Bacterial Pneumonia Caused Most Deaths in 1918 Influenza Pandemic

[Hannah Bell]

http://www.nih.gov/news/health/aug2008/niaid-19.htm

Bacterial Pneumonia Caused Most Deaths in 1918 Influenza Pandemic
Implications for Future Pandemic Planning

The majority of deaths during the influenza pandemic of 1918-1919 were not caused by the influenza virus acting alone, report researchers from the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health. Instead, most victims succumbed to bacterial pneumonia following influenza virus infection. The pneumonia was caused when bacteria that normally inhabit the nose and throat invaded the lungs along a pathway created when the virus destroyed the cells that line the bronchial tubes and lungs.

A future influenza pandemic may unfold in a similar manner, say the NIAID authors, whose paper in the Oct. 1 issue of The Journal of Infectious Diseases is now available online. Therefore, the authors conclude, comprehensive pandemic preparations should include not only efforts to produce new or improved influenza vaccines and antiviral drugs but also provisions to stockpile antibiotics and bacterial vaccines as well.

[Fire_Medic_Dave]

1. One simple question.

Given the evidence, do you think that the pneumonia vaccine should be given to high risk individuals in conjunction with the flu vaccine?

David

[Hannah Bell]

2. I think your question has too many unexamined assumptions hiding

behind it.

[Fire_Medic_Dave]

3. Let's discuss them.

[Hannah Bell]

4. Your assumption seems to be: if flu vaccine doesn't prevent pneumonia,

then let's vaccinate for pneumonia.

From there, you can add more vaccinations - for different flu/bacterial strains - e.g. if this one doesn't cover everything, let's add another. Same with the 50-odd strains of hpv, & same with everything.

The focus, IMO, is wrong-headedly narrow. In the same way that, e.g., feedlots use antibiotics to reduce the "normal" but harmful effects of their commercial practices: like overcrowding, immobility, massive piles of shit, etc. & thus increased possibility of disease trasmission with reduced immunity (secondary to reduced mobility, abnormal diet, etc.).

My starting point wouldn't be anything to do with that particular question, it would be to look at the bigger picture first. In an ideal world, of course.

But in this world, only the well-off have this privilege.

[Fire_Medic_Dave]

5. Only the well off have what privilege?

The flu vaccine isn't intended to prevent pneumonia. The pneumonia vaccine is. Do you believe in using any vaccination to protect public health?

David

[Hannah Bell]

6. The flu vaccine is intended to prevent flu deaths. Most of which are due to

pneumonia. But we got a flu vaccine anyway. Because that's where the science was.

&, btw, the efficacy of the existant pneumonia vaccine is similarly debatable.

I think most of the childhood vaccines were merited, given conditions when they were developed. My criteria would be: large number of cases w/ high death/disability rate, relative ineffectiveness of preventative or mitigative measures, & ease of transmission by casual contact.

your incomprehension in reply to my post & exmple is one of the reasons i said the hidden assumptions load the question - & make discussion an exercise in misunderstanding.

[Hannah Bell]

7. Some info on how the well-off are able to arrange their lives to avoid risk:

"The researchers compared the death rates during the 1918-1920 period with those in the three years before and after the pandemic. This gave an estimate of "excess mortality" during the flu years, which was assumed to be caused directly or indirectly by the virus...The extra deaths ranged from 0.2 percent of the population in Denmark to 7.8 percent in the Central Provinces and Berar region of India -- a 39-fold difference.

In the United States, they ranged from a low of 0.25 percent in Wisconsin to 1 percent in Colorado. ...Flu death rates varied greatly over short distances. Virginia's excess mortality, 0.47 percent, was well below Maryland's, 0.72 percent. Sweden's (0.66 percent) was three times Denmark's (0.2 percent).

Murray and his colleagues analyzed the death patterns and deduced that about half the variation from region to region was explained by differences in per capita income. For every 10 percent increase in income, a person's risk of dying during the pandemic fell 10 percent."


