Abstract
Tuberculosis (TB) mortality declined after the 1918 pandemic, suggesting that influenza killed those who would have died from TB. Few studies have analyzed TB as a direct risk factor for 1918 influenza morbidity and mortality by age and sex. We study the impacts of TB on influenza-like illness (% of population sick) and case fatality (% of cases dying) by age and sex through case-control comparisons of patients (N = 201) and employees (N = 97) from two Norwegian sanatoriums. Female patients, patients at Landeskogen sanatorium, and patients aged 10–39 years had significantly lower morbidity than the controls. None of the 62 sick employees died, while 15 of 84 sick patients did. The case-control difference in case fatality by sex was only significant for females at Lyster sanatorium and females at both sanatoriums combined. Non-significant case-control differences in case fatality for males were likely due to small samples. Patients 20–29 years for both sexes combined at Lyster sanatorium and at both sanatoriums combined, as well as females 20–29 years for both sanatoriums combined, had significantly higher case fatality. We conclude that TB was associated with higher case fatality, but morbidity was lower for patients than for employees. The results add to the study of interactions between bacterial and viral diseases and are relevant in preparing for pandemics in TB endemic areas.
Highlights
Killing an estimated 50–100 million people worldwide, the 1918 pandemic has long been recognized as a syndemic, in which synergistic conditions, such as co-infection with bacterial pathogens, exacerbate outcomes, within the context of social inequalities and chronic stresses [1,2,3,4]
We use published aggregate-level data on cases of influenza-like illness (ILI) and ILI deaths by age and sex from patients and employees at Lyster and Landeskogen TB sanatoriums in Norway in the fall of 1918
The analyses presented here add to the literature base of the 1918 influenza pandemic by comparing morbidity and case fatality data at two sanatoriums in Norway, considering patients and staff controls as well as age and sex subgroups
Summary
Killing an estimated 50–100 million people worldwide, the 1918 pandemic has long been recognized as a syndemic, in which synergistic conditions, such as co-infection with bacterial pathogens, exacerbate outcomes, within the context of social inequalities and chronic stresses [1,2,3,4]. A chronic, slow bacterial disease, TB can damage lung tissue, creating additional surfaces for other respiratory pathogens to attach, and impair recovery and the immune system [6,7,8,9,10]. Other studies have produced mixed results, ; for example, de Paus et al [15] did not find a correlation between the presence of influenza A antibodies and the development of TB, antibody titers were enhanced, suggesting recent infection
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