Time from Illness Onset to Death, 1918 Influenza and Pneumococcal Pneumonia

mission within families with children: incidence of symptomatic and asymptomatic infections.tion of adenovirus in clinical specimens by polymerase chain reaction and liquid-phase hybridization quantitated by time-resolved fl uorometry. al. Presence of specifi c viruses in the middle ear fl uids and respiratory secretions of young children with acute otitis media.manske RF Jr, Gern JE. Serial viral infections in infants with recurrent respiratory illnesses. To the Editor: Brundage and Shanks (1) have studied time to death from the onset of infl uenza symptoms during the 1918 pandemic in military and civilian populations and found a median time to death of 7–11 days. They argue that these data support the idea that the deaths may be predominantly due to bacterial superinfection after the acute phase of infl uenza. We observed a similar 10-day median time to death among soldiers dying of infl u-enza in 1918 (2), a fi nding consistent with the time to death for a bacterial superinfection, specifi cally pneumo-coccal bacteremic pneumonia (3). The major bacterial pathogen associated with infl uenza-related pneumonia in 1918 was Streptococ-cus pneumoniae (1,3). Neither anti-microbial drugs nor serum therapy was available for treatment in 1918. To further analyze the time course of death from infl uenza in relation to that of pneumococcal pneumonia in 1918, we examined data collected by Tilgh-man and Finland (4) from the pre– antimicrobial drug era of the 1920s and 1930s. The Figure shows the distribution of time from onset of illness to death due to infl uenza-related pneumonia in 1918 compared with time to death due to untreated pneumococcal pneumonia in the 1920s and 1930s. The Figure indicates a close concordance of the times to death. Similar times to death do not prove the specifi c bacterial etiology of the 1918 deaths. However, pneumococcal bacteremia was associated with most of the pneumonia deaths reported by Tilghman and Finland (4), and most 1918 infl u-enza-related deaths were due to bacterial pneumonia (5). Also, up to 50% of patients dying from pneumonia in 1918 had pneumococcal bacteremia (3). These similar times to death provide additional evidence that the infl u-enza-related pneumonia deaths during the 1918 infl uenza pandemic were largely due to the pneumococcus.