Baker M, et al. Key transmission parameters of an institutional outbreak during the 1918 influenza pandemic estimated by mathematical modelling. Theor Biol Med Model. 2006; 3(38).
- Nishiura H, Wilson N. Transmission dynamics of the 1918 influenza pandemic in New Zealand: analyses of national and city data. N Z Med J. 2009; 122(1296):81–86.
- Eyre JWH, Lowe EC. Report upon the Autumn Influenza Epidemic (1918) as it affected the N.Z.E.F. in the United Kingdom. Lancet. 1919; 193(4988):553–560.
- McSweeny K, Coleman A, Fancourt N, et al. Was rurality protective in the 1918 influenza pandemic in New Zealand? N Z Med J. 2007; 120(1256):U2579.
- Shanks GD, MacKenzie A, Waller M, Brundage J. Low but highly variable mortality among nurses and physicians during the influenza pandemic of 1918–19. Influenza Other Respir Viruses. 2011; 5:213–219.
- Wilson N, Barnard Telfar L, Summers J, et al. Differential Mortality Rates by Ethnicity in 3 Influenza Pandemics Over a Century, New Zealand. Emerg Infect Dis. 2011; 18(1):71–77.
- Shanks GD, Summers JA, Wilson N. Large mortality differences between Australian and New Zealand soldiers during 1918–19 influenza pandemic., in 61st Annual Meeting of the American Society of Tropical Medicine and Hygiene. 2012, American Journal of Tropical Medicine and Hygiene: Atlanta, USA. p. 72.
- Wilson N, Summers J, Baker M. Injury Epidemiology and New Zealand military forces in World War One. Inj Prev., 2012. 18 (Suppl 1)(A153).
- Summers JA, Shanks GD, Baker MG, Wilson N. Severe impact of the 1918–19 pandemic influenza in a national military force. N Z Med J. 2013; 126(1378):36–47.
- Summers J, Wilson N, Baker MG, Gottfredsson M. The influenza pandemic of 1918–1919 in two remote island nations: Iceland and New Zealand. N Z Med J. 2013; 126(1373):74–80.
- Summers J, Stanley J, Baker MG, Wilson N. Risk factors for death from pandemic influenza in 1918–1919: a case–control study. Influenza Other Respir Viruses. 2014; 8(3):329–338.
- Wilson N, Oliver J, Rice G, et al. Age-specific mortality during the 1918–19 influenza pandemic and possible relationship to the 1889–92 influenza pandemic. J Infect Dis., 2014; 210(6):993–995.
- Wilson N, Boyd M, Nisa S, et al. Did exposure to a severe outbreak of pandemic influenza in 1918 impact on long-term survival? Epidemiol Infect., 2016. 144(15): p. 3166–3169.
- Wilson N, Rice G, Thomson G, Baker M. Re-evaluating a local public health control measure used in New Zealand for the pandemic influenza of 1918. N Z Med J. 2005; 118(1224):U1714.
- Summers JA, Wilson N, and Baker MG, Ethnic gradient in mortality amongst the New Zealand military personnel in World War One [poster presentation], in Australasian Epidemiological Association Annual Scientific Meeting. 2010: Sydney, Australia.
- Champtaloup S. A study of the influenza epidemic in New Zealand 1918: epidemiology, administration and bacteriology, with a report on the pathology of twenty-five fatal cases. 1920, University of Edinburgh.
- Maclean FS. Challenge for Health: A History of Public Health in New Zealand. 1964, Wellington: R.E. Owen, Government Printer.
- Wright-St Clair RE. Influenza in New Zealand and the doctors who died from it. N Z Med J. 1983; 96:765–768.
- Rice GW. Influenza in New Zealand before 1918: a preliminary report. Am J Epidemiol. 2018.
- Rice GW. ‘That Terrible Time’: Reflections on the 1918 Influenza Pandemic in New Zealand. N Z Med J. 2018; 131(1481):6–8.
- Rice GW. Black November: The 1918 Influenza Epidemic in New Zealand. 1988, Wellington: Allen and Unwin.
- Rice GW. Black Flu 1918: The story of New Zealand’s worst public health disaster. 2017, Christchurch, New Zealand: Canterbury University Press.
- Pool DI. The effects of the 1918 Pandemic of Influenza on the Maori Population of New Zealand. Bull Hist Med. 1973; 47:273–281.
- Rice GW. A disease deadlier than war. N Z Med J. 2013; 126(1378):12–14.
- Rice G. Microgeography of Historical Influenza Mortality: A New Zealand example from the 1918 Pandemic, in 1990, One Thousand Years of New Zealand Population: Heeding the Past and Planning for the Future., N.Z.D.S. Conference, Editor. 1989: University of Waikato, Hamilton, New Zealand.
- Charania NA, Turner NM. 100 years since the 1918 influenza pandemic—progress made, yet questions remain. A synopsis of the 4th New Zealand Influenza Symposium, February 2018. N Z Med J. 2018; 131(1481):50–55.
- Rice G. Maori mortality in the 1918 influenza epidemic. N Z Population Rev., 1983; 9(1):44–61.
- Bennett C. Now the War is Over, We Have Something Else to Worry Us”: New Zealand Children’s Responses to Crises, 1914–1918. J History Childhood Youth. 2014. 7(1):19–41.
- Lange KJ. “Child’s Play?”: The Role of Children in the 1918 Influenza Epidemic in New Zealand. 2015, Dickinson College.
- Rice GW. Why did Wellington suffer nearly double the death rate of Christchurch in the 1918 influenza pandemic?, in In: The 2018 Jim Gardner Memorial Lecture. 2018, Canterbury History Foundation: Christchurch, New Zealand.
