1918 - a war, a movie, and a pandemic
People who claim to follow the science should probably try following the science.
In the midst of reading way too much about pneumonia, I ran across something interesting in one of the references. It’s a paper about the 1918-1919 influenza pandemic, which is generally believed to have caused millions (or tens of millions) of deaths worldwide.
It will probably not come as a shock to learn that we didn’t really do that many autopsies in 1918, but modern researchers have put some effort into trying to analyze the pandemic. The title of this particular paper contained something that really caught my eye.
Predominant Role of Bacterial Pneumonia as a Cause of Death in Pandemic Influenza: Implications for Pandemic Influenza Preparedness (Morens et al 20081)
Silly me, I had always assumed that the primary cause of death in an influenza pandemic was, well, the flu. It turns out we didn’t really know the specific causes of death in large influenza pandemics.
Despite the availability of published data on 4 pandemics that have occurred over the past 120 years, there is little modern information on the causes of death associated with influenza pandemics.
Yeah, that’s what I just said.
Right up front the authors tell us something fascinating (well, fascinating to me - morbid to others, I assume).
The majority of deaths in the 1918–1919 influenza pandemic likely resulted directly from secondary bacterial pneumonia caused by common upper respiratory–tract bacteria. Less substantial data from the subsequent 1957 and 1968 pandemics are consistent with these findings.
How did they figure this out? Time machine? Frozen heads? Please let it be frozen heads.
We reviewed hematoxylin and eosin–stained slides recut from blocks of lung tissue obtained during autopsy from 58 influenza fatalities in 1918–1919. These materials, sent during the pandemic from various United States military bases to the National Tissue Repository of the Armed Forces Institute of Pathology, represent all known influenza cases from this collection for which lung tissue is available.
The what? National Tissue Repository? Are we making a Frankenstein army? The more I learn, the more bringing back those German scientists after WWII is looking like a bad idea. So we had lung tissue on deposit, or whatever they call it, at The Repository and they made a few withdrawals for testing.
They tested the tissue samples and determined that although the influenza virus made people sick, most of them died from bacterial pneumonia. Remember this is before the discovery of penicillin and other antibiotics, so the most effective modern treatments for bacterial infections didn’t exist yet.
Although the cause of influenza was disputed in 1918, there was almost universal agreement among experts that deaths were virtually never caused by the unidentified etiologic agent itself, but resulted directly from severe secondary pneumonia caused by well-known bacterial “pneumopathogens” that colonized the upper respiratory tract (predominantly pneumococci, streptococci, and staphylococci).
That means even at the time, the experts agreed that although they didn’t know what was causing the primary infection (the influenza virus wasn’t isolated until 19332), the secondary bacterial pneumonia was really the thing driving the fatalities.
Without this secondary bacterial pneumonia, experts generally believed that most patients would have recovered.
From this I am going to infer that if we had those previously mentioned antibiotics, the death count would have been much lower. The authors agree:
Staphylococcus aureus, a relatively minor cause of the 1918 fatalities, was predominant in the culture results from 1957–1958, and negative lung tissue cultures were more common, possibly as a result of the widespread administration of antibiotics.
Bacterial pneumonia is probably the primary cause of death for pandemic influenza viruses in general.
We believe that the weight of 90 years of evidence (table 3), including the exceptional but largely forgotten work of an earlier generation of pathologists, indicates that the vast majority of pulmonary deaths from pandemic influenza viruses have resulted from poorly understood interactions between the infecting virus and secondary infections due to bacteria that colonize the upper respiratory tract.
And… the “next pandemic” caused by a virus will probably be similar.
If the next pandemic is caused by a human-adapted virus similar to those recognized since 1918, we believe the infection is likely to behave as it has in past pandemics, precipitating severe disease associated with prevalent colonizing bacteria.
And the authors have some recommendations for us. We need to be prepared, with antibiotics and other treatments, and be sure to treat the secondary infections.
Recent reviews have discussed the importance of new and improved influenza antiviral drugs and influenza vaccines in controlling a pandemic. The present work leads us to conclude that in addition to these critical efforts, prevention, diagnosis, prophylaxis, and treatment of bacterial pneumonia, as well as the stockpiling of antibiotics and bacterial vaccines, should be among the highest priorities in pandemic planning.
So among the “highest priorities” they include antibiotics and bacterial vaccines for known bacterial infections, since these infections might be the real cause of death for many people.
This sounds like some advice that would be extremely useful if there were another pandemic, say in 2020, involving some kind of new virus. It could make an enormous difference in how we care for patients, and maybe aggressively treating those secondary infections could have a big impact on deaths, even without the availability of vaccines for this novel virus.
[For example, some of the “alternative” treatment plans for the current pandemic have included more than just Ivermectin and/or monoclonal antibodies. They also often include an antibiotic like doxycycline, which is commonly prescribed for pneumococcal pneumonia.3]
It’s a shame that these authors don’t get interviewed by reporters, or aren’t people who occupy positions in government health agencies where they could use this knowledge to help guide clinical responses to a new pandemic.
But unfortunately I’ve never even heard of the first two authors, and the third is apparently some kind of useless little troll.
The authors of this paper?
David M. Morens, Jeffrey K. Tautenberger, and Anthony S. Fauci
Morens DM, Taubenberger JK, Fauci AS. Predominant role of bacterial pneumonia as a cause of death in pandemic influenza: implications for pandemic influenza preparedness. J Infect Dis 2008; 198:962–70.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2599911/
J. Flint, V.R. Racaniello, G.F. Rall, A.M. Skalka. Principles of Virology, Fourth Edition, Bundle. American Society of Microbiology (2015). doi:10.1128/9781555819521. ISBN 978-1-55581-952-1.
Caballero J, Rello J. Combination antibiotic therapy for community-acquired pneumonia. Ann Intensive Care. 2011;1:48. Published 2011 Nov 23. doi:10.1186/2110-5820-1-48.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3248869/