tag:theconversation.com,2011:/uk/topics/flu-series-2018-49222/articlesFlu series 2018 – The Conversation2019-09-27T11:19:33Ztag:theconversation.com,2011:article/1242572019-09-27T11:19:33Z2019-09-27T11:19:33ZWhy the flu shot cannot give you the flu (and why you should get one now)<figure><img src="https://images.theconversation.com/files/294411/original/file-20190926-51425-1vkgk69.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A nurse in Atlanta prepared the flu vaccine for a shot on Feb. 7, 2019. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Flu-Season/eb907f2c836c49318bb029d5a8fe5765/83/0">David Goldman/AP Photo</a></span></figcaption></figure><p>Flu vaccination prevents millions of flu-related illnesses and deaths annually, but <a href="https://www.cdc.gov/flu/fluvaxview/coverage-1718estimates.htm">vaccination rates</a> are low for many reasons. </p>
<p>During the 2018-2019 flu season, the Centers for Disease Control and Prevention reported that about <a href="https://www.cdc.gov/flu/fluvaxview/coverage-1819estimates.htm">45% of U.S. adults</a> received the flu vaccine. While this is an increase of 8% from 2017-2018, it falls way below the national <a href="https://www.healthypeople.gov/2020/topics-objectives/topic/immunization-and-infectious-diseases/objectives">goal of 70%</a> of American adults receiving a flu shot. </p>
<p>One of the <a href="https://www.cdc.gov/flu/prevent/misconceptions.htm">common myths</a> that leads people to avoid the flu shot is that they think the shot will give them the flu. But that is simply not true. The virus in the vaccine is not active, and an inactive virus cannot transmit disease. What is true is that you may feel the effects of your body mounting an immune response, but that does not mean you have the flu.</p>
<p>I am a nursing professor with <a href="https://scholar.google.com/citations?user=Pdh4gSgAAAAJ&hl=en&oi=ao">experience in public health promotion</a>, and I hear this and other myths often. Here are the facts and the explanations behind them.</p>
<h2>Inactive virus</h2>
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<img alt="" src="https://images.theconversation.com/files/294414/original/file-20190926-51414-3yhg7t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/294414/original/file-20190926-51414-3yhg7t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/294414/original/file-20190926-51414-3yhg7t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/294414/original/file-20190926-51414-3yhg7t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/294414/original/file-20190926-51414-3yhg7t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/294414/original/file-20190926-51414-3yhg7t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/294414/original/file-20190926-51414-3yhg7t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Kilian Daugherty, 1, being prepared for a chest X-ray in Thomaston, Ga., Feb. 9, 2019, because of flu symptoms.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Flu-Season/2c0ba619b0c7459ab46a3a3c42a41741/57/0">David Goldman/AP Photo</a></span>
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<p><a href="https://www.cdc.gov/flu/about/keyfacts.htm">Influenza</a>, or the flu, is a common but serious infectious respiratory disease that can result in hospitalization or even death. The CDC estimates that during a “good” flu season, approximately <a href="https://www.cdc.gov/flu/about/keyfacts.htm">8% of the U.S. population could get the flu</a>. That is roughly 26 million people. </p>
<p>Each year the flu season is different, and the flu virus also affects people differently. One dangerous complication of the flu is pneumonia, which can result when your body is working hard to fight the flu. This is particularly dangerous in older adults, young children, and those whose immune systems aren’t working well, such as those receiving chemotherapy or transplant recipients.</p>
<p><a href="https://www.cdc.gov/flu/about/burden/2017-2018.htm">Historically</a> millions of Americans get the flu each year, hundreds of thousands are hospitalized and tens of thousands of people die from flu-related complications. During the <a href="https://www.cdc.gov/flu/pandemic-resources/1918-commemoration/1918-pandemic-history.htm">1918 flu pandemic</a>, one-third of the world’s population, or about 500 million people, were infected with the flu. Since that time, vaccine science has dramatically changed the impact of infectious diseases. </p>
<p>The cornerstone of flu prevention is vaccination. The CDC <a href="https://www.cdc.gov/flu/prevent/keyfacts.htm">recommends</a> that everyone 6 months of age and older who does not have contraindications to the vaccine, receive the flu shot. </p>
<p>And just as the polio vaccine won’t give a child polio, the flu vaccine will not cause the flu. That’s because the flu vaccine is made with <a href="https://www.cdc.gov/flu/prevent/how-fluvaccine-made.htm">inactive strains of the flu virus</a>, which are not capable of causing the flu.</p>
<p>That said, some people may feel sick after they receive the flu shot which can lead to thinking they got sick from the shot. </p>
<p>However, feeling under the weather after a flu shot is actually a positive. It can be a sign that your body’s immune response is working. What happens is this: When you receive the flu shot, your body recognizes the inactive flu virus as a foreign invader. This is not dangerous; it causes your immune system to develop antibodies to attack the flu virus when exposed in the future. This natural immune response may cause some people to develop a low-grade fever, headache or overall muscle aches. These side effects can be mistaken for the flu but in reality are likely the body’s normal response to vaccination. </p>
<p>And the good news is these natural symptoms are short-term side effects compared to the flu, which can last much longer and is more severe. It is estimated that <a href="https://www.livescience.com/40279-flu-shot-information.html">less than 2%</a> of people who get a flu shot will develop a fever. </p>
<p>Also, people often confuse being sick with a bad cold or stomach flu with having influenza. Influenza symptoms can include a fever, chills, sore throat, runny or stuffy nose, body aches, fatigue and headaches. Cold symptoms can be similar to the flu but are typically milder. The stomach flu, or gastroenteritis, can be caused by several different bacteria or viruses. Symptoms of gastroenteritis involve nausea, vomiting and diarrhea. </p>
<h2>Pre-shot exposures and mismatches</h2>
<p>Some people do get the flu after they have received a flu shot, but that is not from the shot. It can happen for a couple of reasons. </p>
<p>[_<a href="https://theconversation.com/us/newsletters/science-editors-picks-71/?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=science-corona-important">The Conversation’s most important coronavirus headlines, weekly in a science newsletter</a>.]</p>
<p>First, they could have been <a href="https://www.cdc.gov/flu/prevent/keyfacts.htm">exposed to the flu</a> before they had the shot. It can take up to two weeks after receiving the flu shot to develop full immunity. Therefore, if you do get the flu within this period, it is likely that you were exposed to the flu either prior to being vaccinated or before your full immunity developed.</p>
<p>Second, depending on the strain of the flu virus that you are exposed to, you could still get the flu even if you received the vaccine. Every year, the flu vaccine is created to best match the strain of the flu virus circulating. Therefore, the effectiveness of the flu vaccine depends on the similarity between the virus circulating in the community and the killed viruses used to make the vaccine. </p>
<p>If there is a close match between the two, then the <a href="https://www.cdc.gov/flu/vaccines-work/vaccineeffect.htm">effectiveness of the flu vaccine</a> will be high. However, if there is not a close match, vaccine effectiveness could be reduced. Still, it is imperative to note that even when there is not a close match between the circulating virus and the virus used to make the vaccine, the vaccine will still lessen the severity of flu symptoms and also help prevent flu-related complications. </p>
<p>Bottom line: You cannot get influenza from getting the flu vaccine. As someone who has treated many people who do get the flu, I strongly urge you to get the shot.</p><img src="https://counter.theconversation.com/content/124257/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Libby Richards does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A common myth cited as a reason for not getting the flu shot is that the shot will give you the flu. That is scientifically impossible. Here’s why.Libby Richards, Associate Professor of Nursing, Purdue UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1053402018-10-25T10:48:17Z2018-10-25T10:48:17ZGet a flu shot now – for your benefit and your neighbors’<figure><img src="https://images.theconversation.com/files/241468/original/file-20181019-105782-1y1un4z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A nurse in Atlanta reaches for a vial of vaccine to prepare for an injection. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Flu-Season/eb907f2c836c49318bb029d5a8fe5765/3/0">David Goldman/AP Photo</a></span></figcaption></figure><p>If you do nothing else the next few days, get a flu shot. </p>
<p>The best time to get a flu shot is by the <a href="https://www.cdc.gov/flu/about/season/flu-season-2018-2019.htm">end of October</a>, the Centers for Disease Control and Prevention advises. Considering the severity of last year’s flu, it is especially important for everyone over age six months to be vaccinated. This includes pregnant women. </p>
<p>Last year’s <a href="https://www.washingtonpost.com/national/health-science/last-years-flu-broke-records-for-deaths-and-illnesses-new-cdc-numbers-show/2018/09/26/97cb43fc-c0ed-11e8-90c9-23f963eea204_story.html">flu killed 80,000 people</a>, the CDC reported, making it the most lethal flu epidemic in decades. Also, about <a href="https://www.cdc.gov/flu/about/season/flu-season-2017-2018.htm">710,000 people were hospitalized</a> because of it. </p>
<p>As of Oct. 6, 2018, <a href="https://www.cdc.gov/flu/about/season/flu-season-2017-2018.htm">183 of those deaths were in children</a>, the CDC reported. Additionally, there has already been <a href="https://www.nytimes.com/2018/10/16/health/child-flu-death-florida.html">one pediatric death</a> this current flu season. And <a href="https://www.cdc.gov/flu/about/season/flu-season-2017-2018.htm">80 percent of those children who died last year</a> along with the recent pediatric death had not been vaccinated. </p>
<p>You play an important role in stopping the spread of flu, not just to yourself but to others. As a doctor and public health professional who has treated many people with influenza, I’ll explain why. </p>
<h2>Protecting yourself, protecting others</h2>
<p>The <a href="https://www.cdc.gov/flu/about/qa/vaccineeffect.htm">influenza vaccine</a> has been shown to be one of the most important preventive measures against the flu. Though the <a href="https://theconversation.com/why-did-the-flu-kill-80-000-americans-last-year-105095">effectiveness of the vaccine can vary</a> – and last year’s rate was low, at about 40 percent – this still meant that the flu vaccine reduced a person’s overall risk of having to seek medical care at a doctor’s office for flu illness by 40 percent. Considering the seriousness of the illness, however, you need all the protection you can get. </p>
<p>And the vaccine reduces the severity and potential complications of your illness if you do get the flu. A large <a href="https://doi.org/10.1093/cid/cix468">study published in 2017</a> of patients hospitalized during the 2013-2014 flu season found that vaccinated adults were <a href="https://www.cdc.gov/flu/spotlights/vaccine-reduces-severe-outcomes.htm">52 to 79 percent less likely to die</a> than unvaccinated patients. Put another way, a hospitalized flu patient who was unvaccinated was two to five times more likely to die than someone who had been vaccinated.</p>
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<p>Almost everyone can receive the flu vaccine. Exceptions include babies younger than six months and people who have serious reactions to the flu vaccine, like <a href="http://www.aaaai.org/conditions-and-treatments/allergies/anaphylaxis">anaphylaxis</a>, a life-threatening reaction. </p>
<p>Some people gets hives from eggs, but this is not considered a serious reaction. If you are one of these people, it is <a href="http://www.cdc.gov/flu/protect/vaccine/egg-allergies.htm">still OK for you to get a flu shot</a> from standard providers. Even those who have a serious egg allergy can get the flu vaccine in a medical setting.</p>
<p>Getting the vaccine is not just good for you but also for the larger community. About 70 percent of the population needs to receive the flu vaccine to ensure what we call “<a href="https://www.vaccines.gov/basics/work/protection/index.html">herd immunity</a>
.” That happens when a critical portion of a community is immunized against a contagious disease.</p>
<p>When that occurs, <a href="https://www.vaccines.gov/basics/work/protection/index.html">most members of the community</a>, including those who are not vaccinated, are protected against that disease because there is little opportunity for an outbreak. Even those who are not eligible for certain vaccines get some protection because the spread of contagious disease is contained. This can effectively stop the spread of disease in the community. </p>
<p>You might even consider getting the vaccine to be a civic duty. </p>
<h2>Other things to know</h2>
<p>While the vaccine has been shown to be one of the most important preventive measures against the flu, you can do other things, too. <a href="https://theconversation.com/why-washing-your-hands-well-is-so-important-to-protect-your-family-from-the-flu-105348">Wash your hands</a>. If you cough or sneeze, cover your mouth or nose with your sleeve, not your hands. Avoid those who are ill. Stay home if you are sick.</p>
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<img alt="" src="https://images.theconversation.com/files/142809/original/image-20161023-15955-1u5u0qa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/142809/original/image-20161023-15955-1u5u0qa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/142809/original/image-20161023-15955-1u5u0qa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/142809/original/image-20161023-15955-1u5u0qa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/142809/original/image-20161023-15955-1u5u0qa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/142809/original/image-20161023-15955-1u5u0qa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/142809/original/image-20161023-15955-1u5u0qa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Cough into your elbow, not your hands.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-38010103/stock-photo-little-girl-demonstrates-coughing-or-sneezing-into-her-elbow-to-avoid-spreading-unwanted-germs.html?src=CJ35HLYLgA8orPGV3NvfOw-1-1">From www.shutterstock.com</a></span>
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<p>Antiviral medication can help you feel better if you contract the flu, but it must be started early in your illness, so call your health provider when symptoms begin. </p>
<p>A new, <a href="https://www.cdc.gov/flu/about/disease/65over.htm">higher-dose vaccine</a> is available for the elderly. If you are 65 or older, ask your doctor about this. About <a href="https://www.cdc.gov/flu/about/disease/65over.htm">54 to 70 percent of hospitalizations</a> for flu occur among people 65 and older. No matter which formulation you receive, it is essential to be vaccinated. Don’t miss the opportunity to do so. </p>
<p>Remember that getting the vaccine will not give you the flu. That is because vaccines today are made with killed viruses. A killed virus cannot infect anybody. If you hear someone say they came down with symptoms after receiving the vaccine, it could be because they had been exposed to flu before they were vaccinated.</p>
<p>Even if you can’t get to your doctor or pharmacy by the end of October, you should still get the flu vaccine. While the best immunity is conferred if you get the vaccine earlier, you will be protected. </p>
<p>And remember, even if it’s not a perfect match, it can protect you and your loved ones from getting a potentially life-threatening, yet preventable, disease.</p>
<p>Good advice: Stay home if you have the flu. Better advice: Get the flu vaccine!</p>