The reasons for the relation of income & risk, though apparently somewhat mystifying to the Washington Post writer, are amply documented in the literature of epidemiology.

In terms of my feedlot example: the well-off can avoid factory-farmed beef without sacrificing other goods. The less well-off must "choose" - Walmart beef v no gas, for example.

Adding insult to injury, the well-off often presume to lecture the less well-off on their poor "choices," & relish the delicious frisson of moral superiority while consuming their grass-fed, free-range beef.

[cosmik debris]

8. I can't believe you would say such crazy shit as that.

The flu vaccine is intended to prevent flu deaths.

or this

The finding = no benefit from flu or pneumonia vaccination.

In fact, the flu vaccine was intended to prevent the occurrence of flu and to reduce the severity of the symptoms when it does occur. And it works very well in most cases.

The implication that it has no benefit unless it prevents death is just bat-shit crazy. It prevents an enormous amount of suffering, and that is a huge benefit to the individual as well as to society. When you pretend that the prevention of suffering is not a benefit, you come off as an incredibly callous individual.

[Hannah Bell]

21. pretty, pretty straw man. nice ad hom. gee you're cute.

[salvorhardin]

22. How is cosmik making a straw man argument?

He's neither exaggerating your claim or attributing to you a claim you never made. He's quoting you verbatim!

Nor is he arguing ad hominem. He is calling your claim bat-shit crazy, not you.

[HamdenRice]

23. What else does he have?

What else has space junk ever posted but ad hom and strawman. But if you want a breakdown, here goes:

"I can't believe you would say such crazy shit as that."

Of course it's not crazy. Her claims make perfect sense. Calling a perfectly rational argument "crazy shit" when it isn't is ad hom -- even if it's directed at the claim not the person. Non crazy people don't make bat shit crazy claims -- crazy people do. That's the implication.

"In fact, the flu vaccine was intended to prevent the occurrence of flu and to reduce the severity of the symptoms when it does occur. And it works very well in most cases."

Wrong. The flu vaccine has several intended benefits. But the fact that public health authorities recommend it primarily for the elderly, the very young and the immuno compromised shows that their main goal is to prevent mortality, not morbidity. If its main goal was to prevent morbidity, it would be recommended for all citizens, including the healthy.

"The implication that it has no benefit unless it prevents death is just bat-shit crazy."

She never implied that it has no benefits beyond prevention of death. That's strawman. She said suggested its main intended benefit is to prevent deaths.

"It prevents an enormous amount of suffering, and that is a huge benefit to the individual as well as to society. When you pretend that the prevention of suffering is not a benefit, you come off as an incredibly callous individual."

No one "pretends that the prevention of suffering is not a benefit." That's more stupid, idiotic strawman. "Incredibly callous individual" is ad hom considering that the poster in question was not in the first place "pretending" there were no other benefits.

[Hannah Bell]

25. thanks, more to the point than my response.

but regardless, i have the suspicion the poster will find fault with it.

[cosmik debris]

26. Sometimes I forget how nice it is to have a stalker

I know I can always count on you to show up and make me look good by comparison.

Thanks a million!

[Hannah Bell]

24. "The implication that it has no benefit unless it prevents death"

"is just bat-shit crazy. It prevents an enormous amount of suffering, and that is a huge benefit to the individual as well as to society. When you pretend that the prevention of suffering is not a benefit, you come off as an incredibly callous individual."


Check. Flu vaccination is all about "preventing suffering," but not death.

Obviously my claim that it's intended to prevent death is bat-shit crazy, & obviously by making it I'm asserting prevention of death is its only benefit & prevention of suffering has no benefit.
& obviously, these claims reflect on my character.

& obviously, the claimants are experts on logic, immunology & public health. or else, just assholes.

[HamdenRice]

27. No, sorry ...

My response was lame compared to this. Yours was a masterpiece of irony! This is a classic of showing just how stupid these strawman can get! I love the tactic of some of them saying that if you would like to see cost benefit analysis done, you want millions to die.

