World war I may have allowed the emergence of “Spanish” influenza.
Abstract
The 1918 influenza pandemic caused 40 million deaths, and so dwarfed in mortality and morbidity the preceding pandemic of 1889 and the 1957 and 1968 pandemics. In retrospect, much can be learnt about the source, the possible subterranean spread of virus, and the genetic basis of virulence. The World Health Organization has urged every nation to prepare a pandemic plan for the first global outbreak of the 21st century. We present an appraisal of epidemiological and mortality evidence of early outbreaks of respiratory disease in France and the UK in the years 1915 to 1917. Certain of these earlier focal outbreaks--called epidemic bronchitis rather than influenza--occurred during the winter months when influenza was known to be in circulation, and presented with a particular heliotrope cyanosis that was so prominent in the clinical diagnosis in the world pandemic outbreak of 1918-1919 (the Great Pandemic). The outbreaks in army camps at Etaples in France and Aldershot in the UK in 1916-1917 caused very high mortality in 25-35 year olds. Increased deaths from bronchopneumonia and influenza were also recorded in England. We deduce that early focal outbreaks of influenza-like disease occurred in Europe and on the balance of probability the Great Pandemic was not initiated in Spain in 1918 but in another European country in the winter of 1916 or 1917. We suggest that the pandemic had its origins on the Western Front, and that World War I was a contributor.
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At least 90% of lung tissue samples from 1918 pandemic post-mortems showed evidence of bacterial infection.
“Additional post-mortems of lung tissue suggest that at least 90% of samples showed evidence of bacterial infection (Oxford et al., 2002; Morens et al., 2008; Chien et al., 2009).”
From Secondary bacterial infections associated with influenza pandemics (2017) · cites this paper as Oxford et al., 2002
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Christophersen, O. A., & Haug, A. (2007) · Microbial Ecology in Health and Disease · doi:10.3402/mehd.v19i2.7666 · Cited by 9 · see citing works
Pan, H., Liu, J., Li, F., Wang, W., Huang, X., Li, H., Yang, X., & Chen, X. (2025) · Frontiers in Public Health · doi:10.3389/fpubh.2025.1662775 · Cited by 6 · see citing works
Anomalies of the 1919 influenza pandemic remain unexplained after 100 years
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Animal minds: The case for emotion, based on neuroscience
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The Curious Case of the Spanish Flu
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The Spanish flu pandemic in 1918 in Russia. Questions a hundred years later
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The 1918 influenza pandemic in Montevideo: The southernmost capital city in the Americas
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Why is the world so poorly prepared for a pandemic of hypervirulent avian influenza?
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Evolutionary Medicine IV. Evolution and Emergence of Novel Pathogens
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Why is the world so poorly prepared for a pandemic of hypervirulent avian influenza?
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Проблема бактериальных осложнений при респираторных вирусных инфекциях
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- Authors
- Oxford, J., Sefton, A., Jackson, R., Innes, W., Daniels, R., & Johnson, N.
- Affiliations
- University of London (GB)
- University of Cambridge (GB)
- ORCID
- Venue
- The Lancet Infectious Diseases
- Publisher
- Elsevier BV
- Published
- 2002-02
- Volume
- 2
- Issue
- 2
- Pages
- 111-114
- ISSN
- 1473-3099 (ISSN-L)
- OpenAlex
- W2164014373
- Cited by
- 139
- References
- 25
- Citations by year
- 2026: 2 · 2025: 4 · 2024: 3 · 2023: 3 · 2022: 7 · 2021: 19 · 2020: 8 · 2019: 6 · 2018: 11 · 2017: 3 · 2016: 3 · 2015: 3 · 2014: 8 · 2013: 4 · 2012: 2
- FWCI
- 3.02
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- The Lancet Infectious Diseases (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Epidemiology › Influenza Virus Research Studies
- Health Sciences › Medicine › Epidemiology › Respiratory viral infections research
- Social Sciences › Sociology and Political Science › Historical and modern epidemiology studies
- Keywords
- 1918 influenza pandemic, pandemic origins, World War I, military camps, Etaples, Aldershot, bronchopneumonia, influenza mortality, pandemic preparedness, viral virulence
- MeSH terms
- Disaster Planning, Disease Outbreaks, France, United Kingdom, Humans, Influenza, Human, Warfare, History, 20th Century
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
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