<p><em>Editor’s note: This is an updated version of an <a href="https://theconversation.com/why-its-your-job-to-get-a-flu-shot-and-call-in-sick-if-you-do-get-the-flu-66738">article</a> that originally was published Oct. 23, 2016.</em></p><img src="https://counter.theconversation.com/content/105340/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Patricia Schnabel Ruppert does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The flu shot is most effective if you receive it by the end of October. With 80,000 deaths from flu during last year’s flu season, a doctor explains why you should act now.Patricia Schnabel Ruppert, Assistant Professor of Medicine, Columbia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1053482018-10-23T14:38:26Z2018-10-23T14:38:26ZWhy washing your hands well is so important to protect your family from the flu<figure><img src="https://images.theconversation.com/files/241662/original/file-20181022-105773-1f9v07r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">One-year-old Kilian Doherty being prepared for a chest X-ray Feb. 9, 2018 to determine if he had flu.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Flu-Season/2c0ba619b0c7459ab46a3a3c42a41741/26/0">David Goldman/AP Photo</a></span></figcaption></figure><p>During my second year of graduate school, I moved in with my sister’s family to save money. “You must get the flu shot if you are going to live here,” my sister declared. Both of my nieces were under the age of 5, putting them at a <a href="https://www.cdc.gov/flu/protect/children.htm">high risk of flu complications</a>; therefore, it was critical that I do my part in, first, getting vaccinated to minimize my risk of getting the flu, and second, <a href="https://www.cdc.gov/flu/about/disease/high_risk.htm">not passing the flu</a> to a vulnerable population. A key part of this was, and still is, <a href="https://www.ncbi.nlm.nih.gov/pubmed/29601610">washing my hands regularly</a>.</p>
<p>This is serious business. The Centers for Disease Control and Prevention estimates that more than 900,000 people were hospitalized from the flu last season and more than <a href="https://www.cdc.gov/flu/spotlights/press-conference-2018-19.htm#ref1">80,000 people died</a> in the U.S. As the flu season approaches, it’s important to marshal all our defenses against influenza.</p>
<p>As someone who has a history of fainting after shots, including an experience that resulted in multiple stitches just shy of my temple, I understand high anxiety when it comes to needles. But in the evenings when my 4-year-old niece is looking at the intriguing images within my microbiology textbook and asks with each turn of page, “Auntie Chelle, what’s that?” I couldn’t fathom putting her at a higher risk of the flu or any sickness by not getting vaccinated or not washing my hands regularly.</p>
<h2>How does the flu virus spread?</h2>
<p>The flu virus spreads by droplets made from a cough, sneeze or talk of people who are infected. These <a href="https://www.cdc.gov/flu/about/disease/spread.htm">droplets can land</a> within the mouths, lungs or noses of people up to 6 feet away. Heavily populated places, such as schools or airports, could increase the transmission of the virus and put people at higher risk of getting the flu. It’s also possible to get the flu by touching a surface, such as chairs, tables or door handles that has flu virus on it and then touching your own <a href="https://www.ncbi.nlm.nih.gov/books/NBK459363/">mucous membranes</a> in your mouth, nose or eyes. A behavioral study of medical students at the University of New South Wales found that of the 26 participants, students touched their face an average of <a href="https://www.ncbi.nlm.nih.gov/pubmed/25637115">23 times per hour and 44 percent of the time</a> it was in contact with a mucous membrane.</p>
<p>With flu season ahead of us and also our holiday travels, do we really stand a chance of preventing the spread of the flu and other germs by keeping our hands clean? Yes, but it takes some work.</p>
<h2>Two-fisted approach</h2>
<p>There are two main strategies in hand washing. </p>
<p>The first is to decrease the overall biomass of microbes – that is, decrease the amount of bacteria, viruses and other types of microorganisms. We do this by lathering with soap and rinsing with water. Soap’s chemistry helps remove microorganisms from our hands by accentuating the slippery properties of our own skin.</p>
<p>Studies have shown that effectively <a href="https://www.ncbi.nlm.nih.gov/pubmed/15173145">washing with soap and water</a> significantly reduces the bacterial load of diarrhea-causing bacteria.</p>
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<img alt="" src="https://images.theconversation.com/files/198567/original/file-20171211-27686-vibmly.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/198567/original/file-20171211-27686-vibmly.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/198567/original/file-20171211-27686-vibmly.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/198567/original/file-20171211-27686-vibmly.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/198567/original/file-20171211-27686-vibmly.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/198567/original/file-20171211-27686-vibmly.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/198567/original/file-20171211-27686-vibmly.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Washing hands with warm soap and water is the best way to keep your hands clean.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/hygiene-cleaning-hands-washing-soap-630315251?src=KMSzfDIzHKwmAgJIJze_bw-1-0">r.classen/Shutterstock.com</a></span>
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<p>The second strategy is to kill the bacteria. We do this by using products with an <a href="http://emerald.tufts.edu/med/apua/about_issue/agents.shtml">antibacterial agent</a> such as alcohols, chlorine, peroxides, chlorhexidine or triclosan. </p>
<p>Some academic work has shown that <a href="https://www.ncbi.nlm.nih.gov/pubmed/28876132">antibacterial soaps</a> are more effective at reducing certain bacteria on soiled hands than soaps without them. </p>
<p>However, there’s a problem. Some <a href="https://pubchem.ncbi.nlm.nih.gov/compound/Triclocarban#section=Top">bacterial cells</a> on our hands may have genes that enable them to be resistant to a given antibacterial agent. This means that after the antibacterial agent kills some bacteria, the resistant strains remaining on the hands can flourish. </p>
<p>Further, the genes that allowed the bacteria to be resistant could pass along to other bacteria, causing more resistant strains. Together, the “take-over” of resistant strains would render the use of the antibacterial agent essentially ineffective.</p>
<p>Also, the long-term use of some <a href="https://www.ncbi.nlm.nih.gov/pubmed/28504614">antibacterial products</a> may harm your health. </p>
<p>For example, animal studies investigating the antibacterial agent triclosan, which used to be in soaps, toothpastes and deodorant, has been shown to alter the way <a href="https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm378393.htm">hormones work in the body</a>. The Food and Drug Administration has prohibited the use of over-the-counter antiseptic wash products containing triclosan and many other antibacterial active ingredients. </p>
<p>Nonetheless, the flu is caused by a virus, rendering products with antibiotics useless.</p>
<p>With this in mind, you may want to stick with plain old soap and water.</p>
<h2>Best practices</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/198573/original/file-20171211-27714-1ichuov.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/198573/original/file-20171211-27714-1ichuov.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/198573/original/file-20171211-27714-1ichuov.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/198573/original/file-20171211-27714-1ichuov.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/198573/original/file-20171211-27714-1ichuov.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/198573/original/file-20171211-27714-1ichuov.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/198573/original/file-20171211-27714-1ichuov.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Kids traveling during the holidays often have a hard time keeping their hands clean, just as adults do.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/christmas-car-travel-happy-kids-winter-717864226?src=9Obj5yFsFT8Oe_PU0fa7jw-1-37">NadyaEugene/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>To clean our hands, the CDC <a href="https://www.cdc.gov/handwashing/when-how-handwashing.html">recommends</a> that we: </p>
<ul>
<li>wet hands with clean water </li>
<li>apply soap and lather/scrub every nook and cranny of your hands for 20-30 seconds (about the time to sing “Happy Birthday” twice)</li>
<li>rinse well with clean running water</li>
<li>dry hands with a clean paper towel or air-dry.</li>
</ul>
<p>I was shocked to read a study that indicated that <a href="https://www.ncbi.nlm.nih.gov/pubmed/17577074">93.2 percent</a> of 2,800 survey respondents did not wash their hands after coughing or sneezing. Also, one study showed that across a college-town environment with observations of 3,749 people, the average hand-washing time was approximately <a href="https://www.ncbi.nlm.nih.gov/pubmed/23621052">six seconds</a>. </p>
<p>If soap and water are not unavailable, the CDC recommends using an alcohol-based <a href="https://www.cdc.gov/handwashing/show-me-the-science-hand-sanitizer.html">hand sanitizer</a> that contains at least 60 percent ethanol. Alcohols have a broad-spectrum of antimicrobial activity and are <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC88911/">less selective for bacterial resistance</a> compared to other antibacterial chemicals. </p>
<p>However, alcohol-based hand <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2600642/">sanitizers may not work</a> on all classes of germs. </p>
<p>So what is the take-home message? </p>
<p>There is no doubt that <a href="https://www.ncbi.nlm.nih.gov/pubmed/28258814">washing our hands</a> with liquid soap and water is effective in reducing the spread of infectious microorganisms, including those that are resistant to antimicrobial agents.</p>
<p>When you don’t have the opportunity to wash your hands after touching questionable surfaces, use an alcohol-based hand sanitizer. Limit the touching of your hands to your mouth, nose and eyes. </p>
<p>Further, build additional protection against pathogens via maintaining a balanced gut-bacteria community by “fertilizing” them with a diversity of plant-based foods. </p>
<p>It’s not only a small world, but a dirty one as well.</p>
<p><em>Editor’s note: This is an updated version of an <a href="https://theconversation.com/you-and-most-of-the-millions-of-holiday-travelers-you-encounter-are-washing-your-hands-wrong-87158">article that originally was published</a> Dec. 13, 2017.</em></p><img src="https://counter.theconversation.com/content/105348/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michelle Sconce Massaquoi does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Regular hand washing is important not only to keep from getting the flu but also to prevent passing it to others, such as young children and seniors, who may be even more vulnerable. Here’s how.Michelle Sconce Massaquoi, Doctoral candidate, microbiology, University of OregonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1050952018-10-23T10:42:41Z2018-10-23T10:42:41ZWhy did the flu kill 80,000 Americans last year?<figure><img src="https://images.theconversation.com/files/241730/original/file-20181022-105782-1x5js8k.jpg?ixlib=rb-1.1.0&rect=344%2C0%2C5009%2C3492&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">An Atlanta hospital set up a mobile ER to deal with the large number of flu cases.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Flu-Season/f65dc500f98a425cbe2be0f1439099c8/2/0">AP Photo/David Goldman</a></span></figcaption></figure><p>The 2017-2018 flu season was <a href="https://www.cdc.gov/flu/about/season/flu-season-2017-2018.htm">historically severe</a>. Public health officials estimate that <a href="http://www.nfid.org/newsroom/news-conferences/2018-nfid-influenza-pneumococcal-news-conference/press-release.pdf">900,000 Americans were hospitalized and 80,000 died</a> from the flu and its complications. For comparison, the previous worst season from the past decade, 2010-2011, saw 56,000 deaths. In a <a href="https://www.cdc.gov/flu/about/disease/us_flu-related_deaths.htm">typical season, 30,000 Americans die</a>.</p>
<p>So why was the 2017-2018 season such a bad year for flu? There were two big factors.</p>
<p>First, one of the circulating strains of the influenza virus, A(H3N2), is particularly virulent, and vaccines targeting it are less effective than those aimed at other strains. In addition, most of the vaccine produced was mismatched to the circulating A(H3N2) subtype.</p>
<p>These problems reflect the special biology of the influenza virus and the methods by which vaccines are produced.</p>
<h2>Flu virus is a quick change artist</h2>
<p>Influenza is not a single, static virus. There are three species – A, B and C – that can infect people. A is the most serious and C is rare, producing only mild symptoms. Flu is further divided into various subtypes and strains, <a href="https://doi.org/10.1016/j.vaccine.2008.07.039">based on the viral properties</a>. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/241734/original/file-20181022-105782-1rlcp91.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/241734/original/file-20181022-105782-1rlcp91.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/241734/original/file-20181022-105782-1rlcp91.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=395&fit=crop&dpr=1 600w, https://images.theconversation.com/files/241734/original/file-20181022-105782-1rlcp91.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=395&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/241734/original/file-20181022-105782-1rlcp91.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=395&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/241734/original/file-20181022-105782-1rlcp91.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=497&fit=crop&dpr=1 754w, https://images.theconversation.com/files/241734/original/file-20181022-105782-1rlcp91.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=497&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/241734/original/file-20181022-105782-1rlcp91.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=497&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Cartoon depiction of an influenza virus structure. Different strains are named after their versions of the haemagglutinin and neuraminidase proteins, as in H1N1 ‘swine flu.’</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/structure-influenza-virus-infographics-vector-illustration-542924464?src=ixiW0w-59I3I17RpN4L3wQ-1-12">Timonina/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Viruses consist of protein packages surrounding the viral genome, which, in the influenza virus, consists of RNA divided into eight separate segments. The influenza virus is enveloped by a membrane layer derived from the host cell. Sticking through this membrane are spikes made up of the proteins haemagglutinin (HA) and neuraminidase (NA), both of which are required for the virus to successfully cause an infection.</p>
<p>Your immune system reacts first to these two proteins. Their properties determine the H and N designations of various viral strains – for instance, the <a href="https://www.cdc.gov/h1n1flu/">H1N1 “swine flu”</a> that swept the globe in 2009.</p>
<p>Both HA and NA proteins are constantly changing. The process that copies the viral RNA genome is inherently sloppy, plus these two proteins are under strong pressure to evolve so they can evade attack by the immune system. This evolution of the HA and NA proteins, <a href="https://www.cdc.gov/flu/about/viruses/change.htm">called antigenic drift</a>, prevents people from developing lasting immunity to the virus. Although the immune system may be prepared to shutdown previously encountered strains, even slight changes can require the development of a completely new immune response before the infected person becomes resistant. Thus we have seasonal flu outbreaks.</p>
<p>In addition, <a href="https://theconversation.com/influenzas-wild-origins-in-the-animals-around-us-91058">various subtypes of influenza A infect animals</a>, the most important of which, for humans, are domestic birds and pigs. If an animal is simultaneously infected with two different subtypes, the segments of their genomes can be scrambled together. Any resulting virus may have new properties, to which humans may have little or no immune defense. This process, <a href="https://www.cdc.gov/flu/about/viruses/change.htm">called antigenic shift</a>, is responsible for the <a href="https://doi.org/10.3201/eid1201.051254">major pandemics that have swept the world</a> in the last century.</p>
<h2>Forecasting flu, producing vaccine</h2>
<p>Against this background of antigenic change, every year the World Health Organization predicts <a href="https://www.who.int/influenza/vaccines/virus/recommendations/2018_19_north/en/">which strains of flu virus will be circulating</a> during the next flu season, and vaccines are formulated based on this information.</p>
<p><iframe id="ajXan" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/ajXan/2/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>In 2017-2018 the vaccine was directed against specific subtypes of A(H1N1), A(H3N2) and B. The Centers for Disease Control and Prevention estimates that this <a href="https://www.cdc.gov/flu/about/season/flu-season-2017-2018.htm">vaccine was 40 percent effective</a> in preventing influenza overall. But, significantly, it was only 25 percent effective against the especially dangerous A(H3N2) strain. This mismatch probably reflects the way most of the vaccines are produced.</p>