- Rice GW. Christchurch in the 1918 Influenza Epidemic: a preliminary study. NZJH., 1979; 13(2):109–131.
- Bryder L. “Lessons” of the 1918 influenza epidemic in Auckland. NZ J History. 1982; 16(2):97–121.
- Bryder L. The 1918 Influenza Epidemic in Auckland. 1980, University of Auckland.
- Bulling GM. Preventable deaths?: the 1918 influenza pandemic in Nightcaps. 1991, University of Otago, Dunedin, New Zealand.
- Jamieson JPS. Notes of the recent epidemic of Influenza in Nelson. N Z Med J. 1919; 18:46–51.
- Rice G. Crisis in a country town: the 1918 epidemic in Temuka. Historical News. 1985; 51:7–13.
- Lovell Gregg J. How Coromandel kept the Influenza Epidemic at bay. N Z Med J. 1919; 18:51–53.
- Rice G. Australia and New Zealand in the 1918–19 influenza pandemic. Occas Pap Med Hist Aust. 1990; 4:67–74.
- Rice GW. Japan and New Zealand in the 1918 influenza pandemic: comparative perspectives on official responses and crisis management, in The Spanish Influenza Pandemic of 1918–19., H. Phillips and D. Killingray, Editors. 2003, Routledge: Taylor and Francis Group: London and New York.
- Richardson GM. The onset of pneumonic influenza in 1918 in relation to the wartime use of mustard gas. N Z Med J. 1948; 47(257):4–16.
- Brundage JF, Shanks GD. What really happened during the 1918 Influenza Pandemic? The importance of Bacterial Secondary Infections. J Infect Dis. 2007; 196(11):1717–1718.
http://www.nzetc.org/tm/scholarly/name-140805.html - Carbery ARD. The New Zealand Medical Service in the Great War, 1914–1918. 1924; Available from:
- Wilson N, Summers J, Baker MG. Impact of the 1918–19 influenza pandemic on the New Zealand Military and persisting lessons for pandemic control. Microbiol Aust., 2014; 35(3):138–140.
- Wilson N, Summers J, Baker M, Rice G. A bizarre case of drowning as a result of pandemic influenza (1918 pandemic). N Z Med J. 2009; 122(1302).
- McLane JR. Setting a Barricade Against the East Wind: Western Polynesia and the 1918 Influenza Pandemic. 2012, University of Otago, Dunedin, New Zealand.
- McLeod MA. Baker M, Wilson N, et al. Protective Effect of Maritime Quarantine in South Pacific Jurisdictions, 1918–19 Influenza Pandemic. Emerg Infect Dis. 2008; 14(3):468–470.
- Elliot G, Wilson T, Sefton Moorhouse WH. H-31c SAMOAN EPIDEMIC COMMISSION (REPORT OF) APPENDIX TO THE JOURNALS OF THE HOUSE OF REPRESENTATIVES, 1 JANUARY 1919. 1919, Wellington, New Zealand.
- Wilson N, Ferguson C, Rice G, et al. Remembering the 1918 influenza pandemic: national survey of memorials and scope for enhancing educational value around pandemic preparedness. N Z Med J. 2017; 130(1465):53–70.
- Edwards V. Pestilence from abroad? The 1918 influenza epidemic. N Z Med J. 1986; 99(812):809–812.
- Bradshaw W, Learning the lessons of the 1918 Spanish influenza epidemic. Nurs N Z., 2005; 11(10):22–23.
- Roddick JA. Delirium and fever in the antipodes: Nursing and the 1918 influenza epidemic in Dunedin Hospital, New Zealand. J Res Nurs. 2006; 11(4):357–370.
- Wood PJ, Managing boundaries between professional and lay nursing following the influenza pandemic, 1918–1919: insights for professional resilience today? J Clin Nurs. 2017; 26(5–6):805–812.
- Roddick JA. When the Flag Flew at Half Mast: Nursing and the 1918 Influenza Epidemic in Dunedin. 2005, Otago Polytechnic, Dunedin, New Zealand.
- Rice GW. The making of New Zealand’s 1920 Health Act. N Z Med J. 1988; 22(1):3–22.
- Fitchett F, Bowie JT, Champtaloup ST, Drennan AM. A Report on the recent “Influenza Epidemic” in Dunedin, New Zealand. N Z Med J. 1919; 18.
- Archives New Zealand, Books of Active Service Casualty Forms, New Zealand Expeditionary Force 1914–1918, in Agency: AABK Series: 519. 1914–1918.
- NZ Government, The Great War, 1914–1918 : New Zealand Expeditionary Force Roll of Honour. 1924, Government Printer: Wellington.
- New Zealand Department of Statistics, The New Zealand Official Yearbook. 1924, Wellington: Eyre and Spottiswoode.
- New Zealand Department of Statistics, The New Zealand Official Yearbook. 1920, Wellington: Eyre and Spottiswoode.
- Killick E, Financing the Influenza Epidemic. Journal of the Department of Public Health, Hospitals, and Charitable Aid. 1919. 2:6–12.
- Mamelund SE. A socially neutral disease? Individual social class, household wealth and mortality from Spanish influenza in two socially contrasting parishes in Kristiania 1918–19. Soc Sci Med. 2006; 62:923–940.
- Bengtsson T, Dribe M, Eriksson B. Social class and excess mortality in Sweden during the 1918 influenza pandemic. Am J Epidemiol. 2018.