:rofl:

[Fire_Medic_Dave]

10. Your fundamental incomprehension of public health is what's on display.

The flu vaccine is intended to prepare the bodies immune system for exposure to the influenza virus. In most cases it prepares the immune system so well the vaccinated don't contract the flu and if they do the symptoms are much less severe. I personally gave over 300 flu shots last year. Not a single serious adverse affect. Our local health department gave out 10,000 flu shots free of charge. Instead of talking about that you are talking about beef. Your advanced degrees cannot be in any science field for you say the things you do.

David

[Hannah Bell]

20. got your number. enjoy yourself.

i don't have a science degree, but you have to ask someone what a confounder is. uh-huh.

[Fire_Medic_Dave]

29. Actually your credentials are impressive.

I would be very interested to learn more about your perspective on the correlations between poor nutrition and infectious disease. I still don't understand your big problem with the flu vaccine, it's cheap, effective and extremely safe. Again though it pays to be specific, I didn't ask what a confounder was.

David

[Hannah Bell]

32. are there 2 of you?

you just told me i had no science degree.

Let's see if I've got it right: paramedics, lab techs, nurses, medical physicists & drug reps have special expertise in immunology & vaccine research. This special expertise qualifies them to shut down anyone who ventures to differ with them, or who posts research with conclusions they don't like.

Only paramedics, techs, nurses, radiation & drug guys have the requisite, highly specialized background needed to deliver just the right quantities of snark & disdain to the "unqualified," while at the same time cluttering threads with nitpicks over word choice, argument ad hom, straw men, appeals to ridicule, false attribution, & other devices intended to insure that the topics will be unreadable.

Did I get it right? Okey-dokey.

[Fire_Medic_Dave]

34. It was a guess.

I just asked for your background. I do believe in nit picking over words, only because they matter. You dietitians seem to do a pretty good job at delivering just the right quantities of snark & disdain to the "unqualified," while at the same time cluttering threads with nitpicks over word choice, argument ad hom, straw men, appeals to ridicule, false attribution, & other devices intended to insure that the topics will be unreadable.

David

[Hannah Bell]

30. "Your advanced degrees cannot be in any science field"

Prereqs for admission to Master of Science Program, Human Nutrition

1. Undergraduate degree in human or animal nutrition or dietetics, or a related biological or social science.

Required course prerequisites:

6 credits in chemistry (inorganic and organic)
3 credits physiology
3 credits biochemistry
3 credits nutrition

Recommended course prerequisites for students wishing to specializing in certain areas of nutrition

science:
physics
calculus
analytical chemistry

Overall grade-point average of 3.00 (A=4.00) and a B average in nutrition and related sciences

Acceptable score (an average of the quantitative and verbal score above the 50th percentile) on the Graduate Record Examination (GRE). The Medical College Admission Test (MCAT) scores may be substituted for GREs.

Three letters of recommendation

[Fire_Medic_Dave]

31. As I said before your credentials are impressive.

Which is why I can't understand why you are so against the flu vaccine?

[Hannah Bell]

33. as you said before, according to you, i have no science degree.

you're an immunology expert, though.

subtlety is apparently unknown to you & your friends: either for or against, no middle ground. nothing but "god, i love vaccines!" is allowed to be discussed.

[Fire_Medic_Dave]

35. I never claimed to be a an expert at anything.

Some of your earlier posts seem to indicate you had no science degree. You posted your credentials I believe you. I'm still waiting to hear your position on the flu vaccine.

David

[Hannah Bell]

36. When you say things like: "Your fundamental incomprehension of public health is what's on display."

OR "Your advanced degrees cannot be in any science field for you say the things you do."

the implicit claim is that you have special, superior expertise. & ESP.


I don't have a position on flu vaccination. I haven't looked at enough of the evidence to have a "position". But I'm aware that the evidence of benefit & efficacy isn't so one-sided as some seem to think.


