Assessing the 1918/19 Pandemic Influenza and Respiratory Tuberculosis Interaction in Malta: Operationalizing a Syndemic During a Crisis Event.

Studies have indicated that there was a disease interaction of pandemic influenza with respiratory tuberculosis (TB) in Malta, which could explain the heightened mortality recorded in young adults. We revisit the 1918/19 influenza and TB syndemic potential on the island of Malta. Borrowing from crisis studies that explore the harvesting effect, we used the method of assessing changes in pre-pandemic, pandemic, fallow, and post-pandemic mortality/life expectancy to reveal the syndemic experience. Pre-pandemic (1914-1917) life expectancy at birth was significantly higher, at 37.91 years, than during the pandemic (1918), when life expectancy dropped to 33.26 years (Z = 10.56, < 0.0001). Post-pandemic (1919) life expectancy rose to 43.49 years, which was an even longer life expectancy than pre-pandemic (Z = 17.61, < 0.0001). There were significant changes in TB mortality death rates during the four periods in those of reproductive age. Augmenting our framework for studies of syndemics involving short-term events, we proposed the identification of contributing, driving, and limiting factors. Underlying living conditions contributed to the syndemic. The exacerbation of housing conditions, the economy associated with the First World War, and meteorological measures-temperature, relative humidity, and rainfall-were driving factors. The early implementation of mitigation strategies, such as restrictions on mass gatherings, were limiting factors of the syndemic.