<p>The common way of producing influenza vaccine starts by <a href="https://doi.org/10.3390/vaccines6020019">growing the virus in fertilized chicken eggs</a>. After several days, the viruses are harvested, purified and inactivated, leaving the surface proteins, HA and NA, intact. But, when the virus is grown in eggs, individual viruses with changes in the HA protein that increase its ability to bind to chicken cells can grow better and thus become more common.</p>
<p>When people receive vaccines produced from these egg-adapted viruses, their immune system learns to target the egg-influenced HA proteins and may not react to the HA proteins <a href="https://doi.org/10.1056/NEJMp1714916">on the viruses actually circulating in humans</a>. Thus, the virus used to produce much of the 2017-2018 vaccine provoked an immune response that did not fully protect against the A(H3N2) virus circulating in the population – although it <a href="https://doi.org/10.1016/j.vaccine.2018.07.028">may have lessened the severity of the flu</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/241731/original/file-20181022-105748-72zkeq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/241731/original/file-20181022-105748-72zkeq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/241731/original/file-20181022-105748-72zkeq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=488&fit=crop&dpr=1 600w, https://images.theconversation.com/files/241731/original/file-20181022-105748-72zkeq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=488&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/241731/original/file-20181022-105748-72zkeq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=488&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/241731/original/file-20181022-105748-72zkeq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=614&fit=crop&dpr=1 754w, https://images.theconversation.com/files/241731/original/file-20181022-105748-72zkeq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=614&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/241731/original/file-20181022-105748-72zkeq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=614&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Influenza vaccine has been produced in chicken eggs for decades.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Watchf-AP-A-IN-USA-APHS235246-Mmed-amp-Surg-/b8663fde84aa410ab8c302755c6a0777/5/0">AP Photo</a></span>
</figcaption>
</figure>
<h2>Small improvements and a universal vaccine</h2>
<p>Scientists are on the hunt for a better way to protect the world’s population from influenza.</p>
<p>Two new vaccines that do not use egg-grown viruses are currently available. One, a <a href="https://www.statnews.com/2018/03/09/cell-culture-flu-vaccine-flucelvax/">vaccine made from viruses grown in mammalian cells</a>, proved in preliminary studies to be only 20 percent more effective against A(H3N2) than egg-produced vaccine. The other, <a href="https://www.cdc.gov/flu/protect/vaccine/qa_flublok-vaccine.htm">a “recombinant” vaccine</a> consisting of only the HA proteins, is <a href="https://doi.org/10.1177/2051013615595595">produced in insect cells</a>, and its effectiveness is still being evaluated.</p>
<p>The ideal solution is <a href="https://www.scientificamerican.com/article/we-need-a-universal-flu-vaccine-before-the-next-pandemic-strikes/">a “universal” vaccine</a> that would protect against all influenza viruses, no matter how the strains mutate and evolve. One effort relies on the fact that flu’s HA protein “stalk” is less variable than the “head” that interacts with the host cell surface; but <a href="https://doi.org/10.3389/fimmu.2018.01479">vaccines made from a cocktail of HA protein “stalks”</a> have proved disappointing so far. A vaccine composed of <a href="https://clinicaltrials.gov/ct2/show/NCT03277456">two proteins internal to the virus</a>, M1 and NP, which are much less variable than surface-exposed proteins, is in clinical trials, as is another vaccine made up of a proprietary mixture of <a href="https://clinicaltrials.gov/ct2/show/NCT03450915">pieces of viral proteins</a>. These vaccines are designed to stimulate the “memory” immune cells that persist after an infection, possibly providing lasting immunity.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/241732/original/file-20181022-105751-13ehbb1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/241732/original/file-20181022-105751-13ehbb1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/241732/original/file-20181022-105751-13ehbb1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=389&fit=crop&dpr=1 600w, https://images.theconversation.com/files/241732/original/file-20181022-105751-13ehbb1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=389&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/241732/original/file-20181022-105751-13ehbb1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=389&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/241732/original/file-20181022-105751-13ehbb1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=489&fit=crop&dpr=1 754w, https://images.theconversation.com/files/241732/original/file-20181022-105751-13ehbb1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=489&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/241732/original/file-20181022-105751-13ehbb1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=489&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">This year’s vaccine looks like it will be a better match.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/California-Flu-Season/bc91acbda14d47d8a7f47107d56d3c71/4/0">AP Photo/Jeff Chiu</a></span>
</figcaption>
</figure>
<h2>Will the 2018-2019 flu season be as bad?</h2>
<p>Based mainly on the recent flu season in South America, the <a href="http://www.who.int/influenza/vaccines/virus/recommendations/201802_recommendation.pdf">World Health Organization recommended</a> changing the A(H3N2) subtype in the vaccine to one that better matches last year’s circulating A(H3N2). They also recommended changing the B subtype to one that appeared in the U.S. late in the 2017-2018 season and became increasingly common elsewhere. The WHO anticipated that the circulating A(H1N1) subtype will be the same as last year and so no change was necessary on that front. So, although the same strains will most likely be circulating, epidemiologists expect the vaccines to provide better protection. </p>
<p>The CDC recommends that everyone 6 months and older <a href="https://www.cdc.gov/flu/prevent/vaccinations.htm">get a flu shot every year</a>, but, typically, <a href="https://www.cdc.gov/flu/fluvaxview/interactive.htm">fewer than half of Americans do so</a>. Flu and its complications can be life-threatening, particularly for the young, the old and the otherwise debilitated. Most years the vaccine is well matched to the circulating virus strain, and even a poorly matched vaccine offers protection. Plus, wide-spread vaccination stops the virus from spreading and protects the vulnerable.</p>
<p>The first flu death of the 2018-2019 season has already occurred – a <a href="https://www.nytimes.com/2018/10/16/health/child-flu-death-florida.html">healthy but unvaccinated child died</a> in Florida – affirming the importance of getting the flu shot.</p><img src="https://counter.theconversation.com/content/105095/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Patricia L. Foster receives funding from the US Army Research Office. She is affiliated with Union of Concerned Scientists and Concerned Scientists at Indiana University. </span></em></p>Part of the problem was a mismatch between the influenza strains circulating and the vaccine available. Here’s how annual flu shots are formulated.Patricia L. Foster, Professor Emerita of Biology, Indiana UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1007992018-08-20T10:30:59Z2018-08-20T10:30:59ZThree reasons the US is not ready for the next pandemic<figure><img src="https://images.theconversation.com/files/232140/original/file-20180815-2897-16tpvs7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A poster from a world summit in Hong Kong on preparing for worldwide pandemics in June 2010. Despite efforts to develop plans, none is yet in place. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Hong-Kong-Next-Pandemic/95011033061a403bb7257e8f1f8786b8/100/0">Vincent Yu/AP Photo</a></span></figcaption></figure><p><strong>Note: This article was published in 2018</strong></p>
<p>Over a hundred years after the Great Influenza pandemic of 1918, global health leadership stands at a crossroads. The United States continues to expand its <a href="https://www.washingtonpost.com/news/to-your-health/wp/2018/02/01/cdc-to-cut-by-80-percent-efforts-to-prevent-global-disease-outbreak/">policy of isolationism</a> at a time when international cooperation in health could not be more important. The state of pandemic preparedness and the necessary steps for protecting the people throughout the world was the topic of The Scowcroft Institute for International Affairs’ <a href="http://issuu.com/tamuvetmed/docs/2018pandemicwhitepaper?e=10250889/61709576">2nd Annual White Paper</a>. </p>
<p>As pandemic policy scholars, with two of us spending the majority of our career in the federal government, we believe that it is essential to prepare the country and the world for the next pandemic. It is not a matter of if, but when, the next disease will sweep the world with deadly and costly consequences. </p>
<p>There are many topic areas that national leaders must address to create better preparedness and response capabilities, but we believe three are most urgent. These include targeting the resistance to antimicrobial agents that has come about because of overuse and misuse of antibiotics; ensuring continuity of supply chains; and improving and strengthening leadership. </p>
<h2>Overuse of a wonder drug</h2>
<p>Prior to Alexander Fleming’s <a href="https://www.pbs.org/newshour/health/the-real-story-behind-the-worlds-first-antibiotic">discovery of penicillin</a>, even the smallest scratch could be deadly. Its discovery, however, helped contribute to the perception that man had conquered disease, despite Fleming’s <a href="https://www.businessinsider.com/alexander-fleming-predicted-post-antibiotic-era-70-years-ago-2015-7">warning</a> that “the thoughtless person playing with penicillin treatment is morally responsible for the death of a man who succumbs to infection with the penicillin resistant organism.” Now, 70 years later, society is quickly reaching the precipice of that reality.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/232143/original/file-20180815-2903-1kvi3me.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/232143/original/file-20180815-2903-1kvi3me.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/232143/original/file-20180815-2903-1kvi3me.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/232143/original/file-20180815-2903-1kvi3me.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/232143/original/file-20180815-2903-1kvi3me.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/232143/original/file-20180815-2903-1kvi3me.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/232143/original/file-20180815-2903-1kvi3me.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Penicillin fungi growing in petri dishes.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/penicillin-fungi-petri-dishes-263963465?src=an__v-iSSNGB2o6mr3E8jw-1-7">science photo/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>The problem of antibiotic overuse and misuses is extensive. In fact, in the United States, <a href="https://www.ncbi.nlm.nih.gov/pubmed/26464037">80 percent of all antibiotic use</a> occurs in the agricultural sector and the majority of this use is nontherapeutic, meaning it is not medically necessary. Misuse of antibiotics also occurs frequently in the human health sector, however. The Review on Antimicrobial Resistance estimated that if changes are not made, the world could witness <a href="https://amr-review.org/sites/default/files/AMR%20Review%20Paper%20-%20Tackling%20a%20crisis%20for%20the%20health%20and%20wealth%20of%20nations_1.pdf">10 million deaths annually</a> due to antimicrobial resistant infections. </p>
<p>To help prevent this public health threat from reaching that level of crisis with potential catastrophic implications, we recommend four actions. </p>
<p>First, an increase of investment needs to be made by the federal government and the private sector into research, development and production of new antimicrobials. In 2014, WHO also called for <a href="http://www.who.int/phi/implementation/consultation_imnadp/en/">greater investment</a> in discovering new antimicrobials, but in the last 50 years, <a href="https://www.sciencedirect.com/science/article/pii/S1198743X16300271">only one new class</a> of antibiotics has been discovered. </p>
<p>Second, governments throughout the world need to create stronger internationally harmonized regulatory systems for agriculture production and veterinary use of antimicrobials. For example, in the United States, antibiotics cannot be purchased without a prescription from either a medical doctor or a veterinarian (for the agricultural sector). But many countries in the developing world have no oversight for animal or human use of antibiotics. In some places, particularly African countries, many antibiotics can be purchased <a href="https://aricjournal.biomedcentral.com/articles/10.1186/s13756-017-0208-x">over the counter</a>.</p>
<p>You may already have experienced the third recommendation, if your doctor has sent you home from an appointment without an antibiotic prescription because your illness was viral. Health care providers and consumers need to decrease misuse and overuse of antimicrobials in human health by only prescribing antibiotics in cases of bacterial infection. The Centers for Disease Control and Prevention has issued guidelines for this, including <a href="https://www.cdc.gov/antibiotic-use/community/improving-prescribing/index.html">recommendations for patients</a>. </p>
<p>Last, governments throughout the world need to understand that fighting antimicrobial resistance requires a collaboration between animal health, human health and environmental health. This idea, known as One Health, works to bring together researchers and professionals from these three areas to address disease-related challenges. While these actions require monetary and time investments, they are essential. Without taking these actions society may find itself in a post-antibiotic world. This world, as former Director-General of the World Health Organization <a href="http://www.who.int/dg/speeches/2012/amr_20120314/en/">Margaret Chan explained in 2012</a>, means “the end of modern medicine as we know it. Things as common as strep throat or a child’s scratched knee would once again kill.”</p>
<h2>Will global supply chains collapse?</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/232145/original/file-20180815-2921-1qtc7d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/232145/original/file-20180815-2921-1qtc7d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=361&fit=crop&dpr=1 600w, https://images.theconversation.com/files/232145/original/file-20180815-2921-1qtc7d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=361&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/232145/original/file-20180815-2921-1qtc7d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=361&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/232145/original/file-20180815-2921-1qtc7d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=454&fit=crop&dpr=1 754w, https://images.theconversation.com/files/232145/original/file-20180815-2921-1qtc7d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=454&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/232145/original/file-20180815-2921-1qtc7d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=454&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Global supply chains involve complicated logistics of getting goods to and from trucks, ships and jets all around the world. If one piece is interrupted, disaster can sometimes strike.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/logistics-transportation-container-cargo-ship-plane-722794939?src=NnOEq7mY82YB80SYGV3EKg-1-1">Travel Mania/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Modern society is able to function and flourish in large part because of the global <a href="http://www.businessdictionary.com/definition/supply-chain.html">supply chains</a> transporting parts, equipment and supplies with speed, efficiency and <a href="https://financial-dictionary.thefreedictionary.com/Just-In-Time+Delivery">just-in-time delivery</a>, which allows business to keep carrying costs low because they can order what they need and have it shipped quickly, or “just in time.” Global supply chains, which consist of production specialization through comparative advantage, has enabled great economic development, but their just-in-time structure also leaves them exceedingly vulnerable. Components of the critical medical infrastructure, such as components essential to running life support machines or insulin for diabetics, are<a href="https://www.amazon.com/Deadliest-Enemy-Against-Killer-Germs/dp/B06XKQLD4X"> always in transit</a>. </p>