- Grantz KH, Rane MS, Salje H, et al. Disparities in influenza mortality and transmission related to sociodemographic factors within Chicago in the pandemic of 1918. Proc Natl Acad Sci U S A. 2016; 113(48):13839–13844.
- Wilson N. Clement C, Boyd M, et al. The long history of health inequality in New Zealand: occupational class and lifespan in the late 1800s and early 1900s. Aust N Z J Public Health. 2018; 42:175–179.
- Markel H, Lipman HB, Navarro JA, et al. Nonpharmaceutical interventions implemented by US cities during the 1918–1919 influenza pandemic. JAMA. 2007; 298(6):644–654.
- Bloom-Feshbach K, Simonsen L, Viboud C, et al. Natality decline and miscarriages associated with the 1918 influenza pandemic: the Scandinavian and United States experiences. J Infect Dis. 2011; 204(8):1157–64.
- Chandra S, Yu YL. Fertility Decline and the 1918 Influenza Pandemic in Taiwan. Biodemography Soc Biol. 2015; 61(3):266–72.
- Chandra S, Sarathchandra D. The influenza pandemic of 1918–1919 in Sri Lanka: its demographic cost, timing, and propagation. Influenza Other Respir Viruses. 2014; 8(3):267–73.
- Yuen CY, Tarrant M. A comprehensive review of influenza and influenza vaccination during pregnancy. J Perinat Neonatal Nurs. 2014; 28(4):261–70.
- Dow DA. Safeguarding the Public Health: A History of the New Zealand Department of Health. 1995, Wellington: Victoria University Press.
- Boyd M, Baker MG, Mansoor OD, et al. Protecting an island nation from extreme pandemic threats: Proof-of-concept around border closure as an intervention. PLoS One. 2017; 12(6):e0178732.
- Boyd M, Mansoor OD, Baker MG, Wilson N. Economic evaluation of border closure for a generic severe pandemic threat using New Zealand Treasury methods. Aust N Z J Public Health. 2018.
http://www.archway.archives.govt.nz/ - Archives New Zealand. Archway Search Engine. 2012; Available from:
- Wellcome Library. The library at Wellcome Collection. 2017 [cited 2017 November].
- Moher D, Liberati A, Tetzlaff J, et al. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med. 2009. 6(7):e1000097.
For the PDF of this article,
contact nzmj@nzma.org.nz
New Zealand s experience of the 1918 19 influenza pandemic: a systematic review after 100 years
View Article PDF
The 1918–19 influenza pandemic was one of the most severe natural disasters in recorded human history. It occurred during the final stages of the First World War (WW1) and this particularly lethal H1N1 viral pandemic strain of influenza is estimated to have killed 50–100 million people worldwide.1 Very few localities (other than a few remote islands) escaped the deadly impact of this pandemic, and for the peoples of New Zealand, the pandemic would be described as “the worst single human disaster in recorded New Zealand history”.2
Various aspects of New Zealand’s experience of the pandemic have been documented using both historical and epidemiological methods. The knowledge of the events leading up to the pandemic, and its long-term effects, are also increasingly well documented. However, a century later, it is prudent to re-examine all the evidence from a range of sources to gain a clearer perspective of this pandemic and its impact on New Zealand. Therefore, this current paper aimed to review the literature related to the 1918–19 influenza pandemic in New Zealand and among its peoples (including New Zealand military personnel overseas) and to identify any research gaps. The latter is of importance for this country’s preparedness for inevitable influenza and other pandemics in the future.
Methods
We aimed to systematically identify all published literature related to the 1918–19 influenza pandemic either in New Zealand or among New Zealanders outside of New Zealand. The searches were conducted using the Cochrane Library, Google Scholar, Embase, PubMed, various University thesis repositories and grey literature for all studies published from 1914 to 2018 (to take into account evidence of pre-pandemic waves3,4). Search strategies used in databases and other archival/thesis catalogues are detailed in the Appendix (Appendix 1, 2 and 3). We also examined the bibliographies of all the identified literature for additional publications.
Results
The experience of the pandemic in New Zealand and among New Zealanders has been evaluated both during and since the pandemic occurred in 1918, from a variety of primary sources from the period (for example military records or personal accounts) and secondary historical/epidemiological publications. A total of 61 publications were identified which relate to the 1918–19 influenza pandemic in New Zealand or among New Zealanders as a primary focus and provide understating of the pandemic (with further details on each publication in Appendix 4). In total, we identified five books, two case-series, nine discussion/commentary pieces, 15 epidemiological studies, 24 reviews and six theses. These publications use a variety of methods and spanned different academic fields, such as social history, epidemiology, public health, health services and biostatistics.
The earliest identified publication was a case series in 1918 of New Zealand military personnel in the New Zealand Expeditionary Force (NZEF), which described post-mortem details of cases.5 In contrast, the most recent publication was published in 2018 and it reviewed mortality patterns within the Pacific region during the pandemic.6
There has been steady increase in the number of publications on the pandemic and New Zealand, with the vast majority of studies being published in the last decade. This pattern may reflect the increasing availability of records from 1918 such as the digitisation of military files for online archives and online newspaper records (Figure 1). But there has also been a growth in all medical research, including for “seasonal influenza” in the New Zealand context (eg, 63 Medline-indexed publications as of late 2018).
Figure 1: Cumulative frequency of publications related to New Zealand’s experience of the 1918–19 influenza pandemic.
