Download Influenza, not Ebola, More Likely the Cause of

Influenza, not Ebola, More
Likely the Cause of 430 BCE
Athenian Outbreak
TO THE EDITOR—Kazanjian [1] offers an
interesting argument that the Athenian
outbreak during the Peloponnesian war
in 430 BCE, described by Thucydides [2],
was caused by Ebola. However, as hypothesized by Langmuir et al [3, 4], the
Athenian outbreak is far more likely to
have resulted from an influenza pandemic, possibly associated with toxic shock
syndrome. Contemporaneous and subsequent observers of the 1918 pandemic
observed signs and symptoms similar to
those noted by Thucydides [5–7].
The Athenian pandemic caused deaths
among animals as well as humans, including, notably, “birds of prey,” which reportedly “disappeared” [2]. Although Ebola
may infect such animals as bats, primates,
and rodents, it has not thus far been linked
to large numbers of bird or other animal
deaths. Influenza, by contrast, is harbored
by and affects many animal species [8, 9].
The Athenian outbreak varied in severity over a period of 4 or 5 years [1, 3]. Influenza pandemics may likewise occur in
waves [9]. Kazanjian suggests that a multiyear Ebola outbreak is plausible, but to
date this does not seem to have occurred.
Although Ebola is associated with labored breathing, it does not, in contrast
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to the disease described by Thucydides,
seem to be typically associated with “hard
cough,” chest pain, sneezing, or hoarseness, which seem more characteristic of
respiratory infections [2, 10, 11]. Thucydides also commented that the year of the
Athenian outbreak was “unprecedentedly
free from sickness” [2]. So too did some
during the 1918 pandemic remark on
“the almost entire absence of any other
disease” [5]. “Everything was influenza,”
one physician wrote [5]. Clinical manifestations and sequelae of recent influenza pandemics, such as the 2009 H1N1
(swine) flu [12, 13], further strengthen
the hypothesis of Langmuir et al [3, 4].
Finally, just as those afflicted by Ebola
[10] and the 1918 influenza [14, 15] also
suffered from such comorbid conditions
as malaria and tuberculosis, so too was
the Athenian outbreak possibly aggravated by unrecognized chronic and acute
conditions affecting ancient Greece [16].
Many deaths were also probably attributable to poor sanitation, malnutrition,
poverty, and overcrowding, problems
only exacerbated by the war that was
Thucydides’ primary focus.
Note
Potential conflict of interest. Author certifies
no potential conflicts of interest.
The author has submitted the ICMJE Form
for Disclosure of Potential Conflicts of Interest.
Conflicts that the editors consider relevant to the
content of the manuscript have been disclosed.
Mitchell Berger
Public Health Advisor, Exton, Pennsylvania
References
1. Kazanjian P. Ebola in antiquity? Clin Infect
Dis 2015; 61:963–8.
2. Thucydides. The history of the Peloponnesian
War. Translated by Richard Crawley. Project
Gutenberg. Available at: http://www.gutenberg.
org/files/7142/7142-h/7142-h.htm. Accessed 31
July 2015.
3. Langmuir AD, Worthen TD, Solomon J,
Ray GC, Petersen E. The Thucydides syndrome: a new hypothesis for the cause of the
plague in Athens. NEJM 1985; 313:1027–30.
4. Langmuir AD, Ray CG. The Thucydides syndrome. JAMA 1987; 257:3071.
5. Myers SW. Clinical observations in a recent
epidemic of influenza. Boston Med Surg J
1919; 180:98–101.
6. Locke EA, Ronne GE, Lande H. The clinical
aspects of the recent influenza epidemic. Boston Med Surg J 1919; 180:124–35.
7. Ordway MD. Report of neurological sequelae
of influenza in the Boston city hospital neurological outpatient department from July,
1918 to July, 1919. Boston Med Surg J 1920;
182:194–200.
8. H1N1 Flu in Animals - Information, California Department of Public Health. Available
at: http://www.cdph.ca.gov/HEALTHINFO/
DISCOND/Pages/H1N1Animals.aspx. Accessed 31 July 2015.
9. Taubenberger J, Morens D. 1918 influenza:
the mother of all pandemics. Emerg Infect
Dis 2006; 12:15–22.
10. Barry M, Toure A, Traore FA, et al. Clinical predictors of mortality in patients with
Ebola virus disease. Clin Infect Dis 2015; 60:
1821–4.
11. Clark DV, Kibuuka H, Millard M, et al.
Long-term sequelae after Ebola virus disease in Bundibugyo, Uganda: a retrospective cohort study. Lancet Infect Dis 2015;
15:905–12.
12. Ekstrand JJ, Herbener A, Rawlings J, et al.
Heightened neurologic complications in children with pandemic H1N1 influenza. Ann
Neurol 2010; 68:762–6.
13. Writing Committee of the WHO Consultation on Clinical Aspects of Pandemic (H1N1)
2009 Influenza. Clinical aspects of pandemic
2009 influenza A (H1N1) virus infection. N
Engl J Med 2010; 362:1708–19.
14. Brabin BJ. Malaria’s contribution to World
War One—the unexpected adversary. Malar
J 2014; 13:497.
15. Oei W, Nishiura H. The relationship between
tuberculosis and influenza death during the
influenza (H1N1) Pandemic from 1918–19.
Comput Math Methods Med 2012; doi:10.
1155/2012/124861.
16. Kousoulis AA, Chatzigeorgiou KS, Danis K,
et al. Malaria in Laconia, Greece, then and
now: a 2500-year-old pattern. Int J Infect
Dis 2013; 17:e8–11.
Correspondence: Mitchell Berger, MPH, 203 Ravenwood Rd,
Exton, PA 19341 ([email protected]).
Clinical Infectious Diseases® 2015;61(9):1492–3
© The Author 2015. Published by Oxford University Press
on behalf of the Infectious Diseases Society of America. All
rights reserved. For Permissions, please e-mail: journals.
[email protected].
DOI: 10.1093/cid/civ604
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