<p>This means that even a localized disease could deprive people of needed medical supplies. For example, if an epidemic hits a town in Asia where <a href="https://www.health.ny.gov/publications/2805/index.htm">N95 masks</a>, which are used to protect people from hazardous substances, are manufactured, there may no longer be any N95 masks to be shipped to the United States or elsewhere. The United States experienced supply chain breakdown when Hurricane Maria caused a <a href="https://www.smithsonianmag.com/innovation/saline-shortage-this-flu-season-exposes-flaw-in-our-medical-supply-chain-180967879/">disruption in the supply</a> of small bag IV saline. A manufacturer in Puerto Rico that produces <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2681062">nearly half of all the saline</a> utilized in the U.S. had to halt production because of the hurricane. </p>
<p>This interconnectedness of the global economy and the expansiveness of medical supply chains means that a disruption anywhere along the line could spell disaster worldwide. To help prevent such a disaster, the federal government needs to understand the United States’ critical supply chains. The federal government and private sector should be aware of likely points of breakdown. </p>
<p>Once there is understanding, the U.S. must implement new policies that enable private sector innovation to diversify production and transportation where possible. Diversification of production and transportation means that there is not just one production source for critical supplies. Thus, a disruption in one geographical location would not cripple the entire supply chain. </p>
<h2>Centralized, involved leadership</h2>
<p>Diseases do not respect borders, and for this reason, pandemics are a global threat. Therefore, the U.S. must address the threat of pandemics in cooperation with all other nations and with multilateral institutions such as the World Health Organization, the U.N. Security Council, UNICEF and more. We believe that investment in global health security, such as the establishment of a permanent fund for influenza preparedness and response, and remaining engaged with the international community to prevent an outbreak from becoming a pandemic is the best way to protect the American people.</p>
<p>Additionally, we believe that the U.S. should commit to pandemic preparedness by creating a position of authority within the White House that transcends administrations and elevates pandemics as existential threats to a national security priority. There is a need to have decision-making authority and oversight vested at the highest levels of government.</p>
<p>In the midst of a pandemic, decisions must be made quickly. Quick decision-making can often be hindered by the absence of high-level leadership. The need for high-level leadership, coordination and a new strategy are essential to mitigate the <a href="http://www.biodefensestudy.org/a-national-blueprint-for-biodefense">threat of pandemics</a>, but these fundamental <a href="http://bush.tamu.edu/scowcroft/white-papers/The-Growing-Threat-of-Pandemics.pdf">pandemic preparedness gaps persist</a>.</p>
<p>The next great pandemic is coming. The true question is: Will we be ready when it does? Right now, that answer is no, because the country lacks the sufficient safeguards we have outlined. But if the United States chooses to elevate the issue of pandemic preparedness and biosecurity as a national security priority, we could be. Outbreaks are inevitable, but pandemics are not if we take action now.</p><img src="https://counter.theconversation.com/content/100799/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew S.Natsios I sit on the board of directors and own shares in Canadian-based Fio Corporation, a hitech startup which works in developing countries in remote diagoses of malaria, HIV/AIDS, and other infectious diseases.</span></em></p><p class="fine-print"><em><span>Christine Crudo Blackburn and Gerald W Parker do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>It’s not a matter of if, but when, the next deadly pandemic will strike. Will the world be ready?Christine Crudo Blackburn, Deputy Director, Pandemic & Biosecurity Policy Program, Scowcroft Institute of International Affairs, Bush School of Government and Public Service, Texas A&M UniversityAndrew Natsios, Director of the Scowcroft Institute of International Affairs and Executive Professor, Texas A&M UniversityGerald W Parker, Associate Dean For Global One Health, College of Veterinary Medicine & Biomedical Sciences; and Director, Pandemic and Biosecurity Policy Program, Scowcroft Institute for International Affairs, Bush School of Government and Public Service, Texas A&M UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/978232018-07-02T10:41:30Z2018-07-02T10:41:30ZFlu lasts for more than an hour in air and on surfaces – why cleaning can really help<figure><img src="https://images.theconversation.com/files/223655/original/file-20180618-85819-k97yad.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Cleaning counters and keyboards can remove flu virus, which can survive well there, a study suggests.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/attractive-brunette-male-carefully-cleaning-table-34494346?src=AUk_yetWwtuKTNi5X3C_iQ-1-61">AVAVA/Shutterstock.com</a></span></figcaption></figure><p><em><a href="https://theconversation.com/la-gripe-sobrevive-mas-de-una-hora-en-el-aire-y-en-las-superficies-105558">Leer en español</a></em>.</p>
<p>Influenza, or flu, viruses cause about <a href="https://www.cdc.gov/flu/about/disease/burden.htm">200,000 hospitalizations</a> every year in the U.S. Annual seasonal vaccination is our best line of defense, but in recent years, it has become clear that <a href="https://www.cdc.gov/flu/professionals/vaccination/effectiveness-studies.htm">mismatches in the vaccine</a> can limit its effectiveness.</p>
<p>We study how the flu virus spreads between people. While we strongly encourage everyone to get the flu vaccine, the findings from <a href="https://www.ncbi.nlm.nih.gov/pubmed/29878137">our study</a> on the stability of flu viruses in the air can provide useful information for parents, teachers and health care officials to limit the spread of flu in the community. </p>
<p>By employing simple strategies to reduce the amount of flu virus in our environment, we can decrease the number of infections every year.</p>
<h2>How the flu spreads</h2>
<p>Flu spreads through the community in three ways: </p>
<ol>
<li><p>Direct contact – when you shake hands with or otherwise touch an infected individual.</p></li>
<li><p>Indirect contact – when the virus spreads via a contaminated surface like a door handle.</p></li>
<li><p>Aerosols – when the virus is expelled into the air by coughing, sneezing or <a href="http://www.pnas.org/content/115/5/1081.short">just exhaling</a> and is then inhaled by a susceptible individual.</p></li>
</ol>
<p>It is clear that all three routes promote the spread of flu each season, but the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5909391/">relative importance</a> of each is still unknown. </p>
<p>Scientists have long believed that flu viruses in aerosols would be inactivated quickly at moderate and high humidity. In 2018, we showed that <a href="https://www.ncbi.nlm.nih.gov/pubmed/29878137">human respiratory mucus</a> protects flu viruses that are in aerosols and in droplets on a surface from decay regardless of the humidity.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/222522/original/file-20180611-191974-1nf6b2m.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/222522/original/file-20180611-191974-1nf6b2m.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/222522/original/file-20180611-191974-1nf6b2m.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/222522/original/file-20180611-191974-1nf6b2m.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/222522/original/file-20180611-191974-1nf6b2m.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/222522/original/file-20180611-191974-1nf6b2m.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/222522/original/file-20180611-191974-1nf6b2m.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Members of the team from left to right: Karen Kormuth, Kaisen Lin and AJ Prussin stand by the rotating drum inside a biosafety cabinet.</span>
</figcaption>
</figure>
<p>In our studies, we sprayed flu viruses into a rotating drum to test whether they were still infectious after an hour at a wide range of different humidities. We found no loss in the amount of infectious virus at any humidity, which means that expelled aerosols containing flu viruses are stable in the air for at least one hour. Our other unpublished data suggest that flu viruses, in the presence of mucus, can persist on some surfaces for up to 16 hours with very little loss in infectivity. These data demonstrate that infectious flu viruses are highly stable in the indoor environment.</p>
<h2>How to reduce the chances of spreading the virus</h2>
<p>There are some simple measures that can help reduce the chances of the virus spreading to other people. The following steps can help remove infectious flu virus from surfaces and the air.</p>
<p>Removing flu virus from surfaces:</p>
<ol>
<li><p>Wipe down frequently touched surfaces such as doorknobs, tables, elevator buttons and faucets. Simple alcohol-based cleaning products are <a href="https://www.ncbi.nlm.nih.gov/pubmed/20430477">effective to inactivate flu</a>. </p></li>
<li><p>The classic advice of hand-washing can also help reduce transmission by direct and indirect contact.</p></li>
<li><p>Coughing and sneezing into your shirt rather than your elbow or hand is a good way to keep droplets and aerosols from traveling through the air and depositing on surfaces.</p></li>
</ol>
<p>Removing flu virus from the air:</p>
<ol>
<li><p>Increasing air circulation in the room can dilute flu viruses in the air and limit their spread. This can be achieved by increasing the exchange rate of building ventilation systems, turning on ceiling or portable fans, and, if possible, opening windows.</p></li>
<li><p>Air purifiers designed to remove particles should be effective at removing viruses from air too, although this has not been tested directly. A purifier with a HEPA filter and a high flow rate will remove the most particles.</p></li>
<li><p>Surgical masks are particularly useful if <a href="http://journals.plos.org/plospathogens/article?id=10.1371/journal.ppat.1003205">worn by sick individuals</a>. This intervention will help keep an infected person from spreading viruses around, as they come out even when you’re just exhaling. If you’re not sick but are around people who have the flu, wearing a surgical mask can help <a href="https://jamanetwork.com/journals/jama/fullarticle/184819">protect you from getting infected</a> as long as it’s <a href="https://www.nature.com/articles/jes201642">tight-fitting</a>. If there are gaps around the sides, then it’s not helping much.</p></li>
</ol><img src="https://counter.theconversation.com/content/97823/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Seema Lakdawala receives funding from National Institutes of Health and American Lung Association</span></em></p><p class="fine-print"><em><span>Linsey Marr has received funding from the National Institutes of Health, National Science Foundation, US Environmental Protection Agency, Army Research Office, Sloan Foundation, Water Environment Research Foundation, Virginia Department of Environmental Quality, National Park Service, Fulbright Program, US Department of Agriculture, Molina Center for Energy and the Environment, National Oceanographic and Atmospheric Administration, American Honda Foundation, U.S.-Mexico Foundation for Science. </span></em></p>Vaccination against the flu is the best way to stop its spread, but a recent study suggests increasing air circulation and cleaning surfaces to remove the virus from the environment.Seema Lakdawala, Assisstant Professor, University of PittsburghLinsey Marr, Professor, Virginia TechLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/910582018-03-09T11:39:47Z2018-03-09T11:39:47ZInfluenza’s wild origins in the animals around us<figure><img src="https://images.theconversation.com/files/209607/original/file-20180308-30954-1affwjl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People and animals live side by side – and can have pathogens in common.</span> <span class="attribution"><span class="source">Nichola Hill</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span></figcaption></figure><p>In the early 20th century, the <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/mm4829a1.htm">leading cause of death</a> was infectious disease. Epidemics erupted with little warning, seemingly out of the blue. When the “Great Influenza” struck in 1918, it <a href="https://www.penguinrandomhouse.com/books/288950/the-great-influenza-by-john-m-barry/9780143036494">killed thousands of people a week</a> in American cities and spread like wildfire around the globe. My great aunt, still a teenager, and living in the San Francisco area, was one of its estimated <a href="https://dx.doi.org/10.3201/eid1201.050979">50 to 100 million victims worldwide</a>.</p>
<p>Neither public health authorities nor medical researchers understood that it was a virus that caused the 1918 pandemic – most of the world at that time didn’t even know what a virus was. A century later, <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/mm4829a1.htm">death due to infection is much less common</a>, thanks to public health efforts and improved medical technology and expertise. <a href="http://www.berkeleywellness.com/healthy-community/health-care-policy/article/cdcs-top-10-public-health-achievements-20th-century">Once common diseases are now rare</a>. Nonetheless, infectious disease specialists like me still fear the emergence of viral diseases that we will not be able to control, including influenza.</p>
<p><a href="https://runstadlerlab.mit.edu/">My laboratory</a>, along with others around the world, is working to understand how and why new influenza viruses may grip us again. To do so, we need to go far beyond human hospitals and into the wild, where viruses persist in animal populations. As <a href="https://www.nature.com/scitable/knowledge/library/disease-ecology-15947677">disease ecologists</a>, we aim to understand the dynamics of pathogens in the environment and their interactions with hosts. By understanding more about what’s happening with viruses in animals, we believe we can be better prepared to evaluate, predict and respond if an infection spills over to humans, making people sick.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/209334/original/file-20180307-146650-1g83a4m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/209334/original/file-20180307-146650-1g83a4m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/209334/original/file-20180307-146650-1g83a4m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=465&fit=crop&dpr=1 600w, https://images.theconversation.com/files/209334/original/file-20180307-146650-1g83a4m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=465&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/209334/original/file-20180307-146650-1g83a4m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=465&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/209334/original/file-20180307-146650-1g83a4m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=584&fit=crop&dpr=1 754w, https://images.theconversation.com/files/209334/original/file-20180307-146650-1g83a4m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=584&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/209334/original/file-20180307-146650-1g83a4m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=584&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Tens of millions died, but no one knew a virus was to blame.</span>
<span class="attribution"><a class="source" href="http://resource.nlm.nih.gov/101399244">U.S. National Library of Medicine</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<h2>Identifying the invisible, infectious virus</h2>
<p>Until well into the 1930s, the <a href="http://www.history.com/news/ask-history/why-was-it-called-the-spanish-flu">“Spanish flu”</a> was mistakenly thought to be a bacterial infection, with <em>Haemophilus influenzae</em> commonly blamed. This bacterium is a pathogen in its own right and may have contributed heavily to the 1918 pandemic’s death toll – but it was a secondary infection in many of the severe cases, not the original cause of victims’ illnesses.</p>