The main impact of the 1918–19 influenza pandemic occurred in New Zealand during November 1918 for both civilian and military populations situated within New Zealand (Figure 2). While for New Zealand military personnel situated either at sea (on board the troopship HMNZT Tahiti) or in the Northern Hemisphere, the experience of the pandemic was rather different. Official reports of the troopship outbreak are held at Archives New Zealand7–9 and detail the course of the outbreak and the outcomes for the military personnel. These reports have been used in several epidemiological studies of the outbreak as they provide detailed description of the individuals on board.4,10,11 Those on board the Tahiti experienced one of the worst ship outbreaks worldwide during the pandemic, and the personnel in the Northern Hemisphere experienced two mortality waves, in November 1918 and in late February 1919 (much like other populations in Europe) (Figure 3).
Figure 2: Pandemic-related mortality per week among the civilian populations in the North and South Islands of New Zealand and NZEF personnel who died in New Zealand.4,12
Note: some of the civilian data include discharged NZEF personnel.
Figure 3: Pandemic-related mortality among New Zealand military personnel by location during the 1918–19 in the defined pandemic periods.4
Research domains identified in a previous review article for New Zealand as areas which needed further development included epidemiology, Māori history, social history, military history and disaster sociology/psychology.2 Given the significant increase in publications, many of these domains have been developed (Table 1), along with several studies examining the health system in New Zealand during the pandemic.
Table 1: Identified literature on the 1918–19 influenza pandemic in New Zealand categorised by major research domains.
Figure 4: Plate 1 (Coloured) Lung Case 680: ‘haemorrhagic oedema type’.
Figure 5: Plate 2 (Coloured) Trachea & Bronchi: ‘along the trachea and bronchi appear swollen lymphatic glands dotted with haemorrhages’.
Discussion
Main findings and interpretation
A century has passed since the 1918–19 influenza pandemic reached the shores of New Zealand and among the New Zealand military personnel serving in the Northern Hemisphere as part of WW1. The influenza pandemic occurred during the final stages of WW1 and no doubt spread further during Armistice celebrations resulting in the pandemic having the grim record as New Zealand’s worst human disaster. The works of Rice12,34 and one of the current author’s thesis,4 has identified 8,831 deaths as a results of the 1918–19 pandemic among New Zealanders. Rice’s34 more recent book suggests a more accurate total may be over 9,000 deaths if undocumented deaths among the Māori population are taken into account. The majority of these deaths occurred in New Zealand during a six-week period in November and December 2018. However, the first substantial numbers of New Zealanders dying during the pandemic occurred eight weeks earlier in September 1918 on board the troopship HMNZT 107 Tahiti on route to the UK carrying New Zealand military reinforcements.
Studies in the last decade have increasingly focused on the pandemic’s impact on military populations; due to access to rich and detailed medical records for large volumes of individuals. As roughly 40% of eligible male New Zealanders served in the NZEF during WW1, estimates of morbidity and mortality can be generalised to the wider population, such as the identification of increased pandemic mortality risks associated with being a young adult, being Māori or Pacific, or having had pre-pandemic respiratory admissions to hospital.
Patterns consistent with the international data
In general, the epidemiology of the pandemic in New Zealand was similar to that of other countries. A notable similarity was the w-shaped age distribution for mortality rates (albeit with some more in-depth analysis that may relate to the role of the 1890s influenza pandemic in this pattern).24 The higher mortality rate for Māori and Pacific soldiers in the New Zealand military (see Table 1), is also consistent with the higher burden for indigenous peoples from this pandemic.6 Similarly, risk factors for death identified in a New Zealand case-control study23 were often the same as those reported elsewhere (eg, co-existing chronic disease or being a recent military recruit). The spread of the pandemic via railway and shipping networks was also part of the international pattern—though rarely has it been shown in such detail as in the work of Rice for New Zealand.12 Our informal observations are that memorials to this pandemic are rare internationally—which is also the case for New Zealand.60
Unusual patterns with the New Zealand data
There were unusual patterns for pandemic impacts and response in New Zealand which contrast with other populations around the world, such as the following:
- Some novel risk factors for pandemic-related mortality were identified in a New Zealand case-control study; with males with larger chest size having an increased mortality risk (possibly related to the increased lung capacity of soldiers which might ‘increase the chance of a cytokine storm’).23
- There was an apparent lack of a socio-economic gradient in mortality rates for the New Zealand European population10,12,23 with no apparent variation by different housing districts in Auckland.45 This finding (albeit with only the two military studies using modern analytic methods), is in contrast to some of the international literature. For example, a socio-economic gradient has been described for Norway,73 Sweden74 and Chicago, US.75 The finding of no gradient in New Zealand is also in contrast with evidence for lifespan differences by male occupational class in New Zealand at this time.76
- The similar male vs female mortality rates among Māori were also somewhat unusual—in contrast to the relatively higher mortality in males vs females in the New Zealand European population.31 One of the possible reasons is Māori being exposed to greater crowding (more mixing of men and women), but possibly also the greater similarities in chronic respiratory disease burdens by sex in Māori (eg, due to greater similarities in smoking prevalence). However, this area requires further research.
- New Zealand was like most settings where there were only a few (or no) successful acts of border control or ‘protective sequestration’ (ie, there were only some successful moves in a small town26 and a few institutions.12 In contrast, some other jurisdictions successfully used maritime quarantine,58 road closures22 and measures such as school closures and public gathering bans.77
Strengths and limitations of this review
A strength of this review is that it is the first systematic review of this pandemic in the New Zealand context in the journal literature. It has also encompassed a wide variety of academic fields. However, this review also has its limitations. For example it has focused on secondary sources mostly as they provide summary accounts/data. Furthermore, there was little review of first-hand accounts, such as newspaper articles, letters or diaries (other than military sources, eg, Summers et al11). It is also conceivable that there are journal articles or theses that were published in the early part of last century which have not yet been included in the online medical databases which we searched.