I dislike credentialism. I don't like it when someone makes a claim, & I make a counterargument, & rather than refute my argument politely, they say, "I have a DEGREE in this, therefore, you're wrong." Even worse when they say something like "You're obviously ignorant."

If I made what sounded like a dingbat claim on nutrition, i'd expect someone to challenge it politely. Either I could explain my reasoning to their satisfaction, or not, & if both parties stay polite, those sort of arguments can be fun & educational.

But I'd be ashamed if my first response was to flash my degree & call them a fool.

[Fire_Medic_Dave]

37. I disagree.

I don't think those phrases make any implicit or explicit claim. You say you don't have a position on the flu vaccine but you post negative stories without asking a single question. So instead of looking like someone who is objectively trying to learn more information about a topic you come across as a anti-vax nut.

David

[HamdenRice]

9. You're assuming that pneumonia is caused by one bacteria

It isn't. It is caused by any number of bacteria that can attack the lungs after they have been damaged by flu. It is therefore impractical to vaccinate against pneumonia.

[Fire_Medic_Dave]

11. You are assuming.

I have specifically stated different on various posts.

David

[HamdenRice]

12. The how can you vaccinate against an unknown bacterial agent?

If you acknowledge that pneumonia can be caused by many different strains of bacteria, how could a vaccine be created?

The pneumonia vaccine vaccinates only against pneumoccocus.

[Fire_Medic_Dave]

15. Streptococcus pneumoniae, "pneumococcus", is the most common bacterial cause of pneumonia.

That is in every age group except newborns. The pneumococcal polysaccharide vaccine (PPV)protects against 23 types of pneumococcal bacteria. I would think that vaccinating people against 23 different types of pneumococcal bacteria that are the most common cause of pneumonia would be the best course of action for the public health.

David

[HamdenRice]

17. "23 types of pneumococcal bacteria"

That makes sense -- like the MMR triple virus vaccine.

I wonder why there aren't more multiple antigen vaccines? Too much immune stress at once perhaps?

On my first trip to rural Africa I had to get maybe 7-10 vaccines. One, yellow fever vaccine, made me extremely, extremely sick for about 24 hours. They got successively easier because my immune system was really revved up.

On edit: meant to write "23"

[Fire_Medic_Dave]

18. There are more than 90 types of pnuemococcal bacterias.

The vaccine protect against 23 of the most common. Yellow fever is a bear of a vaccine, I didn't get sick but I got the Yellow Fever vaccine in one arm and the Typhoid vaccine in the other arm for a extremely short notice military deployment to a country in the middle east. I have never been so sore in my life.

David

[HamdenRice]

19. Yellow fever

I actually had not just pain but fever, sweating, cramps -- symptoms of a mild form of the disease.

I understand it's a hemorrhagic disease, like Ebola.

[Fire_Medic_Dave]

28. Doesn't sound like fun.

Where did you go in Africa? I had a buddy that ran a business importing stuff from Africa and just loved the country.

David

[Fire_Medic_Dave]

16. You seem woefully uninformed.

Streptococcus pneumoniae, often called "pneumococcus", is the most common bacterial cause of pneumonia in all age groups except newborn infants. The pneumococcal polysaccharide vaccine (PPV)protects against 23 types of pneumococcal bacteria. In regards to flu vaccination, you do realize that you are in disagreement with almost every epidemiologist and infection control specialist in the world. What is your problem with the flu and pneumonia vaccines anyway? They are incredibly safe and very effective.

David

[Hannah Bell]

45. you assume too much. for example, you assume because i posted studies

delimiting the efficacy of flu vaccine, i'm "against" it.

shouldn't jump to conclusions.

[Fire_Medic_Dave]

47. I know that now. You don't have a opinion on it.

You have said that. I understand that now.

David

[LeftishBrit]

13. Yes, but if they hadn't had the flu in the first place, they mostly wouldn't have got the other

infections.