<p>Researchers had only identified viral particles for the first time less than 30 years before the height of the flu pandemic and the fledgling field of virology was just beginning to identify them as causes of disease in plants and animals. Scientists were only first able to visualize a virus, the tobacco mosaic virus, after the 1931 invention of the electron microscope. Though the technology, knowledge and pace of research was different early in the 20th century, why did the discovery of influenza virus take so long? </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/209348/original/file-20180307-146666-1bkumam.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/209348/original/file-20180307-146666-1bkumam.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/209348/original/file-20180307-146666-1bkumam.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=637&fit=crop&dpr=1 600w, https://images.theconversation.com/files/209348/original/file-20180307-146666-1bkumam.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=637&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/209348/original/file-20180307-146666-1bkumam.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=637&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/209348/original/file-20180307-146666-1bkumam.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=801&fit=crop&dpr=1 754w, https://images.theconversation.com/files/209348/original/file-20180307-146666-1bkumam.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=801&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/209348/original/file-20180307-146666-1bkumam.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=801&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A transmission electron microscopic image of recreated 1918 influenza viral particles.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/sanofi-pasteur/34028429785">CDC/Dr. Terrence Tumpey</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>The answer, it seems, lay at least in part in people’s naiveté about the relationship between animals, the environment and human disease. In 1918, veterinarian J.S. Koen <a href="http://www.medicalecology.org/diseases/influenza/influenza.htm">noted a very similar disease to influenza in pigs</a>. Yet, it wasn’t until 1931 that researcher Richard Shope identified a filterable agent, smaller than bacteria, as the cause of the disease in pigs and demonstrated the transmission of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2391305/">an influenza virus</a>. That work spurred the description of human influenza virus in 1933.</p>
<p>The tools of molecular biology, including <a href="https://www.yourgenome.org/stories/what-is-dna-sequencing">nucleic acid sequencing</a>, developed through the latter half of the 20th century, finally helped open the vault on the origins of the 1918 pandemic. In 2005, through a combination of sleuthing and sequencing of the viral genome, <a href="https://scholar.google.com/citations?user=pksBzvYAAAAJ&hl=en&oi=ao">Jeffrey Taubenberger</a> and a team of researchers pieced together the <a href="https://doi.org/10.1126/science.1119392">genetic sequence of the deadly 1918 virus</a>, using viruses collected from the corpses of soldiers and other bodies preserved in the Arctic permafrost who died during the pandemic.</p>
<p>They were able to connect the origins and evolution of the 1918 pandemic with viruses that circulate in other animals, particularly those from birds and the pigs examined by Dr. Koen. Just as seen in more recent outbreaks of new influenza viruses, the 1918 pandemic traced its origins to virus strains circulating in nature.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/209530/original/file-20180308-30972-k3j39x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/209530/original/file-20180308-30972-k3j39x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/209530/original/file-20180308-30972-k3j39x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/209530/original/file-20180308-30972-k3j39x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/209530/original/file-20180308-30972-k3j39x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/209530/original/file-20180308-30972-k3j39x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/209530/original/file-20180308-30972-k3j39x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/209530/original/file-20180308-30972-k3j39x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Disease ecologists now know that waterfowl can be a reservoir for influenza virus, and conduct surveillance on wild birds.</span>
<span class="attribution"><span class="source">Paige Gingrich</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<h2>Natural world a reservoir for human disease</h2>
<p>The critical insight that led to the work reconstructing the 1918 virus had come in the 1970s. Led by the determination of virologist Rob Webster, researchers realized that <a href="http://mmbr.asm.org/content/56/1/152.short">influenza viruses are rampant in the natural world</a>, particularly in waterfowl. In birds and possibly other animals, influenza viruses are able to replicate and transmit to new hosts without causing any severe disease. On rare occasions, given the right circumstance, this new host is a different species. This cycle, common in many pathogens, is an important part of how virus is maintained in nature and explains how animals can be a reservoir for novel influenza viruses that can cause human illnesses.</p>
<p>As researchers have sequenced the influenza viruses found in ducks and other birds, as well as people, swine and other animals, a picture of viral ecology based in nature has come into focus. Birds serve as a reservoir for a vast diversity of influenza viruses to which all the major human pandemics <a href="https://www.cdc.gov/flu/pandemic-resources/basics/past-pandemics.html">trace their origin</a>. People were largely unaware that at the same time as the 1918 flu pandemic, pigs were sick with the disease and influenza viruses were also causing ongoing fowl plague epidemics. Exactly how and where the 1918 virus <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC340389/">entered the human population</a> remains controversial. But the realization that influenza virus happily exists in a wild animal reservoir has influenced the way scientists study flu – and moreover, emerging disease of any sort.</p>
<p>This understanding is also part of what underlies the One Health movement – the concept that the health of humans is entwined with the health of animals and of the environment. The <a href="http://www.onehealthinitiative.com/index.php">One Health</a> and <a href="https://isemph.org/">Evolutionary Medicine</a> initiatives are forging collaborations between medical doctors, veterinarians, ecologists, environmental researchers and those in many other fields to describe the connections among environmental change, animals and human health.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/209609/original/file-20180308-30975-16qf7e2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/209609/original/file-20180308-30975-16qf7e2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/209609/original/file-20180308-30975-16qf7e2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/209609/original/file-20180308-30975-16qf7e2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/209609/original/file-20180308-30975-16qf7e2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/209609/original/file-20180308-30975-16qf7e2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/209609/original/file-20180308-30975-16qf7e2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/209609/original/file-20180308-30975-16qf7e2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Understanding virus ecology means figuring out what strains are circulating and how new strains are created in the wild.</span>
<span class="attribution"><span class="source">Nichola Hill</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<h2>Watching the wild world to protect human health</h2>
<p>We now know that a full <a href="https://www.cdc.gov/ncezid/">60 percent of human infectious diseases are spread from animals</a>. In the past 20 years, that awareness has resulted in stronger efforts at <a href="http://www.who.int/influenza/human_animal_interface/en/">influenza surveillance worldwide</a> and the identification of several other influenza viruses that threaten public health. In my lab’s work, we endeavor to describe the ecology and natural history of influenza virus in animals to understand how new viruses arise and what the risk is of spillover into new hosts where they may cause disease.</p>
<p>For instance, human activity – such as the existence of open landfills, habitat destruction or farming practices – can attract or force animals to crowd into spaces they normally may not. When interactions between species and the environment are disrupted in this way, how does it affect the circulation, evolution and movement of influenza viruses or other pathogens that those animals host? Changes in the ecology of pathogens in the wild are what most frequently leads to spillover into human populations and disease outbreak. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/209531/original/file-20180308-30983-1et9gln.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/209531/original/file-20180308-30983-1et9gln.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/209531/original/file-20180308-30983-1et9gln.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/209531/original/file-20180308-30983-1et9gln.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/209531/original/file-20180308-30983-1et9gln.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/209531/original/file-20180308-30983-1et9gln.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/209531/original/file-20180308-30983-1et9gln.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/209531/original/file-20180308-30983-1et9gln.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The author and colleagues draw samples from wild seals in New England.</span>
<span class="attribution"><span class="source">Yvonne Vaillancourt, obtained under NMFS #17670</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p>Following an epidemic of seal deaths in 2011 in New England, <a href="https://www.nefsc.noaa.gov/press_release/pr2016/scispot/ss1602/">our broad group of collaborators</a> has spent cold winter days sampling seals, where we’ve discovered evidence of persistent circulating influenza viruses. These results are leading us to explore how influenza is affecting the seals, but also what the impact of a rapidly expanding seal population will be on the virus. If seals are a mammalian reservoir more commonly infected than we knew, their populations may affect influenza disease ecology. </p>
<p>Surveillance and research work like that on influenza and its animal hosts has led to more aggressive efforts to stamp out emerging infections before they become human pandemics. It gives biomedical researchers a head start on characterizing possible pandemic viruses to understand their potential impact. And public health workers gain new insights on prevention and control of infection.</p>
<p>That information may be crucial in identifying and containing the next pandemic virus. The One Health community’s experience with influenza has informed how scientists try to understand and prevent the spread of other diseases, including <a href="https://evolution.berkeley.edu/evolibrary/news/060101_batsars">SARS</a>, <a href="https://www.cdc.gov/ncezid/stories-features/global-stories/ebola-reservoir-study.html">Ebola</a> and <a href="http://www.sciencemag.org/news/2017/08/zika-has-all-disappeared-americas-why">Zika</a>. Researchers were quick to chase after the animal source of SARS and are still hard at work to identify reservoir hosts and understand the disease ecology of the Zika and Ebola viruses.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/209344/original/file-20180307-146671-1rvnlcj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/209344/original/file-20180307-146671-1rvnlcj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/209344/original/file-20180307-146671-1rvnlcj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/209344/original/file-20180307-146671-1rvnlcj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/209344/original/file-20180307-146671-1rvnlcj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/209344/original/file-20180307-146671-1rvnlcj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/209344/original/file-20180307-146671-1rvnlcj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/209344/original/file-20180307-146671-1rvnlcj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Sampling birds, as at this market in Bangkok, lets researchers keep track of viruses circulating and mixing in human environments.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/usaidasia/16191808288">Richard Nyberg, USAID</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span>
</figcaption>
</figure>
<p>Over one hundred years after the “Great Influenza,” there’s still much to learn to lessen the risk of a repeat of 1918. In the last 10 years, thanks to the efforts of many researchers worldwide, including a <a href="http://www.niaidceirs.org">renewed effort funded by the U.S. National Institutes of Health</a>, the pace of sequencing influenza viruses has leapt forward. Scientists are beginning to understand the true diversity of influenza virus, not only in birds, but in other animals as well.</p>
<p>Efforts at <a href="https://theconversation.com/influenza-the-search-for-a-universal-vaccine-90908">producing a universal vaccine</a> to prevent influenza infection in humans show promise. But the ability to test those vaccines and to prepare for and predict emerging strains will not be complete without a strong understanding of the origin, movement and risk of viruses circulating in the animals and environment around us. With better understanding of these ecological connections coming from continued research, we hope we can be better prepared for the next pandemic.</p><img src="https://counter.theconversation.com/content/91058/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jonathan Runstadler receives funding from National Institutes of Health (HHSN272201400008C)</span></em></p>No one then knew a virus caused the 1918 flu pandemic, much less that animals can be a reservoir for human illnesses. Now virus ecology research and surveillance are key for public health efforts.Jonathan Runstadler, Professor of Infectious Disease and Global Health, Cummings School of Veterinary Medicine, Tufts UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/911942018-03-06T11:39:30Z2018-03-06T11:39:30ZHow vaccination is helping to prevent another flu pandemic<figure><img src="https://images.theconversation.com/files/208693/original/file-20180302-65511-1ty4xhs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">An injectable flu vaccination. Flu vaccines lessen the likelihood of getting the flu and its severity. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/komunews/15409762240">Flickr/</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>Researchers believe that over <a href="https://www.smithsonianmag.com/history/ten-myths-about-1918-flu-pandemic-180967810/">50 million people</a> worldwide died in the 1918 flu pandemic, making it possibly worse than even the <a href="https://www.nationalgeographic.com/science/health-and-human-body/human-diseases/the-plague/">Black Death</a> that began in the 14th century. </p>
<p>Could another catastrophic pandemic like the 1918 pandemic occur again? Yes, unless we protect ourselves better. To do that, we should emphasize high compliance with the flu vaccines that are currently available while we pursue the longer-term goal of a better vaccine.</p>
<p>I am a board-certified infectious disease physician as well as the epidemiologist at University of Florida Health. I have seen the ravages of flu firsthand as well as studied and quantified outbreaks. If vaccines had been available in 1918, there is no doubt that the death toll would have been lower. </p>
<h2>The flu past and present</h2>
<p>Influenza has been infecting humans for thousands of years. It was described by Hippocrates as early as 412 B.C. While the symptoms of influenza and the common cold overlap – including cough, fever, runny nose, headache and body aches – <a href="https://www.cdc.gov/flu/about/qa/coldflu.htm">influenza is more severe</a>.</p>
<p>People whose immune systems are compromised, pregnant women and people aged 65 and older are at particularly high risk for complications from influenza. This includes <a href="https://www.cdc.gov/flu/about/disease/high_risk.htm">respiratory failure and death</a>. Usually, the mortality rate is about <a href="https://www.cdc.gov/flu/weekly/index.htm">0.1 percent</a>. While this doesn’t sound like much, multiply it by hundreds of thousands of infections every year, and the death toll mounts up. </p>
<p>In 1918, the death toll was <a href="https://wwwnc.cdc.gov/eid/article/12/1/05-0979_article">exceptionally high, at about 2.5 percent</a>. When the 1918 virus was reconstructed from <a href="https://www.ncbi.nlm.nih.gov/pubmed/16210530">influenza victims buried in the Alaskan permafrost</a>, we scientists gained some insight into why: The reconstructed virus harbored mutations that enabled it to bind to cells deep in the lungs, causing a viral pneumonia. That is distinct from the less serious upper airway infection that flu usually causes. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/208686/original/file-20180302-65511-1edr5mk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/208686/original/file-20180302-65511-1edr5mk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=890&fit=crop&dpr=1 600w, https://images.theconversation.com/files/208686/original/file-20180302-65511-1edr5mk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=890&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/208686/original/file-20180302-65511-1edr5mk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=890&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/208686/original/file-20180302-65511-1edr5mk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1118&fit=crop&dpr=1 754w, https://images.theconversation.com/files/208686/original/file-20180302-65511-1edr5mk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1118&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/208686/original/file-20180302-65511-1edr5mk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1118&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A flyer from the Chicago Department of Health in 1918, warning residents of the danger of influenza and pneumonia.</span>
