COVID-19 and the Liverpool influenza epidemic of 1950 (2024)

Since the coronavirus pandemic struck at the beginning of 2020, it has become commonplace tomake reference to the pandemic of influenza, commonly known as the Spanish flu, thatdevastated the world in 1918/19 with an estimated 50–100 million deaths worldwide.¹ Less attention has been paid to other major outbreaks of influenza and to theirperiodicity. An understanding of this issue could throw light on those ecological aspects ofaerosol-borne viruses. This could prove to be important as we emerge from the impacts ofCOVID-19 and anticipate what nature may have next in store for us.

One of the significant previous epidemics of influenza struck the city of Liverpool and itssurrounding region in the last week of 1950 and the early weeks of 1951. As described by DrAndrew Semple, the Deputy Medical Officer of Health for the City and Port of Liverpool, at thetime, in the annual Public Health Report for 1950 ‘ … although of short duration (it) was forthree consecutive weeks the cause of the highest weekly death roll, apart from aerialbombardment (during the Blitzkrieg by the German Luftwaffe in May 1941), in the city’s vitalstatistical records since the great cholera epidemic of 1849’.²

The virus responsible for the outbreak was identified as ‘Virus A prime type’, which had alsobeen associated with an outbreak on Tyneside some weeks earlier. A subsequent analysis of the‘Great Towns’ and standard regions of England and Wales showed that taking 23rd December asthe starting point in the epidemic reached its peak in week 4 in the Northern Region andLiverpool, where the death rate was twice as high as elsewhere.³

In the case of Liverpool the first intimation of the epidemic was pressure on generalpractice with unusually high consultation rates beginning just after Christmas and deaths forthe week ending 30th December reaching 301 compared to 229 during the same week of theprevious year. In the days before computers and with influenza not being a notifiable disease,Semple and his colleagues turned to all-cause mortality based on weekly sickness absencereturns from the Corporation’s own departments together with those of the Passenger TransportDepartment. He reported that in the week ending 6th January 1950 the total deaths at 658exceeded that during the worst week of the pandemic of 1918/19 and that the 1950 outbreakpeaked the following week with 894 deaths from all causes.

With strong resonance to the pandemic of 2020/21, the main difficulties identified by Semplein the handling of the emergency were the lack of accurate information, the pressure ongeneral practitioners and domiciliary carers, and the difficulty of gaining admission tohospital. It is especially notable even in the age of computers of how poor the flow ofinformation and intelligence proved to be concerning virus test results and even the numbersof COVID-19 deaths not least at weekends. It is salutary that in 1950/51 the threat posed by arespiratory virus to the residents of care homes for the elderly was clearly identified yet 70years later we colluded in the deaths of tens of thousands of our senior citizens by failingto safeguard them against the virus.

Faced with a later significant influenza outbreak in Liverpool in 1957, the Liverpool publichealth team extended its triangulation of data sources to include daily sickness rates from alocal football pools firm employing mostly women and a large mixed factory. Such imaginativeapproaches to practical action-orientated epidemiology with a provenance dating back toLiverpool’s first Medical Officer of Health, William Henry Duncan, lacked prominence in thenational response to COVID-19 in 2020.⁴ In his evidence to Edwin Chadwick’s Commission on The Sanitary Condition of theLabouring Classes in England in 1842, and in the absence of all but the most rudimentary vitalstatistics, Duncan collected school absence data that compared sickness absence rates betweenthe wealthy and the less salubrious neighbourhoods, an early example of inequalities in healthresearch.^5,6

At a meeting of the Section of Epidemiology and State Medicine of the Royal Society ofMedicine to consider the 1951 influenza epidemic, a discussion led by Dr WH Bradley identifiedthree phenomena which he argued should be considered as part of the background of any epidemicof influenza:

• The periodicity and incidence of the disease in past years

• The nadir of 1948

• The pathology³

Seventy years later we still understand little about the periodicity of these epidemic andpandemic waves such as to put us in a better place to anticipate and mitigate them. Ofconsiderable interest in the light of recent experience of a much-diminished incidence ofinfluenza resulting from the adoption of enhanced hygiene, mask wearing and social distancingover the last 12 months must be the very low incidence of influenza in 1948 that preceded the1950/51 epidemic. This should certainly put us on our guard as to what to expect in the nearfuture. Our catastrophic misreading of the pathology associated with the COVID-19 pandemicshould surely be a warning to the hubris with which we approach nature’s imaginativerepertoire; and as we face the prospect of new variants of COVID-19 travelling around theworld and testing all routes and ports of entry, even to island nations, the weak state ofPort Health compared with its standing in previous epidemics should alert us to how badly wehave neglected this fundamental pillar of public health.

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