At the end of 2018, we remember and respect Influenza, 100 years after the great pandemic

The Mother of All Pandemics
In the 1918-1919 calendar year, the world experienced the worst influenza pandemic in modern times. Coming on the heels of WWI, the H1N1 pandemic occurred in three waves – in the spring of 1918, fall 1918 and spring 1919. Estimates suggest that the pandemic infected a third of the world’s population, with 50 million people dying worldwide, including 675,000 Americans. Mortality was high at extremes of ages, but what sets this particular pandemic apart was the significant mortality (over half of all deaths) in young, healthy 20-40yr olds. Why such devastating morbidity and mortality? Perhaps a combination of war-ravaged, crowded conditions, malnourishment, inadequate healthcare resources (many doctors/nurses were deployed at war), and poor hygiene. In the early 20th century, there were no influenza vaccines to prevent flu or lessen its symptoms; no antivirals to help reduce transmission; no antibiotics to treat post-influenza bacterial pneumonia. The Smithsonian National Museum estimated that the total death toll of the 1918 pandemic outnumbered military deaths in both World War I and II. You can watch a video created by the CDC about the 1918 pandemic here. This avian-origin H1N1 pandemic has been called “The Mother of All Pandemics”, setting the stage for all of the subsequent epidemic and pandemic strains of influenza we have experienced.

After 1918: Influenza still deadly, though not as devastating
In 1957-1958 an H2N2 avian influenza virus caused a pandemic resulting in 1.1 million deaths worldwide including 116,000 Americans. 10 years later, another avian-based virus H3N2 triggered a similar sized pandemic with 1 million deaths worldwide and 100,000 Americans. The H3N2 still circulates as a seasonal flu virus and is included in seasonal vaccines. The next major pandemic was triggered by a novel influenza A virus called H1N1pdm09 in 2009, originating in the United States. By this time, seasonal influenza vaccines had included H1N1 but this variant was completely different from the seasonal flu vaccine, resulting in an estimated over half million deaths worldwide and up to 18,000 Americans.

Today: There is still work to be done
Since 2009's pandemic, seasonal influenza is still prevalent, with an estimate of over 291,000-645,000 deaths from seasonal influenza worldwide. The highest mortality rates are in poorer, developing countries, with individuals at extremes of age being most vulnerable to death from seasonal influenza. We still do not have a universal influenza vaccine, though research is moving in that direction. The 2017-2018 influenza season brought a serious influenza epidemic, with 48.8 million illnesses, 959,000 hospitalizations and 79,400 deaths estimated in the United States alone. This week, the Infectious Diseases Society of America (IDSA) released updated guidelines for diagnosis, and management of seasonal influenza. In the guidelines, they recommend testing for influenza in upper respiratory specimens of high risk patients, when testing can reduce unnecessary additional testing/inappropriate antibiotics, or when testing can influence chemoprophylaxis for high-risk household contacts. Annual seasonal flu vaccination reduces the risk of influenza by 40-60% and is still recommended as the best way to mitigate the impact of seasonal influenza, but antiviral prophylaxis may be necessary in outbreaks or for certain at-risk populations. Other ways to prevent spread include hand hygiene, limiting contact with people who have influenza-like illness, and if you have such an illness yourself, STAY HOME. 

More than 166.6Million influenza vaccines have been distributed in the US as of December 20, 2018.The influenza vaccine may not always be a 100% match to all circulating strains, as we saw with last year's flu season.  This year’s vaccine contains an influenza A H1N1pdm09-like strain, an influenza A H3N2-like strain, and influenza B strains from the Victoria and Yamagata lineages. Updated this year, the Advisory Committee on Immunization Practices (ACIP) also recommends the live-attenuated influenza vaccine (FluMist); however, the American Academy of Pediatrics suggests this only be used if the alternative would be no flu shot at all. The CDC can explain the types of vaccines available and who should get them. 

Final thoughts about the flu 

Regardless of which vaccine is more appropriate, our ancestors would probably encourage us to just get ANY vaccine if it would help avoid recreating the influenza pandemic of 1918. There's still time - it's not too late so if you haven't gotten your flu shot, consider getting it today!

Final thoughts

This is my last post on Controversies. I’ve been writing online since 2000, first with residency and fellowship friends on qfever.com and then on various medical sites to pay off school debt and buy some non-futon furniture. In 2009, Dan and Mike were kind enough to invite me to join this blog and I’ve greatly enjoyed the camaraderie and experience. I could write a book about what I’ve learned and unlearned and the tremendous colleagues and science journalists that I’ve met.

Back in 2009, Mike, Dan and I were all at different institutions. For me, this blog was a place to try out ideas. I didn’t have any expectation to be perfect – only our families were reading. In fact, the blog name Dan/Mike selected was great – they acknowledged the imperfection of infection control science and that we needed a place to work through ideas, to be wrong - to fail. And I greatly appreciated the feedback on my posts. Failure is how we learn.

But in 2018, we three are all at Iowa and even though we’ve added tremendous new talent to the blog, we are still seen as an Iowa blog. Now, when I write deeply questioning posts about hand hygiene, I’m seen as writing with an institution behind me and I have to be more careful or safer. And it’s not just Iowa. As SHEA treasurer, I had to worry about how my posts would be viewed. I direct a VA HSR&D Center of Innovation and sometimes I worried about how my posts would reflect on the 70 people in our Center. I now have positions with ICPIC, the Decennial, and as ID Editor for JAMA Network Open. Too many filters, too much noise. 

Finally, it needs to be acknowledged that our readers and our field are amazingly generous. You have been incredibly forgiving when I’ve tried and failed. I'm incredibly grateful for your generosity.

I will miss this blog and our readers. Thank you. The title of my first post in 2009 was “The end of the beginning.” I think that’s right.

Eye Protection and Seasonal Influenza

At the last HICPAC meeting, Drs. Bryan Christensen and Ryan Fagan led an excellent discussion of the following question: should eye protection be included in droplet precautions for seasonal influenza and other respiratory viruses? 

Eye protection is one aspect of Standard Precautions, of course, to be used whenever there is a risk for splashes or sprays of blood and body fluids (BBF), or during aerosol-generating procedures. However, there is no recommendation for routine use of eye protection as part of Droplet Precautions—it’s an “unresolved issue”. 

Nonetheless, whenever CDC has had to issue interim guidance for new respiratory viral threats (SARS, MERS, novel influenza A viruses, etc.), they’ve included the routine use of eye protection. But seasonal influenza kills far more people annually than any of the novel threats, and there’s little reason to believe that seasonal flu strains can’t use the eye as a portal of entry (in addition to rarely causing direct ocular disease). The same applies to various of the other respiratory viruses (adeno, RSV, rhinovirus, hMPV, etc.). 

As is so often the case, we don’t have much published data to help answer this question: some work done in the 80’s suggested that eye protection was important for RSV transmission prevention, and Dr. Werner Bischoff demonstrated in an experimental system (air chamber into which live attenuated influenza vaccine virus was aerosolized) that the eyes could serve a portal of entry for influenza. So definitely wear goggles if Werner invites you to enter an airtight test chamber.

Anyway, thanks to Bryan and Ryan for their review (I will link to it when the transcript is out), and to HICPAC members for the lively discussion that followed…so what do you think? Does your center use eye protection routinely for droplet precautions for seasonal flu?