<span class="attribution"><a class="source" href="https://collections.nlm.nih.gov/catalog/nlm:nlmuid-101447458-img">John Dill Robertson/Chicago Department of Health</a></span>
</figcaption>
</figure>
<p>However, the 1918 virus was similar to other flu strains with regards to its propensity to cause a well-known complication of influenza called “post-influenza bacterial pneumonia,” or PIBP. The thinking is that damage to the lining of the respiratory tract caused by influenza renders a person susceptible to secondary infection by bacteria. In fact, most influenza-associated deaths that occur during normal flu seasons are caused by PIBP.</p>
<h2>Vaccination essential</h2>
<p>Death from PIBP continues to be an important driver of influenza-related mortality. Therefore, prevention is key. Vaccination is a crucial component of prevention efforts, and is <a href="https://www.cdc.gov/flu/protect/keyfacts.htm">recommended by the Centers for Disease Control and Prevention</a> for all individuals 6 months of age and older. </p>
<p>However, only <a href="https://www.cdc.gov/flu/fluvaxview/coverage-1516estimates.htm">about half of all eligible</a> people get the flu shot. Two misconceptions contribute to low vaccination rates: that the vaccine causes influenza and that the vaccine doesn’t work.</p>
<p>The first misconception is easy to dispel. The influenza shot contains only a virus that has been killed, or inactivated. There is no live virus in the vaccine that could cause infection. It’s as simple as that. You can’t catch flu from a dead virus.</p>
<p>Some people will still insist that they came down with the flu because of the vaccine. Confusion may occur if you are vaccinated and then develop influenza a few days later. Here’s why.</p>
<p>You can develop flu after you receive the vaccination, but that doesn’t mean the vaccine gave you influenza. Instead, it means you were already infected with influenza when you were vaccinated. Typically, your body needs about two weeks for the immune response to develop after a flu shot.</p>
<p>Since a person can transmit influenza 24 hours before symptoms begin, you may not realize from whom you caught it, because that person may have appeared healthy.</p>
<h2>Challenges of making an effective vaccine</h2>
<p>A second misconception about the shot “not working” stems from an overly broad extrapolation of “vaccine efficacy” studies. These are designed to approximate how many influenza infections are <a href="https://www.ncbi.nlm.nih.gov/pubmed/28818471">prevented by vaccination</a>. However, vaccine efficacy studies don’t tell us how sick a vaccinated person may be. </p>
<p>Many studies show that <a href="https://www.cdc.gov/flu/spotlights/vaccine-reduces-severe-outcomes.htm">vaccination decreases the severity of influenza</a> as well as influenza-related complications. This is an enormous benefit.</p>
<p>People also misconstrue concerns in the efficacy studies about the difference among influenza subtypes. </p>
<p>There are four main influenza subtypes that infect humans. Two are dubbed “flu A.” They are defined by key proteins, called hemagglutinin (“H”) and neuraminidase (“N”), found on their surfaces. The influenza A subtypes that cause most infections are subtypes H3N2, the prevalent subtype this year, and H1N1. </p>
<p>There are also two influenza B subtypes. They are called Yamagata and Victoria.</p>
<p>Every spring, scientists and public health officials from around the world meet to determine the vaccine formulation for the coming year, based on what they know about the strains that are circulating at that time. </p>
<p>Each influenza vaccine will contain both influenza A strains and one or both of the influenza B strains, depending on whether you receive a formulation with three strains or one with four strains. Efficacy can change each year because flu viruses are constantly mutating, so that the viruses causing infections might be quite different from the vaccine strains chosen months earlier.</p>
<p>For example, over the past few years, the <a href="https://www.cnbc.com/2018/02/15/cdc-releases-preliminary-flu-shot-effectiveness-data.html">efficacy for vaccine for H1N1 and the B strains</a> has been 40-60 percent. Efficacy for H3N2, however, has been lower, probably because it <a href="http://jvi.asm.org/content/80/7/3675.abstract">seems more prone to mutation</a>. </p>
<p>People who are eligible for the influenza shot but choose to skip it unnecessarily place themselves at increased risk for acquiring any of the four influenza strains or for a more severe disease if they do contract influenza. They also endanger others around them by potentially transmitting the infection.</p>
<p>Why doesn’t influenza vaccine efficacy exceed 60 percent? Vaccination against other diseases like measles or tetanus yields efficacy of 90 percent that lasts many years. The problem with influenza is its propensity to mutate, such that the strains causing disease this year are a bit different from last year’s. </p>
<p>When these changes occur in key viral sites such as in hemagglutinin, our immune system doesn’t recognize the mutated virus as well, and efficacy declines. Significant mutation can occur within a season too, as happened during 2014. Initially, the H3N2 vaccine strain chosen for the vaccine in February 2014 was well-matched to circulating strains, but by October of that year, <a href="https://www.ncbi.nlm.nih.gov/pubmed/27702768">H3N2 with mutated hemagglutinin had emerged</a> and was different enough such that H3N2 efficacy declined to 17 percent.</p>
<h2>Yearlong circulation likely increases mutation</h2>
<p>While people tend to think of influenza as a wintertime disease, since it usually peaks sometime between December and February in the Northern Hemisphere, flu is around all year. The year-round presence of influenza viruses amplifies the chance that mutations will accumulate. This leads not only to reduced efficacy but also increased potential for a pandemic.</p>
<p>This problem could be solved if we could engineer a vaccine that stimulated an immune response against a region of the virus that was less prone to mutation. It would be even better if this viral target were common to all influenza strains. Such a “<a href="https://theconversation.com/influenza-the-search-for-a-universal-vaccine-90908">universal vaccine</a>” is the Holy Grail of influenza research. </p>
<p>There are early-stage trials <a href="https://www.niaid.nih.gov/diseases-conditions/universal-influenza-vaccine-research">going on right now</a>. If we are to prevent another catastrophe like the 1918 influenza pandemic, we must continue to support research efforts aimed at developing a universal influenza vaccine.</p><img src="https://counter.theconversation.com/content/91194/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicole Iovine does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The 1918 flu pandemic has long puzzled those who study disease outbreaks. Why was it so severe? While that question is hard to answer, one thing is certain: Vaccines would have lessened the toll.Nicole Iovine, Associate Professor, Infectious Diseases, University of FloridaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/918872018-03-05T11:43:47Z2018-03-05T11:43:47ZHow historical disease detectives are solving mysteries of the 1918 flu<figure><img src="https://images.theconversation.com/files/208334/original/file-20180228-36689-ug6itt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">It can be difficult to find records from epidemics long past.</span> <span class="attribution"><a class="source" href="https://collections.nlm.nih.gov/catalog/nlm:nlmuid-101443594-img">U.S. National Library of Medicine</a></span></figcaption></figure><p>One hundred years ago, a novel pandemic influenza virus spread rapidly around the world. It <a href="https://www.ncbi.nlm.nih.gov/pubmed/11875246">killed about 1 to 2 percent</a> of the human population, primarily young and often healthy adults.</p>
<p>The centennial of the 1918 pandemic is a good time to take stock of how far the world has come since this historic health disaster – and to face the sobering fact that several key mysteries have yet to be resolved.</p>
<p>We and many other researchers around the world have been hard at work uncovering and analyzing old data sitting in dusty libraries, church records and long-forgotten vital statistics books. Together, our team has scoured archives from a number of cities and countries around the world, including in the U.S., Mexico, Chile, Japan and Denmark.</p>
<p>Armed with these data, we can reconstruct epidemics of the past. By understanding the epidemiological patterns associated with the 1918 and other pandemics, we hope that public health officials can better prepare for future health disasters.</p>
<h2>Digging through archives</h2>
<p>Gathering evidence from century-old death records is often tedious and challenging. One hundred years ago, <a href="https://www.ncbi.nlm.nih.gov/pubmed/21757096">death records</a> were not systematically archived and preserved in many areas of the world,
particularly in <a href="https://doi.org/10.1016/j.annepidem.2018.01.002">low-income countries</a>. </p>
<p>Consequently, we sometimes must blindly search for records in cemeteries, public and military archives, parishes and churches - a task with no guarantee of success. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/208333/original/file-20180228-36674-1kr9po2.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/208333/original/file-20180228-36674-1kr9po2.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/208333/original/file-20180228-36674-1kr9po2.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=440&fit=crop&dpr=1 600w, https://images.theconversation.com/files/208333/original/file-20180228-36674-1kr9po2.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=440&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/208333/original/file-20180228-36674-1kr9po2.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=440&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/208333/original/file-20180228-36674-1kr9po2.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=552&fit=crop&dpr=1 754w, https://images.theconversation.com/files/208333/original/file-20180228-36674-1kr9po2.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=552&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/208333/original/file-20180228-36674-1kr9po2.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=552&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Certificate of a death attributed to the 1918 influenza pandemic in Maricopa County, Arizona.</span>
<span class="attribution"><a class="source" href="http://genealogy.az.gov/">Arizona Department of Health Services</a></span>
</figcaption>
</figure>
<p>In the worst cases, the quality of the material has deteriorated substantially, making it impossible to extract key information. In 1918, death certificates were handwritten, and few deaths were certified by physicians. What’s more, data sometimes disappears entirely – as in Madagascar, where we discovered that precious data on childhood epidemics had been consumed in a fire.</p>
<p>Our team also experienced this challenge <a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=chowell+1918+peru">in Peru</a>, where we accessed over 50,000 death records from public archives. The records from Lima were in fair condition. But important details such as age and cause of death were either missing or illegible for the great majority of records from other locations, such as Iquitos City in the Amazonian jungle. </p>
<p>Often, researchers aren’t allowed to take valued historical records out of libraries. So we must spend long hours scanning these old records on-site and then manually digitizing them to make the information machine-readable. Only when the data have been digitally organized can the patterns of past influenza pandemics be revealed. </p>
<h2>Revealing patterns</h2>
<p>The deadly 1918 epidemic posed a few epidemiological puzzles. </p>
<p>The virus spread in an unusual way. Early outbreaks were mild and local – reported in a handful of countries around the world in the first half of 1918 – only to turn into uniquely severe infections later that year. </p>
<p>A single geographic community would be hit by <a href="https://doi.org/10.1016/j.annepidem.2018.02.013">multiple waves of infection</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/23230061">over a short time</a>. For example, the city of Copenhagen experienced <a href="https://www.ncbi.nlm.nih.gov/pubmed/18194088">three distinct outbreaks</a> between July 1918 and March 1919, as well as a fourth wave in the winter of 1919-20.</p>
<p>The pattern of deaths by age was also intriguing. Young adults in their late 20s were at heightened risk. In contrast, influenza infections were frequent among teenagers, but these infections were mild. Senior adults were also less likely than young adults to die from influenza in some but not all countries. Typically, seniors are the age group at highest risk of death <a href="https://www.ncbi.nlm.nih.gov/pubmed/19423872">from seasonal influenza</a>.</p>
<p>The data we’ve collected provides a better understanding of the timing and number of outbreaks <a href="https://doi.org/10.1016/j.annepidem.2018.02.013">before and after 1918</a>. We’ve also been able to construct patterns of death by age in different populations, particularly in the Americas and Europe.</p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/18808337">These studies</a> show that populations that experienced an early and often mild pandemic wave in the first half of 1918 <a href="https://doi.org/10.1016/j.annepidem.2018.02.013">fared better in the deadly autumn wave</a>. Our hypothesis was eventually supported when virologists <a href="https://www.ncbi.nlm.nih.gov/pubmed/21930918">recovered a pandemic-like virus</a> from preserved lung tissue of U.S. soldiers who died in summer 1918. This suggested that the pathogen responsible for the early waves was the novel pandemic virus.</p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/23230061">Our work also underscores</a> that young adults were at highest risk of dying. By contrast, the elderly enjoyed a reduced risk of death in well-connected locations in the U.S., such as <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1182402/">New York City</a>, as well as the U.K. and Denmark – but not in remote settings like <a href="https://www.ncbi.nlm.nih.gov/pubmed/20594109">Mexico</a>, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3310082/">Colombia</a> and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4214284/">Chile</a>.</p>
<p>Why were older adults spared? One popular explanation is that well-connected populations who had seen influenza in the 19th century would be protected upon the return of a similar virus decades later. This is known as the <a href="http://www.jstor.org/stable/985534">“antigen recycling” hypothesis</a>. This hypothesis gained more traction during the 2009 pandemic, when older populations had higher levels of prior antibodies and therefore were less likely to die than younger populations. </p>
<p>Our findings suggest that future influenza pandemics will likely hit in their own waves, depending on the weather and the way people come into contact with another. Moreover, patterns of infection and death may depend upon people’s prior immunity, imprinted by circulation of similar viruses within the last century. </p>
<h2>Lasting mysteries</h2>
<p>The pieces of the puzzles are slowly falling into place. However, key questions remain.</p>
<p>Perhaps the most striking mystery is why severe influenza infections spread so dramatically and disproportionately among young adults in 1918, relative to other influenza epidemics and other diseases. <a href="http://doi.org/10.1056/NEJMp0903906">This pattern was consistent</a> across people of different geographic, demographic and socioeconomic backgrounds.</p>
<p>There’s no shortage of hypotheses that try to explain this, but none has been conclusive so far. Given the paucity of biological material from this historical period, it’s likely that scientists won’t know the answer for a while – perhaps not until similar conditions are met in a future pandemic.</p>
<p>Other important gaps remain in our understanding of the 1918 pandemic, particularly regarding Asia and Africa, where most pandemic deaths likely occurred but records are scarce. </p>
<p>Our efforts are hampered by the gradual loss of historical information and difficulties in locating and accessing historic material. These data are rapidly disappearing. </p>
<p>But there is hope. <a href="https://doi.org/10.1016/j.annepidem.2017.12.005">With increasing availability</a> of online historical death and birth records compiled by private companies focused on ancestry and genealogy issues, we see a bright future for studies like our own.</p><img src="https://counter.theconversation.com/content/91887/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gerardo Chowell receives federal funding from the National Science Foundation and the US National Institutes of Health. He is affiliated with the Fogarty International Center, NIH.