'Therefore, the authors conclude, comprehensive pandemic preparations should include not only efforts to produce new or improved influenza vaccines and antiviral drugs but also provisions to stockpile antibiotics and bacterial vaccines as well.'

So the authors are not saying that one should not deal with the flu itself, but that one should deal with both that *and* possible bacterial infections. Both, not either/or.

By the way, far from being a fanatic for the flu vaccination, I usually don't get it myself, though that will change when there is a vaccine that protects you for several years at a time, rather than needing a new one each year. Also, of course, if there's a threatened pandemic or very nasty strain.

But I strongly believe that flu vaccine should be available for all who want it, even when there is no pandemic. I believe in choice - but that includes the choice to have the vaccine! And if it's not available, or not affordable to most people, then that is a mandate *not* to have it.

[HamdenRice]

14. "for several years at a time" -- is that possible?

My understanding is that the vaccine mutates a great deal every year. Apparently new strains develop in a different species host -- Asian farm ducks -- and then spread to humans.

Unless they can find some antigen common to all strains of flu, it seems that there will never be a multi year flu vaccine.

[Warpy]

38. What a very odd conclusion

Stories of the 1918 influenza tell of a virus that killed very quickly, not a virus that sickened people and went on a couple of days later to an overwhelming bacterial superinfection. It would have taken the bacteria at least 24 and more likely 72 hours to assert; the 1918 flu killed in a few hours.

There were too many stories of men who started out for work in the morning feeling well and who were dead by noon. Given the short duration of the period between "I don't feel so good" and dead, a fatal bacterial infection seems unlikely, although they would definitely find those bacteria in lung tissue.

This study must have been done by a Bush appointee.

Thanks for posting, though.

[Hannah Bell]

39. well, you may have something there, but:

"NIAID co-author and pathologist Jeffery Taubenberger, M.D., Ph.D., examined lung tissue samples from 58 soldiers who died of influenza at various U. S. military bases in 1918 and 1919...

...They also reviewed scientific and medical journals published in English, French and German, and located all papers reporting on autopsies conducted on influenza victims. From a pool of more than 2,000 publications that appeared between 1919 and 1929, the researchers identified 118 key autopsy series reports. In total, the autopsy series they reviewed represented 8,398 individual autopsies conducted in 15 countries.

The published reports "clearly and consistently implicated secondary bacterial pneumonia caused by common upper respiratory flora in most influenza fatalities," says Dr. Morens. Pathologists of the time, he adds, were nearly unanimous in the conviction that deaths were not caused directly by the then-unidentified influenza virus, but rather resulted from severe secondary pneumonia caused by various bacteria. Absent the secondary bacterial infections, many patients might have survived, experts at the time believed...."


http://en.wikipedia.org/wiki/Jeffery_Taubenberger

Jeffery K. Taubenberger is a US-virologist. Together with Ann Reid he was the first to sequence the genome of the influenza virus, which caused the 1918 pandemic of “Spanish flu”.

In 1988 he began a training to become a pathologist at the National Cancer Institute of the National Institutes of Health. In 1993 he was recruited to start a new lab at the Armed Forces Institute of Pathology (AFIP) in order to apply the then current molecular techniques to the Institute's pathology work. After a year he was promoted to chief of the Division of Molecular Pathology. This included a research lab, where he was free to pursue questions of basic science.

[Warpy]

40. Still, the paper also cites the viral pneumonia

that accompanied that particular flu as a major cause.

My guess is that the rapid deaths were all from the primary viral infection, while many of the prolonged deaths were from secondary infection.

Certainly, that flu would have been far less deadly with modern antivirals and antibiotics while a vaccine was being developed.

[Hannah Bell]

41. that would make sense; then the question would be the relative % of each type.

the paper says "most deaths" from bacterial infection.

In relation to which, this is interesting:

"The researchers compared the death rates during the 1918-1920 period with those in the three years before and after the pandemic. This gave an estimate of "excess mortality" during the flu years, which was assumed to be caused directly or indirectly by the virus...The extra deaths ranged from 0.2 percent of the population in Denmark to 7.8 percent in the Central Provinces and Berar region of India -- a 39-fold difference.