Possible implications for future research
A first step is probably to consider further research around those unusual aspects of the pandemic in New Zealand that differed from the international literature as detailed above (ie, the large chest size as a risk factor for death, the apparent lack of a socio-economic gradient in mortality rates, and the similarity of male and female Māori mortality rates). For example, the use of modern biostatistical methods for additional analysis of other data relevant to socio-economic gradients, eg, by using the suburb data in Rice’s Christchurch research43 or the Auckland-based work by Bryder.45
But other apparent gaps are as follows:
- There is scope for better quantifying the extent of undocumented Māori deaths with studies that compare registered deaths with names on memorials in urupā (Māori burial sites). This type of research by a Māori researcher would also have the benefit of further building Māori research capacity.
- Modern spatial analysis could be applied to data on the spread of the pandemic (as detailed in maps on the rail and shipping networks compiled by Rice).12 This analysis could then estimate the speed of pandemic spread (eg, in kilometres per day and week).
- The relationship of the natality shocks of 1918 and 1919 in New Zealand to the pandemic have not been thoroughly analysed, although Pool provides a brief assessment of decreased fertility among Māori women.35 It is known that influenza infection is associated with fetal loss and stillbirth (as documented in Dunedin, New Zealand, during the pandemic)67 and it is likely to have been a factor in the sudden decline in New Zealand’s annual birth rate in 1918 by 9% and in 1919 by 17% (relative to 1917) [Data calculated from the 1924 Yearbook70 and based on changes in rates]. This issue only appears to have been studied in a few international settings, eg, US and Scandinavia,73,78 Taiwan,79 and Sri Lanka.80 This topic has some contemporary relevance given suboptimal vaccination of pregnant woman against influenza.81
Given the importance of learning from pandemics, there is perhaps a case for the Ministry of Health to allocate funds to the Health Research Council to specifically support research to address these knowledge gaps. Once this work was done, an updated review of the potential lessons relevant to modern pandemic planning could be conducted, eg, in terms of external border control, internal border control, health system preparedness and provision of voluntary sector nursing care to neighbours, etc.
Several studies evaluated the effect of the pandemic on the New Zealand health system both during and post-pandemic. There appears to be consensus that the health system was under immense strain, with limited resources/staffing and a crippled administration that was unable to provide clear leadership in the face of an overwhelming influenza pandemic. If anything can be learned from this experience it is that pre-pandemic planning is essential for New Zealand in order to face inevitable future pandemics. Such planning needs to include scenarios of similar intensity to the 1918 influenza pandemic and potentially more extreme events.
A greatly improved Health Act in 1920 was one of the responses to the 1918 influenza pandemic, which aimed to address the limitations of the previous legislation in terms of administrative responsibilities/duties by restructuring the health department and allowing special measures during periods of infectious disease outbreaks.44,66,82 Perhaps New Zealand could use the centennial of the 1918 pandemic as an opportunity to reflect on our readiness for the kinds of pandemics that we may face over the next 100 years and plan accordingly. One example is the need for rapid border closure to prevent entry of particularly severe pandemic diseases. Such measures could be highly cost-effective.83,84
Conclusions
In the centenary year of the 1918–19 influenza pandemic, now is the time for New Zealand to reflect on its impact on New Zealand in terms of its mortality, its long-term effects on the physical and psychological health of survivors, and indeed its role in shaping New Zealand’s health system and society. Most importantly for today’s New Zealanders, the pandemic provides insight into the nature of influenza pandemics and how societies response to such events. Despite the large body of work to date, there remain important knowledge gaps relating to this pandemic in New Zealand. Filling these gaps may contribute to improved planning for managing future pandemics.
Appendix 1: Literature search criteria
Appendix 2: Database search strategies
Cochrane Libraries
Search date: 22nd August 2018
Google Scholar
Search date: 22nd August 2018
Embase
Search date: 22nd August 2018
Embase 1974 to 2018 Week 34
Embase Classic 1947 to 1973
Global Health 1973 to 2018 Week 32
HMIC Health Management Information Consortium 1979 to May 2018
Ovid MEDLINE® Epub Ahead of Print, In-Process & Other Non_indexed Citations, Ovid MEDLINE® Daily, Ovid MedLINE and Versions®
PubMed
Search date: 22nd August 2018
Grey literature
Search date: 22nd August 2018
Grey literature – searched key words such as “1918”, “influenza”, Spanish”, and “Zealand”.
Appendix 3: PRISMA 2009 Flow Diagram87
Appendix 4: Additional detail on the publications (secondary sources) included in this systematic review
Available through external link:
http://www.nzma.org.nz/__data/assets/pdf_file/0003/86655/Appendix-4-FINAL.pdf
Summary
Abstract
Aim
The 1918-1919 influenza pandemic has been New Zealand s most severe disaster event (around 9,000 deaths). We aimed to review the literature related to this pandemic in New Zealand and among New Zealanders overseas, to identify any remaining research gaps (given ongoing risks of future influenza pandemics and from new pathogens, eg, synthetic bioweapons).
Method
Systematic literature searches and comparisons with international findings for this pandemic to facilitate identification of research gaps.