</span></em></p><p class="fine-print"><em><span>This article does not represent the views of the NIH or the U.S. government.</span></em></p><p class="fine-print"><em><span>Lone Simonsen has received funding from the LundbeckFoundation in Denmark, and from EU Horizon2020 Marie Curie grant#659437. </span></em></p>One hundred years after a strange and devastating pandemic, researchers comb for clues in dusty libraries, church records and long- forgotten books.Gerardo Chowell, Professor of Mathematical Epidemiology, Georgia State UniversityCecile Viboud, Senior Research Scientist, National Institutes of HealthLone Simonsen, Professor, Roskilde UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/910452018-03-01T11:40:44Z2018-03-01T11:40:44ZHow the devastating 1918 flu pandemic helped advance US women’s rights<figure><img src="https://images.theconversation.com/files/208319/original/file-20180228-36671-jjv25p.jpg?ixlib=rb-1.1.0&rect=26%2C50%2C961%2C702&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">More women than men were left standing after the war and pandemic.</span> <span class="attribution"><a class="source" href="https://lccn.loc.gov/2011661525">Library of Congress</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>When disaster strikes, it can change the fabric of a society – often through the sheer loss of human life. The 2004 Indian Ocean tsunami <a href="https://www.theguardian.com/world/2005/jan/05/tsunami2004.internationalaidanddevelopment3">left 35,000 children</a> without one or both parents in Indonesia alone. The Black Death <a href="https://www.livescience.com/2497-black-death-changed-world.html">killed more than 75 million people</a> worldwide and <a href="http://www.history.com/topics/black-death">more than a third of Europe’s population</a> between 1347 and 1351. </p>
<p>While disasters are by definition devastating, sometimes they can lead to changes that are a small silver lining. The 2004 tsunami <a href="http://www.worldbank.org/en/news/feature/2012/12/26/indonesia-reconstruction-chapter-ends-eight-years-after-the-tsunami">ended a civil conflict in Indonesia</a> that had left 15,000 dead. The 14th century’s plague, <a href="https://www.rwjf.org/en/culture-of-health/2013/12/the_five_deadliesto.html">probably the most deadly disaster in human history</a>, set free many serfs in Europe, forced wages for laborers to rise, and caused a fundamental shift in the economy along with an increased standard of living for survivors.</p>
<p>One hundred years ago, a powerful strain of the flu swept the globe, infecting one third of the world’s population. The aftermath of this disaster, too, led to unexpected social changes, opening up new opportunities for women and in the process irreversibly transforming life in the United States.</p>
<p>The virus disproportionately affected young men, which in combination with World War I, created a shortage of labor. This gap enabled women to play a new and indispensible role in the workforce during the crucial period just before the ratification of the 19th Amendment, which <a href="https://www.loc.gov/rr/program/bib/ourdocs/19thamendment.html">granted women suffrage in the United States</a> two years later.</p>
<h2>Why did the flu affect men more than women?</h2>
<p><a href="https://theconversation.com/the-greatest-pandemic-in-history-was-100-years-ago-but-many-of-us-still-get-the-basic-facts-wrong-89841">Known as the Spanish flu</a>, the 1918 “great influenza” left <a href="https://www.cnn.com/2018/01/29/health/1918-flu-history-partner/index.html">more than 50 million people dead</a>, including around <a href="https://www.smithsonianmag.com/history/journal-plague-year-180965222/">670,000</a> in the United States.</p>
<p>To put that in perspective, World War I, which concluded just as the flu was at its worst in November 1918, killed around 17 million people – <a href="http://www.bbc.com/news/magazine-25776836">a mere third of the fatalities caused by the flu</a>. <a href="http://www.nytimes.com/books/first/k/kolata-flu.html">More American soldiers died from the flu</a> than were killed in battle, and many of the deaths attributed to World War I were caused by a combination of the war and the flu.</p>
<p>The war provided near perfect conditions for the spread of flu virus via the respiratory droplets exhaled by infected individuals. Military personnel – predominantly young males – spent months at a time in close quarters with thousands of other troops. This proximity, combined with <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1361287/">the stress</a> of war and the malnutrition that sometimes accompanied it, created weakened immune systems in soldiers and allowed the virus spread like wildfire.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/208320/original/file-20180228-36703-1k4dxiw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/208320/original/file-20180228-36703-1k4dxiw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/208320/original/file-20180228-36703-1k4dxiw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=760&fit=crop&dpr=1 600w, https://images.theconversation.com/files/208320/original/file-20180228-36703-1k4dxiw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=760&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/208320/original/file-20180228-36703-1k4dxiw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=760&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/208320/original/file-20180228-36703-1k4dxiw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=955&fit=crop&dpr=1 754w, https://images.theconversation.com/files/208320/original/file-20180228-36703-1k4dxiw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=955&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/208320/original/file-20180228-36703-1k4dxiw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=955&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">When soldiers shipped out, influenza virus could be stowing away onboard.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Eawatchf-AP-I-APHSL-USA-WWI-American-Troops/276539db593a4899b405f9ca175e85fb/1/0">AP Photo</a></span>
</figcaption>
</figure>
<p>Overcrowding in training camps, trenches and hospitals <a href="https://www.theguardian.com/science/grrlscientist/2014/jul/30/influenza-pandemic-1918-viruses-biology-medicine-history">created an ideal environment</a> for the 1918 influenza strain to infect high numbers of people. In fact, the conditions of war helped the virus perfect itself <a href="https://wwwnc.cdc.gov/eid/article/12/1/05-0979_article">through several waves of infection</a>, each more deadly than the last.</p>
<p>Many troops were doomed before they even reached Europe, contracting the flu on the packed troop ships where a single infected soldier could spread the virus throughout. When soldiers returned to the U.S., they scattered to every state, bringing the flu along with them. </p>
<p>It was more than just male conscription in war, however, that led to a greater number of men who were infected and died from the flu. Even at home, among those that were never involved in the war effort, the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2740912/">death rate for men exceeded that of women</a>. Demographic studies show that nearly <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2740912/">175,000 more men died than women in 1918</a>.</p>
<p>In general, epidemics tend to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2740912/">kill more men than women</a>. In disease outbreaks throughout history, as well as almost all of the world’s major famines, women have a longer life expectancy than men and often <a href="http://www.pnas.org/content/early/2018/01/03/1701535115">have greater survival rates</a>.</p>
<p>The exact reason why men tend to be more vulnerable to the flu than women continues to elude researchers. The scoffing modern term “man flu” refers to the perception that men are overly dramatic when they fall ill; But recent research suggests that there <a href="https://doi.org/10.1136/bmj.j5560">may be more to it</a> than just exaggerated symptoms.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/208321/original/file-20180228-36674-1uzoi6r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/208321/original/file-20180228-36674-1uzoi6r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/208321/original/file-20180228-36674-1uzoi6r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=426&fit=crop&dpr=1 600w, https://images.theconversation.com/files/208321/original/file-20180228-36674-1uzoi6r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=426&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/208321/original/file-20180228-36674-1uzoi6r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=426&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/208321/original/file-20180228-36674-1uzoi6r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=535&fit=crop&dpr=1 754w, https://images.theconversation.com/files/208321/original/file-20180228-36674-1uzoi6r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=535&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/208321/original/file-20180228-36674-1uzoi6r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=535&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The flu’s aftermath furthered a trend started by the war effort.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Associated-Press-Domestic-News-Pennsylvania-Uni-/a8dcff1102e5da11af9f0014c2589dfb/2/0">AP Photo</a></span>
</figcaption>
</figure>
<h2>Flu brought more women into the workforce</h2>
<p>The severity of the epidemic in the U.S. was enough to temporarily shut down parts of the economy in 1918. In New England, <a href="http://www.cidrap.umn.edu/sites/default/files/public/downloads/cidrap_coal_report.pdf">coal deliveries were so severely affected</a> that people, unable to keep their homes heated, froze to death at the height of winter. During the 1918 flu outbreak, researchers estimate businesses in Little Rock, Arkansas, saw <a href="https://www.stlouisfed.org/%7E/media/Files/PDFs/Community-Development/Research-Reports/pandemic_flu_report.pdf?la=en">a decline of 40 to 70 percent</a>. </p>
<p>The worker shortage caused by the flu and World War I opened access to the labor market for women, and in unprecedented numbers they took jobs outside the home. Following the conclusion of the war, the number of women in the workforce was <a href="http://www.american-historama.org/1913-1928-ww1-prohibition-era/women-in-the-1920s.htm">25 percent higher than it had been</a> previously and by 1920 <a href="https://www.dol.gov/wb/info_about_wb/interwb.htm">women made up 21 percent</a> of all gainfully employed individuals in the country. While this gender boost is often ascribed to World War I alone, women’s increased presence in the workforce would have been far less pronounced without the 1918 flu.</p>
<p>Women began to move into employment roles that were previously <a href="https://www.thoughtco.com/women-in-world-war-1-1222109">held exclusively by men</a>, many of which were in manufacturing. They were even able to enter fields from which they had been banned, such as the textile industry. As women filled what had been typically male workplace roles, they also began to <a href="http://time.com/3774661/equal-pay-history/">demand equal pay</a> for their work. Gaining greater economic power, women began more actively advocating for various women’s rights issues – including, <a href="http://history.house.gov/Exhibitions-and-Publications/WIC/Historical-Essays/No-Lady/Womens-Rights/">but not limited to, the right to vote</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/208322/original/file-20180228-36703-txw39t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/208322/original/file-20180228-36703-txw39t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/208322/original/file-20180228-36703-txw39t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=341&fit=crop&dpr=1 600w, https://images.theconversation.com/files/208322/original/file-20180228-36703-txw39t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=341&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/208322/original/file-20180228-36703-txw39t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=341&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/208322/original/file-20180228-36703-txw39t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=428&fit=crop&dpr=1 754w, https://images.theconversation.com/files/208322/original/file-20180228-36703-txw39t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=428&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/208322/original/file-20180228-36703-txw39t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=428&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Once a woman’s the boss, how can you deny her the vote?</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Watchf-AP-A-DC-USA-APHS350732-Women-s-Suffrage/3dd9b4d05c8647d1aeb2e4610cdeae7a/3/0">AP Photo</a></span>
</figcaption>
</figure>
<h2>How the flu helped change people’s minds</h2>
<p>Increased participation in the workforce allowed many women to obtain <a href="https://www.warandgender.com/wgwomwwi.htm">social and financial independence</a>. Leadership positions within the workforce could now be occupied by women, especially in the garment industry, but also <a href="http://teachersinstitute.yale.edu/curriculum/units/2002/3/02.03.09.x.html">in the military and police forces</a>. The U.S. even got its <a href="https://www.afscme.org/for-members/womens-leadership-training/leadership-tools/body/Women_in_Labor_History_Timeline.pdf">first woman governor</a>, when Nellie Taylor Ross took her oath of office, in 1923, in Wyoming. An increased ability to make decisions in their personal and professional lives empowered many women and started to elevate their standing.</p>
<p>With the war over and increased female participation in the labor force, politicians could not ignore the critical role that women played in American society. <a href="https://www.nytimes.com/2018/01/30/world/europe/1918-flu-war-centennial.html">Even President Woodrow Wilson</a> began to argue in 1918 that women were part of the American war effort and economy more broadly, and as such, should be afforded the right to vote. </p>
<p>Outside of work, women also became more involved in community decision-making. Women’s changing social role <a href="http://time.com/3774661/equal-pay-history/">increased support</a> for women’s rights. In 1919, the National Federation of Business and Professional Women’s Clubs was founded. The organization <a href="https://www.afscme.org/for-members/womens-leadership-training/leadership-tools/body/Women_in_Labor_History_Timeline.pdf">focused on</a> eliminating sex discrimination in the workforce, making sure women got equal pay and creating a comprehensive equal rights amendment.</p>
<p>The 1918 influenza pandemic was devastating. But the massive human tragedy had one silver lining: It helped elevate women in American society socially and financially, providing them more freedom, independence and a louder voice in the political arena.</p><img src="https://counter.theconversation.com/content/91045/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>With many men ‘missing’ from the population in the aftermath of the 1918 flu, women stepped into public roles that hadn’t previously been open to them.Christine Crudo Blackburn, Postdoctoral Research Fellow, Scowcroft Institute of International Affairs, Bush School of Government and Public Service, Texas A&M UniversityGerald W Parker, Associate Dean For Global One Health, College of Veterinary Medicine & Biomedical Sciences; and Director, Pandemic and Biosecurity Policy Program, Scowcroft Institute for International Affairs, Bush School of Government and Public Service, Texas A&M UniversityMorten Wendelbo, Research Fellow, American UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/909082018-02-15T11:37:52Z2018-02-15T11:37:52ZInfluenza: The search for a universal vaccine<figure><img src="https://images.theconversation.com/files/206388/original/file-20180214-174959-1ookhri.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Could the yearly flu shot become a thing of the past?</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/HealthBeat-Flu-Shots-Things-to-Know/1785b0ccc496487f9768ae2315387e89/6/0">AP Photo/Darron Cummings, File</a></span></figcaption></figure><p>The current 2017-18 flu season is a bad one. <a href="https://www.cdc.gov/media/releases/2018/t0202-flu-update-activity.html">Hospitalization rates are now</a> higher than in recent years at the same point, and <a href="https://www.nytimes.com/2018/02/02/health/flu-symptoms-virus-hospital.html">infection rates are still rising</a>. The best line of defense is the seasonal influenza vaccine. But <a href="https://doi.org/10.1073/pnas.1712377114">H3N2 viruses</a>, like the one that’s infecting many people this year, are particularly hard to defend against, and this year’s shot <a href="https://www.statnews.com/2018/02/01/flu-vaccine-protection-h3n2/">isn’t very protective</a> against H3N2.</p>
