Deaths from Bacterial Pneumonia
during 1918–19 Infl uenza Pandemic
John F. Brundage* and G. Dennis Shanks†
Deaths during the 1918–19 infl uenza pandemic have
been attributed to a hypervirulent infl uenza strain. Hence,
preparations for the next pandemic focus almost exclusively
on vaccine prevention and antiviral treatment for infections
with a novel infl uenza strain. However, we hypothesize that
infections with the pandemic strain generally caused self-lim-
ited (rarely fatal) illnesses that enabled colonizing strains of
bacteria to produce highly lethal pneumonias. This sequential-
infection hypothesis is consistent with characteristics of the
1918–19 pandemic, contemporaneous expert opinion, and
current knowledge regarding the pathophysiologic effects of
infl uenza viruses and their interactions with respiratory bac-
teria. This hypothesis suggests opportunities for prevention
and treatment during the next pandemic (e.g., with bacterial
vaccines and antimicrobial drugs), particularly if a pandemic
strain–specifi c vaccine is unavailable or inaccessible to iso-
lated, crowded, or medically underserved populations.
Emerging Infectious Diseases •
www.cdc.gov/eid • Vol. 14, No. 8, August 2008
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