Results
A total of 61 relevant publications were identified. The epidemiological patterns reported were largely consistent with the international literature for this pandemic. These features included the w-shaped age-distribution for mortality, and the much higher mortality rates for indigenous people (ie, seven-fold for Mori vs New Zealand European). But some novel risk factors were identified (eg, large chest size as a risk factor for death in military personnel), and there was an extremely high mortality troop ship outbreak (probably related to crowding). In contrast to some international work, there was an apparent lack of a socio-economic gradient in mortality rates in two studies using modern analytical methods. New Zealand work has clearly shown how the pandemic spread via the rail network and internal shipping routes and the rarity of successful measures to prevent spread in contrast to some other jurisdictions. It has also found a marked lack of memorials to the pandemic (in contrast to war memorials). Nevertheless, some research gaps remain, including on the apparent marked reduction in birth rates in 1918-1919 and the reasons for no socio-economic gradient despite other New Zealand evidence for occupational class variation in lifespan at this time.
Conclusion
This is a relatively well-studied disaster event but there remain important research questions relating to this pandemic in New Zealand. Filling these gaps may contribute to improved planning for managing future pandemics.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
- Johnson N, Mueller J. Updating the Accounts: GLobal Mortality of the 1918–1920 ‘Spanish’ Influenza Pandemic. Bull Hist Med. 2002; 76:105–115.
- Wilson N, Baker M. Ninety Years on: what we still need to learn from the “Black November” 1918 about pandemic influenza. N Z Med J, 2008; 121(1285):136–138.
- Oxford JS, Sefton A, Jackson R, et al. Early Herald Wave Outbreaks of Influenza in 1916 prior to the Pandemic of 1918. Intl Congr Ser. 2001; 1219:155–161.
- Summers JA. The Burden and Risk Factors for Death from the 1918-19 Influenza Pandemic amongst the New Zealand Military Forces of World War One [PhD thesis]. 2013, University of Otago, Dunedin, New Zealand.
- Eyre JWH, Lowe EC. Prophylactic Vaccinations against Catarrhal affections of the respiratory tract. Lancet. 1918; 192(4963):484–487.
- Shanks GD, Wilson N, Kippen R, Brundage JF. The unusually diverse mortality patterns in the Pacific regions during the 1918–21 influenza pandemic: reflections at the pandemic’s centenary. Lancet Infect Dis., 2018: p. pii: S1473-3099(18)30178-6.
- NZ Government. “Health 40th Reinforcements, Medical Report on “Tahiti” Epidemic 1918” WA.1. Box 1/3/25. Record: 10/79. Wellington: Archives New Zealand, National Office. 1918.
- O’Neill CEJ. Court of Enquiry regarding HMNZT Transport “Tahiti”. 1918: London.
- Denniston SJE, Mitchelson E, McLaren D. Report of the Influenza Epidemic Commission. 1919, Appendix to the Journals of the House of Representatives of New Zealand.
- Summers J, Wilson N, Baker MG, Shanks G. Mortality Risk Factors for Pandemic Influenza on New Zealand Troop Ship, 1918. Emerg Infect Dis. 2010; 16(12):1931–1937.
- Summers J. Pandemic influenza outbreak on a troop ship - diary of a soldier in 1918. Emerg Infect Dis. 2012; 18(11):1900–1903.
- Rice GW. Black November: The 1918 influenza pandemic in New Zealand. 2005, Christchurch: Canterbury University Press.
- Sertsou G, Wilson N, Baker M, et al. Key transmission parameters of an institutional outbreak during the 1918 influenza pandemic estimated by mathematical modelling. Theor Biol Med Model. 2006; 3(38).
- Nishiura H, Wilson N. Transmission dynamics of the 1918 influenza pandemic in New Zealand: analyses of national and city data. N Z Med J. 2009; 122(1296):81–86.
- Eyre JWH, Lowe EC. Report upon the Autumn Influenza Epidemic (1918) as it affected the N.Z.E.F. in the United Kingdom. Lancet. 1919; 193(4988):553–560.
- McSweeny K, Coleman A, Fancourt N, et al. Was rurality protective in the 1918 influenza pandemic in New Zealand? N Z Med J. 2007; 120(1256):U2579.
- Shanks GD, MacKenzie A, Waller M, Brundage J. Low but highly variable mortality among nurses and physicians during the influenza pandemic of 1918–19. Influenza Other Respir Viruses. 2011; 5:213–219.
- Wilson N, Barnard Telfar L, Summers J, et al. Differential Mortality Rates by Ethnicity in 3 Influenza Pandemics Over a Century, New Zealand. Emerg Infect Dis. 2011; 18(1):71–77.
- Shanks GD, Summers JA, Wilson N. Large mortality differences between Australian and New Zealand soldiers during 1918–19 influenza pandemic., in 61st Annual Meeting of the American Society of Tropical Medicine and Hygiene. 2012, American Journal of Tropical Medicine and Hygiene: Atlanta, USA. p. 72.
- Wilson N, Summers J, Baker M. Injury Epidemiology and New Zealand military forces in World War One. Inj Prev., 2012. 18 (Suppl 1)(A153).
- Summers JA, Shanks GD, Baker MG, Wilson N. Severe impact of the 1918–19 pandemic influenza in a national military force. N Z Med J. 2013; 126(1378):36–47.
- Summers J, Wilson N, Baker MG, Gottfredsson M. The influenza pandemic of 1918–1919 in two remote island nations: Iceland and New Zealand. N Z Med J. 2013; 126(1373):74–80.
- Summers J, Stanley J, Baker MG, Wilson N. Risk factors for death from pandemic influenza in 1918–1919: a case–control study. Influenza Other Respir Viruses. 2014; 8(3):329–338.
- Wilson N, Oliver J, Rice G, et al. Age-specific mortality during the 1918–19 influenza pandemic and possible relationship to the 1889–92 influenza pandemic. J Infect Dis., 2014; 210(6):993–995.
