Preparing for the Flu Season

Influenza: Tips from the World Health Organisation

As summer speeds past with the current heat wave which we are enjoying for albeit a short period of time, we will soon be approaching winter and the flu season. Our Flu Update on 12 August 2020 will focus on updating your knowledge and skills on the influenza virus and the 2020 vaccination programme.

Immunization is important as Influenza is a contagious, acute respiratory illness caused by influenza viruses. There are 4 types of seasonal influenza viruses, types A, B, C and D. Influenza A and B viruses circulate and cause seasonal epidemics of disease.

• Influenza A viruses are divided into subtypes according to the specific variety and combinations of two proteins that occur on the surface of the virus, the hemagglutinin or “H” protein and the neuraminidase or “N” protein. Currently, influenza A(H1N1) and A(H3N2) are the circulating seasonal influenza A virus subtypes. This seasonal A(H1N1) virus is the same virus that caused the 2009 influenza pandemic, as it is now circulating seasonally.
• Influenza B viruses are not classified into subtypes, but can be broken down into lineages. Currently circulating influenza type B viruses belong to either B/Yamagata or B/Victoria lineage. They are named after the after the areas where they were first identified, Victoria lineage and Yamagata lineage
• Influenza C virus is detected less frequently and usually causes mild infections, thus does not present public health importance.
• Influenza D viruses primarily affect cattle and are not known to infect or cause illness in people.

Influenza Virus and Animal Transmission

Influenza viruses can infect humans and other animals. Viruses that infect humans circulate in seasonal epidemics, although some tropical regions experience endemic influenza circulation. Influenza viruses are continuously changing, necessitating annual updates of influenza vaccine formulations. Occasionally, animal influenza viruses may also infect humans. These infections can manifest in a broad range of clinical symptoms from mild disease to death. If new or adapted influenza viruses cause disease in humans, and if they can be efficiently transmitted from person to person, then an influenza pandemic may occur. Pandemics are characterized by the rapid dissemination of a new, virulent influenza A viruses to which there is little or no existing immunity within the population. There have been four influenza pandemics since 1900, with the most recent pandemic occurring in 2009 caused by a new influenza A (H1N1) virus. Animal influenza viruses, including influenza A (H5N1) and influenza A (H7N9) have occasionally caused illness in humans. There is limited incidences of efficient human-to-human transmission of these virusesHumans can also be infected with influenza viruses that are routinely circulating in animals, such as avian influenza virus subtypes A(H5N1) and A(H9N2) and swine influenza virus subtypes A(H1N1) and (H3N2). Other species including horses and dogs also have their own varieties of influenza viruses. Even though these viruses may be named as the same subtype as viruses found in humans, all of these animal viruses are distinct from human influenza viruses and do not easily transmit between humans. Some may occasionally infect humans, however, and may cause disease ranging from mild conjunctivitis to severe pneumonia and even death. Usually these human infections of zoonotic influenza are acquired through direct contact with infected animals or contaminated environments, and do not spread very far among humans. If such a virus acquired the capacity to spread easily among people either through adaptation or acquisition of certain genes from human viruses, it could start an epidemic or a pandemic. Over the past decades, there have been multiple instances of sporadic transmission of influenza viruses between animals and humans

Signs and symptoms

Seasonal influenza is characterized by a sudden onset of fever, cough (usually dry), headache, muscle and joint pain, severe malaise (feeling unwell), sore throat and a runny nose. The cough can be severe and can last 2 or more weeks. Most people recover from fever and other symptoms within a week without requiring medical attention. But influenza can cause severe illness or death especially in people at high risk .

Illnesses range from mild to severe and even death. Hospitalization and death occur mainly among high risk groups. Worldwide, these annual epidemics are estimated to result in about 3 to 5 million cases of severe illness, and about 290 000 to 650 000 respiratory deaths. Interestingly, at present the incidence of influenza is lower than previous years, but it is still early days. The current COVID pandemic which ahs results in more stringent infection control, use of PPE, quarantine of infected individuals and shielding may potentially reduce the spread of the influenza virus. However, there is insufficient data on this at present.

In industrialized countries most deaths associated with influenza occur among people age 65 or older. Epidemics can result in high levels of worker/school absenteeism and productivity losses. Clinics and hospitals can be overwhelmed during peak illness periods.

The effects of seasonal influenza epidemics in developing countries are not fully known, but research estimates that 99% of deaths in children under 5 years of age with influenza related lower respiratory tract infections are found in developing countries.

Epidemiology

All age groups can be affected but there are groups that are more at risk than others.

• People at greater risk of severe disease or complications when infected are: pregnant women, children under 59 months, the elderly, individuals with chronic medical conditions (such as chronic cardiac, pulmonary, renal, metabolic, neurodevelopmental, liver or hematologic diseases) and individuals with immunosuppressive conditions (such as HIV/AIDS, receiving chemotherapy or steroids, or malignancy).
• Health care workers are at high risk acquiring influenza virus infection due to increased exposure to the patients and risk further spread particularly to vulnerable individuals.

In terms of transmission, seasonal influenza spreads easily, with rapid transmission in crowded areas including schools and nursing homes. When an infected person coughs or sneezes, droplets containing viruses (infectious droplets) are dispersed into the air and can spread up to one meter, and infect persons in close proximity who breathe these droplets in. The virus can also be spread by hands contaminated with influenza viruses. To prevent transmission, people should cover their mouth and nose with a tissue when coughing, and wash their hands regularly.

