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INFLUENZA A (H1N1) - WORLDWIDE (71): COMMENTS ON 1918 VIRUS (02)
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A ProMED-mail post

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International Society for Infectious Diseases


Date: Fri 19 Jun 2009
From: Julian Tang



Some follow-up comments on the question posed by
Dr Rau in the ProMED-mail post titled: Influenza
A (H1N1) - worldwide (67): comments on 1918
virus, archive number 20090618.2251.
-----------------------------------------------------
I think Dr Rau has raised a valid point, and one
that I have also commented on previously (1);
i.e., it is difficult to assess how accurate the
estimated number of deaths due to the 1918
influenza A(H1N1) virus can be -- especially
without any laboratory confirmation of the causal
agent. The influenza virus was only formally
discovered in 1933 by Smith and colleagues (2),
so before that it would have been difficult to
definitively relate the cause of death to this
unknown pathogen.

Mathematical modellers tend to argue that the
number of excess deaths in what we now know are
fairly predictable influenza seasons (at least in
temperate countries) are almost certainly due to
influenza. Admittedly this may be more true
nowadays because we can control the other causes
of death with clean water, effective sanitation,
modern medicine and vaccination programmes.
However, in 1918, many of these excess deaths
(the death certificates would hardly have been
very accurate at that time) may have been due to
other infectious agents such as TB, cholera,
typhoid (many of which may have gone undiagnosed
in the community and may have presented with
flu-like illness) and bacterial pneumonias. As
pointed out in several recent articles (3,4),
secondary bacterial infection may well have been
the direct cause of death during this 1918
pandemic -- particularly since penicillin was
also not available as a recognised antibiotic
then either. In fact, this also raised the more
philosophical question of exactly how do you
define the cause of death? In such cases,
influenza becomes just a contributing factor,
perhaps like any other lung condition that may
predispose to bacterial infection. So how
meaningful is the stated cause of death on any of
the death certificates during that time?

The oft cited paper on the Copenhagen data (5)
again suffers from the limitations noted above --
that no definitive diagnosis of influenza could
have been made in any of the cases at that time,
since the virus itself had not been discovered
yet. It's quite amazing how one study on the data
from the 1918 pandemic from one city has created
such concerns about the so-called 'lethal 2nd
wave', which may be totally irrelevant to the
modern society in which we now live, with modern
medicine (reducing case fatality rates -- when
widely accessible), influenza vaccination (which,
admittedly, still has a poor uptake rate), rapid
modern travel (perhaps most important, which may
disseminate the virus to multiple locations
worldwide providing rapid herd immunity -- as we
are seeing now with the new H1N1/2009 virus).

In fact, in their abstract, the authors of this
article actually state that the rapid spread of
the milder summer wave may have protected against
a higher mortality in the following fall wave.
So, if we are using the conclusions of this paper
to guide current public health policy with this
new influenza A(H1N1/2009) virus, to provide
greater protection against any potentially more
"lethal fall wave," it seems that we should allow
this current, relatively mild A(H1N1/2009)
influenza virus to disseminate as widely as
possible and not attempt to contain it at all
with isolation/quarantine or the widespread use
of oseltamivir (Tamiflu). But how likely are
governments and public health teams to follow
such a suggestion? Probably not very.
Conclusions
-----------
The Copenhagen summer wave may have been caused
by a precursor A/H1N1 pandemic virus that
transmitted efficiently but lacked extreme
virulence. The R measured in the summer wave is
likely a better approximation of transmissibility
in a fully susceptible population and is
substantially higher than that found in previous
USA studies. The summer wave may have provided
partial protection against the lethal fall wave".
(5)

Perhaps, some comment from the authors of this
paper would be useful to clarify things.

References
----------
(1) Tang JW. Pandemic influenza forecasting: does
past performance indicate future performance? Am
J Infect Control. 2008 Sep;36(7):466-7.
(2) Smith W, Andrewes CH, Laidlaw PP. A virus
obtained from influenza patients. Lancet 1933;
222: 66°V68.
(3) 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 Oct 1;198(7):962-70.
(4) Brundage JF, Shanks GD. Deaths from bacterial
pneumonia during 1918-19 influenza pandemic.
Emerg Infect Dis. 2008 Aug;14(8):1193-9.
(5) Andreasen V, Viboud C, Simonsen
L.Epidemiologic characterization of the 1918
influenza pandemic summer wave in Copenhagen:
implications for pandemic control strategies. J
Infect Dis. 2008 Jan 15;197(2):270-8.

--
Communicated by:
Dr Julian W Tang PhD, MRCP, FRCPath
Consultant/ Virologist
Division of Microbiology/Molecular Diagnostic Centre
Department of Laboratory Medicine
National University Hospital
5 Lower Kent Ridge Road
Singapore 119074



[Another relevant factor might be the therapeutic
interventions available at that time. See for
example: Aspirin in the 1918 pandemic, Tsunetoshi
Shimazu, British Medical Journal, 17 June 2009;
338 b2398
.
- Mod.CP]

[see also:
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Influenza A (H1N1) - worldwide (69): other viral infections 20090618.2254
Influenza A (H1N1) - worldwide (68): southern hemisphere 20090618.2253
Influenza A (H1N1) - worldwide (67): comments on 1918 virus 20090618.2251
Influenza A (H1N1) - worldwide (66): new strain,
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Influenza A (H1N1) - worldwide 20090430.1636
Influenza A (H1N1) "swine flu": worldwide (07),
update, pandemic 5 20090429.1622
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Influenza A (H1N1) virus, human - N America (02) 20090425.1557
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Acute respiratory disease - Mexico, swine virus susp 20090424.1546
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2008
----
Influenza A (H1N1) virus, swine, human - USA (TX) 20081125.3715
2007
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Influenza A (H2N3) virus, swine - USA 20071219.4079
Influenza, swine, human - USA (IA): November 2006 20070108.0077]
...................cp/ejp/lm

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