- Wilson N, Boyd M, Nisa S, et al. Did exposure to a severe outbreak of pandemic influenza in 1918 impact on long-term survival? Epidemiol Infect., 2016. 144(15): p. 3166–3169.
- Wilson N, Rice G, Thomson G, Baker M. Re-evaluating a local public health control measure used in New Zealand for the pandemic influenza of 1918. N Z Med J. 2005; 118(1224):U1714.
- Summers JA, Wilson N, and Baker MG, Ethnic gradient in mortality amongst the New Zealand military personnel in World War One [poster presentation], in Australasian Epidemiological Association Annual Scientific Meeting. 2010: Sydney, Australia.
- Champtaloup S. A study of the influenza epidemic in New Zealand 1918: epidemiology, administration and bacteriology, with a report on the pathology of twenty-five fatal cases. 1920, University of Edinburgh.
- Maclean FS. Challenge for Health: A History of Public Health in New Zealand. 1964, Wellington: R.E. Owen, Government Printer.
- Wright-St Clair RE. Influenza in New Zealand and the doctors who died from it. N Z Med J. 1983; 96:765–768.
- Rice GW. Influenza in New Zealand before 1918: a preliminary report. Am J Epidemiol. 2018.
- Rice GW. ‘That Terrible Time’: Reflections on the 1918 Influenza Pandemic in New Zealand. N Z Med J. 2018; 131(1481):6–8.
- Rice GW. Black November: The 1918 Influenza Epidemic in New Zealand. 1988, Wellington: Allen and Unwin.
- Rice GW. Black Flu 1918: The story of New Zealand’s worst public health disaster. 2017, Christchurch, New Zealand: Canterbury University Press.
- Pool DI. The effects of the 1918 Pandemic of Influenza on the Maori Population of New Zealand. Bull Hist Med. 1973; 47:273–281.
- Rice GW. A disease deadlier than war. N Z Med J. 2013; 126(1378):12–14.
- Rice G. Microgeography of Historical Influenza Mortality: A New Zealand example from the 1918 Pandemic, in 1990, One Thousand Years of New Zealand Population: Heeding the Past and Planning for the Future., N.Z.D.S. Conference, Editor. 1989: University of Waikato, Hamilton, New Zealand.
- Charania NA, Turner NM. 100 years since the 1918 influenza pandemic—progress made, yet questions remain. A synopsis of the 4th New Zealand Influenza Symposium, February 2018. N Z Med J. 2018; 131(1481):50–55.
- Rice G. Maori mortality in the 1918 influenza epidemic. N Z Population Rev., 1983; 9(1):44–61.
- Bennett C. Now the War is Over, We Have Something Else to Worry Us”: New Zealand Children’s Responses to Crises, 1914–1918. J History Childhood Youth. 2014. 7(1):19–41.
- Lange KJ. “Child’s Play?”: The Role of Children in the 1918 Influenza Epidemic in New Zealand. 2015, Dickinson College.
- Rice GW. Why did Wellington suffer nearly double the death rate of Christchurch in the 1918 influenza pandemic?, in In: The 2018 Jim Gardner Memorial Lecture. 2018, Canterbury History Foundation: Christchurch, New Zealand.
- Rice GW. Christchurch in the 1918 Influenza Epidemic: a preliminary study. NZJH., 1979; 13(2):109–131.
- Bryder L. “Lessons” of the 1918 influenza epidemic in Auckland. NZ J History. 1982; 16(2):97–121.
- Bryder L. The 1918 Influenza Epidemic in Auckland. 1980, University of Auckland.
- Bulling GM. Preventable deaths?: the 1918 influenza pandemic in Nightcaps. 1991, University of Otago, Dunedin, New Zealand.
- Jamieson JPS. Notes of the recent epidemic of Influenza in Nelson. N Z Med J. 1919; 18:46–51.
- Rice G. Crisis in a country town: the 1918 epidemic in Temuka. Historical News. 1985; 51:7–13.
- Lovell Gregg J. How Coromandel kept the Influenza Epidemic at bay. N Z Med J. 1919; 18:51–53.
- Rice G. Australia and New Zealand in the 1918–19 influenza pandemic. Occas Pap Med Hist Aust. 1990; 4:67–74.
- Rice GW. Japan and New Zealand in the 1918 influenza pandemic: comparative perspectives on official responses and crisis management, in The Spanish Influenza Pandemic of 1918–19., H. Phillips and D. Killingray, Editors. 2003, Routledge: Taylor and Francis Group: London and New York.
- Richardson GM. The onset of pneumonic influenza in 1918 in relation to the wartime use of mustard gas. N Z Med J. 1948; 47(257):4–16.
- Brundage JF, Shanks GD. What really happened during the 1918 Influenza Pandemic? The importance of Bacterial Secondary Infections. J Infect Dis. 2007; 196(11):1717–1718.
http://www.nzetc.org/tm/scholarly/name-140805.html - Carbery ARD. The New Zealand Medical Service in the Great War, 1914–1918. 1924; Available from:
- Wilson N, Summers J, Baker MG. Impact of the 1918–19 influenza pandemic on the New Zealand Military and persisting lessons for pandemic control. Microbiol Aust., 2014; 35(3):138–140.
- Wilson N, Summers J, Baker M, Rice G. A bizarre case of drowning as a result of pandemic influenza (1918 pandemic). N Z Med J. 2009; 122(1302).
- McLane JR. Setting a Barricade Against the East Wind: Western Polynesia and the 1918 Influenza Pandemic. 2012, University of Otago, Dunedin, New Zealand.