In temperate climates, seasonal epidemics occur mainly during winter, while in tropical regions, influenza may occur throughout the year, causing outbreaks more irregularly. 

The time from infection to illness, known as the incubation period, is about 2 days, but ranges from one to four days.

Diagnosis

The majority of cases of human influenza are clinically diagnosed. However, during periods of low influenza activity and outside of epidemics situations, the infection of other respiratory viruses e.g. rhinovirus, respiratory syncytial virus, parainfluenza and adenovirus can also present as Influenza-like Illness (ILI) which makes the clinical differentiation of influenza from other pathogens difficult. 

Collection of appropriate respiratory samples and the application of a laboratory diagnostic test is required to establish a definitive diagnosis. Proper collection, storage and transport of respiratory specimens is the essential first step for laboratory detection of influenza virus infections. Laboratory confirmation of influenza virus from throat, nasal and nasopharyngeal secretions or tracheal aspirate or washings is commonly performed using direct antigen detection, virus isolation, or detection of influenza-specific RNA by reverse transcriptase-polymerase chain reaction (RT-PCR).

Rapid influenza diagnostic tests (RIDTs) are used in clinical settings, but they have lower sensitivity compared to RT-PCR methods and their reliability depends largely on the conditions under which they are used. 

Treatment

Patients with uncomplicated seasonal influenza:

Patients that are not from a high risk group should be managed with symptomatic treatment and are advised, if symptomatic, to stay home in order to minimize the risk of infecting others in the community. Treatment focuses on relieving symptoms of influenza such as fever. Patients should monitor themselves to detect if their condition deteriorates and seek medical attention Patients that are known to be in a group at high risk for developing severe or complicated illness, (see above) should be treated with antivirals in addition to symptomatic treatment as soon as possible.

Patients with severe or progressive clinical illness associated with suspected or confirmed influenza virus infection (i.e. clinical syndromes of pneumonia, sepsis or exacerbation of chronic underling diseases) should be treated with antiviral drug as soon as possible.

• Neuraminidase inhibitors (i.e. oseltamivir) should be prescribed as soon as possible (ideally, within 48 hours following symptom onset) to maximize therapeutic benefits. Administration of the drug should also be considered in patients presenting later in the course of illness.
• Treatment is recommended for a minimum of 5 days, but can be extended until there is satisfactory clinical improvement.
• Corticosteroids should not be used routinely, unless indicated for other reasons (eg: asthma and other specific conditions); as it has been associated with prolonged viral clearance, immunosuppression leading to bacterial or fungal superinfection. 
• All currently circulating influenza viruses are resistant to adamantane antiviral drugs (such as amantadine and rimantadine), and these are therefore not recommended for monotherapy. 

Prevention

The most effective way to prevent the disease is vaccination. Safe and effective vaccines are available and have been used for more than 60 years. Immunity from vaccination wanes over time so annual vaccination is recommended to protect against influenza. Injected inactivated influenza vaccines are most commonly used throughout the world.

Among healthy adults, influenza vaccine provides protection, even when circulating viruses do not exactly match the vaccine viruses. However, among the elderly, influenza vaccination may be less effective in preventing illness but reduces severity of disease and incidence of complications and deaths. Vaccination is especially important for people at high risk of influenza complications, and for people who live with or care for the people at high risk.

WHO recommends annual vaccination for:

• pregnant women at any stage of pregnancy
• children aged between 6 months to 5 years
• elderly individuals (aged more than 65 years)
• individuals with chronic medical conditions
• health-care workers.

Influenza vaccine is most effective when circulating viruses are well-matched with viruses contained in vaccines. Due to the constant evolving nature of influenza viruses, the WHO Global Influenza Surveillance and Response System (GISRS) – a system of National Influenza Centres and WHO Collaborating Centres around the world – continuously monitors the influenza viruses circulating in humans and updates the composition of influenza vaccines twice a year.

For many years, WHO has updated its recommendation on the composition of the vaccine (trivalent) that targets the 3 most representative virus types in circulation (two subtypes of influenza A viruses and one influenza B virus). Starting with the 2013–2014 northern hemisphere influenza season, a 4th component is recommended to support quadrivalent vaccine development. Quadrivalent vaccines include a 2nd influenza B virus in addition to the viruses in trivalent vaccines, and are expected to provide wider protection against influenza B virus infections. A number of inactivated influenza vaccines and recombinant influenza vaccines are available in injectable form. Live attenuated influenza vaccine is available as a nasal spray.

Pre-exposure or post-exposure prophylaxis with antivirals is possible but depends on several factors e.g. individual factors, type of exposure, and risk associated with the exposure.

Apart from vaccination and antiviral treatment, the public health management includes personal protective measures like:

• Regular hand washing with proper drying of the hands
• Good respiratory hygiene – covering mouth and nose when coughing or sneezing, using tissues and disposing of them correctly
• Early self-isolation of those feeling unwell, feverish and having other symptoms of influenza
• Avoiding close contact with sick people
• Avoiding touching one’s eyes, nose or mouth

Influenza can cause mild to severe illness, and it may predispose to exacerbations of underlying disease or development of secondary bacterial infections. Some people are at risk for serious influenza complications, such as pregnant women, older people, young children, and people with certain chronic health conditions. Immunization is the best intervention to prevent influenza virus infection.

Our Next Flu Update is 21 November 2020.