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Influenza: the lull before the storm

Submitted by on 30 Nov 2010 – 16:44

The influenza 'A' (H1N1) has therefore been incorporated into the yearly seasonal vaccine.

Professor John Oxford highlights the lessons learnt from the 2009 global outbreak of Swine flu

Paradoxically, but also fortunately, preparations for the influenza 2009 ‘A’ Swine (H1N1) outbreak began long ago in 1997. In that year, it became apparent that an avian influenza virus, designated H5N1, had jumped the species barrier from chickens to humans.

By 1997 it had finally become clear that influenza ‘A’ was a truly avian virus and that the irregular global pandemics of 1845, 1889, 1918, 1957 and 1968 could therefore be explained by such viruses being able to jump across the boundary of the bird reservoir. But until 1997 the domesticated pig remained at centre of our virology focus.

The events in 1997 in Hong Kong catalysed a huge international effort to prepare for a future influenza pandemic. In the past, we humans had just waited and taken the influenza attacks as best we could. From 1997 onwards, a new, more strategic, ‘manner of thinking’ can be identified: prepare a three zone, in-depth defence system and then venture out and destroy the vehicles of avian influenza, namely (at that stage) domestic birds. Anti-virals and vaccines would be stockpiled as two defence zones and improved hygiene measures would be promoted as the third. In short, the world had a war plan. Indeed, these battle plans began to be refined not only in governments but in businesses and homes across the world. In Europe the EU formulated its own specific pandemic plan. These plans, spearheaded by WHO and the UN, were to prove critical in March 2009 and thereafter.

So the first lesson that can be drawn from the 2009 pandemic is the absolute need for prior planning; for our 2009 efforts, we can award ourselves a B+. But not all sovereign countries reacted in this way. At least three EU nations were not bothered and did virtually nothing until the new pandemic H1N1 virus arrived at their doorstep. Fortunately, for the first year of this pandemic they escaped lightly.

The history of influenza shows us that newly emerging influenza viruses strike unpredictably. The second lesson we can draw, therefore, is that the unpredictability of influenza needs to be taken to heart.

The influenza ‘A’ (H1N1) has therefore been incorporated into the yearly seasonal vaccine. I have just been vaccinated myself and the vaccine will protect me not only against the H1N1 from now onwards, but also from the epidemic influenza A (H3N2) virus.

The third lesson from the (H1N1) outbreak is that it is not over. At present, we are still calculating the social and medical impact of the 2009 pandemic. So far, the 16,000 laboratory confirmed deaths equate to 2 million years-of-life lost. But the first analyses show us that our interventions, social distancing, hygiene, anti-virals and vaccines reduced levels of mortality and hospitalisation by at least 50%. As in previous global outbreaks, last year nurses and doctors were kept on the front line and were some of the first to fall sick and die; in intensive care units around the world, highly trained specialists saved countless lives. So perhaps somewhat unexpectedly for some, lesson three is not to assume that it is all over. Rather, we should already be preparing for this H1N1 virus to mutate and enable itself to move into the over 60+ year groups, perhaps as early as next year. Most importantly we should already begin to plan for the second pandemic of our new century and I would place two viruses on the risk register, H5N1 and N2N2.

The fourth and final lesson is sobering. There is a growing anti-science chorus objecting to, for example, Genetically Modified foods, to vaccines, to disinfectants, and to evolutionary theories especially in the USA but also in Northern Europe. This retrograde movement sees the world through starry eyes and asks why they need to vaccinate their children to protect them against diphtheria and/or polio when the incidence or these infections, at least in their own country, has dropped. We know, however, that with 93 million EU citizens vaccinated to date without serous side effects, the protective effect of the influenza H1N1 vaccine exceeded 95%.

So, based on the experience of the 2009 Swine flu outbreak, we can conclude that for the future, we must learn to be even more pro-active – improving on our previous good efforts – continue to prepare for the next pandemic and not allow fringe anti-groups to dominate the airways, twitter, blogs and chat rooms. Infectious diseases do ‘not go gentle into that good night’. Smallpox had to be forced off the planet, in spite of protests from religious groups that God’s word was being thwarted. Polio could be forced out this year; but with 6 billion of us on the planet, all our efforts against pandemic and epidemic microbes will need to be harnessed, now and forever.

John Oxford is Professor of Virology at Barts and The Royal London Hospital