In the United States, they ranged from a low of 0.25 percent in Wisconsin to 1 percent in Colorado. ...Flu death rates varied greatly over short distances. Virginia's excess mortality, 0.47 percent, was well below Maryland's, 0.72 percent. Sweden's (0.66 percent) was three times Denmark's (0.2 percent).

Murray and his colleagues analyzed the death patterns and deduced that about half the variation from region to region was explained by differences in per capita income. For every 10 percent increase in income, a person's risk of dying during the pandemic fell 10 percent."


Which I imagine has to do with things like access to clean water, basic sanitation, & adequate nutrition.

[Fire_Medic_Dave]

43. Wow we agree on something.

Murray and his colleagues analyzed the death patterns and deduced that about half the variation from region to region was explained by differences in per capita income. For every 10 percent increase in income, a person's risk of dying during the pandemic fell 10 percent."


Which I imagine has to do with things like access to clean water, basic sanitation, & adequate nutrition.


Do you think putting a priority on high risk low income people getting greatest access to flu vaccines is a good idea?

David

[Hannah Bell]

44. what is the relation between your question & the quote?

[Fire_Medic_Dave]

46. Income.

[Hannah Bell]

48. and? you're suggesting flu vaccination for the malnourished should be subsidized?

[Fire_Medic_Dave]

49. It already is.

You wrote, "Murray and his colleagues analyzed the death patterns and deduced that about half the variation from region to region was explained by differences in per capita income. For every 10 percent increase in income, a person's risk of dying during the pandemic fell 10 percent."

It seems like targeting the high risk low income population for free vaccinations would be an effective strategy from a public health perspective. What is your opinion on that?

David

[Hannah Bell]

50. the article was about the worldwide pandemic 1917-1918.

where is it that free flu vaccine is given to the malnourished?

[Fire_Medic_Dave]

51. Our county health department gave out 10,000 doses last year.

I don't know why you keep bringing up the malnourished I'm talking about income levels. I made that clear. Are you going to answer the question.

David

[Hannah Bell]

52. well, because that was the implication of the original quote:

>>...excess mortality during the flu years...ranged from 0.2 percent of the population in Denmark to 7.8 percent in the Central Provinces and Berar region of India -- a 39-fold difference.

In the United States, they ranged from a low of 0.25 percent in Wisconsin to 1 percent in Colorado...

Murray and his colleagues analyzed the death patterns and deduced that about half the variation from region to region was explained by differences in per capita income. For every 10 percent increase in income, a person's risk of dying during the pandemic fell 10 percent."<<


"explained by differences in per capita income": this isn't personal income, but income of a nation or region, divided by # of inhabitants.


Not everyone makes the same assumptions you do.

Your question, I guess, is specific to the US. Do I think flu vaccine should be subsidized here? I already told you, I don't have a serious opinion about flu vaccine, as I haven't looked at enough of the background research.

The question of whether it should be subsidized would depend on potential benefit v. competing uses of the same public health dollars.

[Fire_Medic_Dave]

53. Ok then.

[HamdenRice]

42. It generally did not kill in hours. In fact its nickname was ...

Many years ago, I worked on a history project in Africa. I was interviewing elderly rural people, many of whom did not know the year they were born. So, I would get a general sense of their age by asking them about the 1918 epidemic, and in particular how old they thought they were during the epidemic, which ravaged rural South Africa.

The universal name for the 1918 flu, among rural South African blacks and whites, was "drie dag," "drie dae," or "drie dag siekte" which is Dutch/Afrikaans for "three days" or "three day sickness."

It turns out that this was its nickname in other parts of the world. The folk wisdom was that once you had symptoms, you either died in 3 days or were going to get better. A few weeks ago I had posted about this in LBN, suggesting that 3 days indicated a virus, but it seems clear from the study and your own calculations that pneumonia could kill in 3 days as well.