- McLeod MA. Baker M, Wilson N, et al. Protective Effect of Maritime Quarantine in South Pacific Jurisdictions, 1918–19 Influenza Pandemic. Emerg Infect Dis. 2008; 14(3):468–470.
- Elliot G, Wilson T, Sefton Moorhouse WH. H-31c SAMOAN EPIDEMIC COMMISSION (REPORT OF) APPENDIX TO THE JOURNALS OF THE HOUSE OF REPRESENTATIVES, 1 JANUARY 1919. 1919, Wellington, New Zealand.
- Wilson N, Ferguson C, Rice G, et al. Remembering the 1918 influenza pandemic: national survey of memorials and scope for enhancing educational value around pandemic preparedness. N Z Med J. 2017; 130(1465):53–70.
- Edwards V. Pestilence from abroad? The 1918 influenza epidemic. N Z Med J. 1986; 99(812):809–812.
- Bradshaw W, Learning the lessons of the 1918 Spanish influenza epidemic. Nurs N Z., 2005; 11(10):22–23.
- Roddick JA. Delirium and fever in the antipodes: Nursing and the 1918 influenza epidemic in Dunedin Hospital, New Zealand. J Res Nurs. 2006; 11(4):357–370.
- Wood PJ, Managing boundaries between professional and lay nursing following the influenza pandemic, 1918–1919: insights for professional resilience today? J Clin Nurs. 2017; 26(5–6):805–812.
- Roddick JA. When the Flag Flew at Half Mast: Nursing and the 1918 Influenza Epidemic in Dunedin. 2005, Otago Polytechnic, Dunedin, New Zealand.
- Rice GW. The making of New Zealand’s 1920 Health Act. N Z Med J. 1988; 22(1):3–22.
- Fitchett F, Bowie JT, Champtaloup ST, Drennan AM. A Report on the recent “Influenza Epidemic” in Dunedin, New Zealand. N Z Med J. 1919; 18.
- Archives New Zealand, Books of Active Service Casualty Forms, New Zealand Expeditionary Force 1914–1918, in Agency: AABK Series: 519. 1914–1918.
- NZ Government, The Great War, 1914–1918 : New Zealand Expeditionary Force Roll of Honour. 1924, Government Printer: Wellington.
- New Zealand Department of Statistics, The New Zealand Official Yearbook. 1924, Wellington: Eyre and Spottiswoode.
- New Zealand Department of Statistics, The New Zealand Official Yearbook. 1920, Wellington: Eyre and Spottiswoode.
- Killick E, Financing the Influenza Epidemic. Journal of the Department of Public Health, Hospitals, and Charitable Aid. 1919. 2:6–12.
- Mamelund SE. A socially neutral disease? Individual social class, household wealth and mortality from Spanish influenza in two socially contrasting parishes in Kristiania 1918–19. Soc Sci Med. 2006; 62:923–940.
- Bengtsson T, Dribe M, Eriksson B. Social class and excess mortality in Sweden during the 1918 influenza pandemic. Am J Epidemiol. 2018.
- Grantz KH, Rane MS, Salje H, et al. Disparities in influenza mortality and transmission related to sociodemographic factors within Chicago in the pandemic of 1918. Proc Natl Acad Sci U S A. 2016; 113(48):13839–13844.
- Wilson N. Clement C, Boyd M, et al. The long history of health inequality in New Zealand: occupational class and lifespan in the late 1800s and early 1900s. Aust N Z J Public Health. 2018; 42:175–179.
- Markel H, Lipman HB, Navarro JA, et al. Nonpharmaceutical interventions implemented by US cities during the 1918–1919 influenza pandemic. JAMA. 2007; 298(6):644–654.
- Bloom-Feshbach K, Simonsen L, Viboud C, et al. Natality decline and miscarriages associated with the 1918 influenza pandemic: the Scandinavian and United States experiences. J Infect Dis. 2011; 204(8):1157–64.
- Chandra S, Yu YL. Fertility Decline and the 1918 Influenza Pandemic in Taiwan. Biodemography Soc Biol. 2015; 61(3):266–72.
- Chandra S, Sarathchandra D. The influenza pandemic of 1918–1919 in Sri Lanka: its demographic cost, timing, and propagation. Influenza Other Respir Viruses. 2014; 8(3):267–73.
- Yuen CY, Tarrant M. A comprehensive review of influenza and influenza vaccination during pregnancy. J Perinat Neonatal Nurs. 2014; 28(4):261–70.
- Dow DA. Safeguarding the Public Health: A History of the New Zealand Department of Health. 1995, Wellington: Victoria University Press.
- Boyd M, Baker MG, Mansoor OD, et al. Protecting an island nation from extreme pandemic threats: Proof-of-concept around border closure as an intervention. PLoS One. 2017; 12(6):e0178732.
- Boyd M, Mansoor OD, Baker MG, Wilson N. Economic evaluation of border closure for a generic severe pandemic threat using New Zealand Treasury methods. Aust N Z J Public Health. 2018.
http://www.archway.archives.govt.nz/ - Archives New Zealand. Archway Search Engine. 2012; Available from:
- Wellcome Library. The library at Wellcome Collection. 2017 [cited 2017 November].
- Moher D, Liberati A, Tetzlaff J, et al. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med. 2009. 6(7):e1000097.
Contact diana@nzma.org.nz
for the PDF of this article
New Zealand s experience of the 1918 19 influenza pandemic: a systematic review after 100 years
Subscriber Content
The full contents of this pages only available to subscribers.
Login, subscribe or email nzmj@nzma.org.nz to purchase this article.