<p>Producing an effective annual flu shot relies on accurately predicting which flu strains are most likely to infect the population in any given season. It requires the coordination of multiple health centers around the globe as the virus travels from region to region. Once epidemiologists settle on target flu strains, vaccine production shifts into high gear; it takes <a href="https://www.cdc.gov/flu/about/season/vaccine-selection.htm">at least six months</a> to generate the <a href="https://www.cdc.gov/flu/professionals/vaccination/vaccinesupply.htm">more than 140 million doses</a> necessary for the American population.</p>
<p><iframe id="FuXSX" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/FuXSX/1/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>Incorrect or incomplete epidemiological forecasting can have major consequences. In 2009, while manufacturers were preparing vaccines against the forecasted strains, an <a href="https://www.cdc.gov/h1n1flu/cdcresponse.htm#A_Pandemic_Is_Declared">unanticipated H1N1 influenza virus</a> emerged. The prepared seasonal vaccine didn’t protect against this unanticipated virus, causing worldwide panic and over 18,000 confirmed deaths. This was likely only a fraction of the true number of deaths, <a href="http://dx.doi.org/10.1016/S1473-3099(12)70121-4">estimated to exceed 150,000</a>. Better late than never, a <a href="https://www.cdc.gov/flu/pastseasons/0910season.htm">vaccine was eventually produced against the emergent H1N1</a>, requiring a second flu shot that year.</p>
<p>Given that influenza has caused the majority of <a href="https://www.cdc.gov/flu/pandemic-resources/basics/past-pandemics.html">pandemics over the past 100 years</a> – including the 1918 flu that <a href="http://doi.org/10.1353/bhm.2002.0022">resulted in as many as 50 million deaths</a> – we’re left with the question: Can scientists produce a “universal” vaccine? An ideal version would be capable of protecting against diverse strains of influenza and wouldn’t require a yearly shot for you.</p>
<h2>Vaccines prime the immune system to fight</h2>
<p>By the 18th century, and arguably much earlier in history, it was commonly known that a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1200696/">survivor of smallpox would not come down with it again</a> upon subsequent exposure. Somehow, infection conferred immunity against the disease. In fact, people recognized that milkmaids who came into contact with cowpox-ridden cattle would similarly be protected from smallpox.</p>
<p>In the late 1700s, farmer <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1200696/">Benjamin Jesty inoculated his family with cowpox</a>, effectively immunizing them against smallpox. Physician <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC495097/">Edward Jenner then catapulted humanity into a new age of immunology</a> when he lent scientific credence to the procedure.</p>
<p>So if one inoculation of cowpox or one exposure to (and survival of) smallpox confers a decade’s worth or even lifelong immunity, why are individuals encouraged to receive the flu vaccine every year? </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/152325/original/image-20170110-29000-ditp3r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/152325/original/image-20170110-29000-ditp3r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/152325/original/image-20170110-29000-ditp3r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=471&fit=crop&dpr=1 600w, https://images.theconversation.com/files/152325/original/image-20170110-29000-ditp3r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=471&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/152325/original/image-20170110-29000-ditp3r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=471&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/152325/original/image-20170110-29000-ditp3r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=592&fit=crop&dpr=1 754w, https://images.theconversation.com/files/152325/original/image-20170110-29000-ditp3r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=592&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/152325/original/image-20170110-29000-ditp3r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=592&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">An artist’s rendition of the anatomy of a virus.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/wellcomeimages/30738089686">Anna Tanczos/Wellcome Images</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<p>The answer lies in how quickly the influenza virus’s anatomy changes. Each virus consists of a roughly spherical membrane encapsulating constantly mutating genetic material. This membrane is peppered with two types of “spikes”: hemagglutinin, or HA, and neuraminidase, or NA, each made up of a stem and a head. HA and NA help the virus with infection by binding to host cells. They mediate the entry of the virus into the cell and, once it replicates, the eventual exit.</p>
<p>Once a doctor injects a vaccine, an individual’s immune system gets to work by making antibodies that recognize, for example, the hemagglutinin it contains. The next time that hemagglutinin shows up – such as in the form of the virus strains the vaccine mimicked – the body’s immune cells recognize them and fight them off, preventing infection.</p>
<p>For vaccine developers, one frustrating characteristic about influenza’s mutating genome is how rapidly HA and NA change. These constant alterations are what send them back to the drawing board for new vaccines every flu season.</p>
<h2>Different methods to design a vaccine</h2>
<p>The smallpox vaccine was one of the earliest to use the “empirical paradigm” of vaccinology – the same strategy we largely use today. It relies on a trial-and-error approach to mimic the immunity induced by natural infection.</p>
<p>In other words, vaccine developers believe the body will react to something in the inoculation. But they don’t focus on which specific patch of the virus is causing that immune response. It doesn’t really matter if it’s a reaction to a small patch of HA that many strains share, for instance. When using an entire virus as starting material, it’s possible to get many different antibodies recognizing many different parts of the virus used in the vaccine.</p>
<p>The seasonal flu shot generally fits into this empirical approach. Each year, epidemiologists forecast which flu strains are most likely to infect populations, typically settling on three or four. Researchers then attenuate or inactivate these strains so they can act as the mimics in that year’s influenza vaccine without giving recipients the flu. The hope is that an individual’s immune system will respond to the vaccine by creating antibodies that target these strains; then when he or she comes into contact with the flu, the antibodies will be waiting to neutralize those strains. </p>
<p>But there’s a different way to design a vaccine. It’s <a href="https://doi.org/10.1371/journal.ppat.1003001">called rational design</a> and represents a potentially game-changing paradigm shift in vaccinology. </p>
<p>The goal is to design some molecule – or immunogen – that can trigger the production of effective antibodies without requiring exposure to the virus. Relative to current vaccines, the engineered immunogen may even allow for more specific responses, meaning the immune response targets particular regions of the virus. There’s the possibility of greater breadth, too, meaning it could target multiple strains or even related viruses.</p>
<p>This strategy works to target specific epitopes, or patches of the virus. Since antibodies work by recognizing structures, the designers want to emphasize to the immune system the structural properties of the immunogens they’ve created. Then researchers can try to design candidate vaccines with those structures in hopes they’ll provoke the immune system to produce relevant antibodies. This path might let them assemble a vaccine that elicits a more effective and efficient immune response than would be possible with the traditional trial-and-error method.</p>
<p>Promising headway has been made in <a href="http://doi.org/10.1038/nature12966">vaccine design for respiratory syncytial virus</a> using this new rational paradigm, but efforts are still underway to use this general approach for influenza.</p>
<h2>Toward a universal flu vaccine</h2>
<p>In recent years, researchers have isolated a number of potent, infleunza-neutralizing antibodies produced in our bodies. While the antibody response to influenza is <a href="http://doi.org/10.1128/JVI.03562-13">primarily directed at the head of the HA spike</a>, several have been found that <a href="http://doi.org/10.1038/nsmb.1566">target HA’s stem</a>. Since the stem is more constant across viral strains than the head, this could be flu’s Achilles’ heel, and antibodies that fix on this region may be a good target for vaccine design.</p>
<p>Researchers are pursuing a number of approaches that could cause the body to produce these antibodies of interest before becoming infected. In one strategy, scientists attached lab-made copies of hemagglutanin stems to a spherical protein nanoparticle. The resultant structure isn’t a virus and doesn’t even contain any viral genetic material. But it looks a lot like a virus to the body’s immune system, and so <a href="https://retrovirology.biomedcentral.com/articles/10.1186/s12977-015-0210-4">elicits a good antibody response</a>. And, because only the stem is attached to the nanoparticle, the immune system can focus the antibody response on these regions which are more similar from strain to strain than the head. This general approach has seen success both <a href="https://doi.org/10.1038/s41467-017-02725-4">in mice</a> <a href="https://doi.org/10.1038/nm.3927">and ferrets</a>, but further testing is required before it can be tried in people.</p>
<p>With current technology, there may never be a “one and done” flu shot. And epidemiological surveillance will always be necessary. However, it is not inconceivable that we can move from a once-per-year model to a once-every-10-years approach, and the field has been making huge strides to achieve this.</p>
<p><em>This is an updated version of an article <a href="https://theconversation.com/influenza-the-search-for-a-universal-vaccine-68947">originally published on Jan. 11, 2017</a>.</em></p><img src="https://counter.theconversation.com/content/90908/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ian Setliff's institution receives funding from the NIH and Ian is affiliated with the Vanderbilt Vaccine Center.</span></em></p><p class="fine-print"><em><span>Amyn Murji receives funding from the NIH and is affiliated with the Vanderbilt Vaccine Center.</span></em></p>Flu virus mutates so quickly that one year’s vaccine won’t work on the next year’s common strains. But rational design – a new way to create vaccines – might pave the way for more lasting solutions.Ian Setliff, Ph.D. Candidate in Chemical & Physical Biology, Vanderbilt Vaccine Center, Vanderbilt UniversityAmyn Murji, Ph.D. Student in Microbiology and Immunology, Vanderbilt Vaccine Center, Vanderbilt UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/915302018-02-12T11:43:37Z2018-02-12T11:43:37ZWhat the flu does to your body, and why it makes you feel so awful<figure><img src="https://images.theconversation.com/files/205740/original/file-20180209-51713-1qvy1ld.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A flu patient at ProMedica Toledo Hospital in Toledo, Ohio on Jan. 8, 2018. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/APTOPIX-Hospitals-Flu-Season-Shortages/22b58bba13a14e07856b08f3731069d4/25/0">AP Photo/Tony Dejak</a></span></figcaption></figure><p>Every year, from 5 to 20 percent of the people in the United States will become infected with influenza virus. An <a href="https://www.webmd.com/cold-and-flu/flu-statistics">average of 200,000</a> of these people will require hospitalization and up to 50,000 will die. <a href="https://www.cdc.gov/flu/about/disease/65over.htm">Older folks</a> over the age of 65 are especially susceptible to influenza infection, since the immune system becomes weaker with age. In addition, older folks are also <a href="https://www.frontiersin.org/articles/10.3389/fimmu.2016.00041/full">more susceptible</a> to long-term disability following influenza infection, especially if they are hospitalized. </p>
<p>We all know the <a href="https://www.cdc.gov/flu/consumer/symptoms.htm">symptoms of influenza</a> infection include fever, cough, sore throat, muscle aches, headaches and fatigue. But just what causes all the havoc? What is going on in your body as you fight the flu?</p>
<p>I am a researcher who specializes in immunology at the University of Connecticut School of Medicine, and my laboratory focuses on how influenza infection affects the body and how our bodies combat the virus. It’s interesting to note that many of the body’s defenses that attack the virus also cause many of the symptoms associated with the flu.</p>
<h2>How the flu works its way into your body</h2>
<p>Influenza virus causes an infection in the <a href="https://www.cdc.gov/flu/keyfacts.htm">respiratory tract</a>, or nose, throat and lungs. The virus is inhaled or transmitted, usually via your fingers, to the mucous membranes of the mouth, nose or eyes. It then travels down the respiratory tract and binds to epithelial cells lining the lung airways via specific molecules on the cell surface. Once inside the cells, the virus hijacks the protein manufacturing machinery of the cell to generate its own viral proteins and create more viral particles. Once mature viral particles are produced, they are released from the cell and can then go on to invade adjacent cells. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/205741/original/file-20180209-51703-12yphpi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/205741/original/file-20180209-51703-12yphpi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/205741/original/file-20180209-51703-12yphpi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/205741/original/file-20180209-51703-12yphpi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/205741/original/file-20180209-51703-12yphpi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/205741/original/file-20180209-51703-12yphpi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/205741/original/file-20180209-51703-12yphpi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Influenza gets a foothold in the respiratory tract but can make a person feel bad all over.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-ill-man-lying-bed-home-626483303?src=l0ISivor8uEQ9Pq_-I4X7Q-1-39">Africa Studio/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>While this process causes some lung injury, most of the symptoms of the flu are actually caused by the immune response to the virus. The initial immune response involves cells of the body’s innate immune system, such as <a href="https://www.hindawi.com/journals/mi/2016/5894347/">macrophages and neutrophils</a>. These cells express receptors that are able to sense the presence of the virus. They then sound the alarm by producing small hormone-like molecules called <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2785020/">cytokines</a> and <a href="https://www.news-medical.net/health/What-are-Chemokines.aspx">chemokines</a>. These alert the body that an infection has been established. </p>
<p>Cytokines orchestrate other components of the immune system to appropriately fight the invading virus, while chemokines direct these components to the location of infection. One of the types of cells called into action are <a href="https://www.medicinenet.com/script/main/art.asp?articlekey=11300">T lymphocytes</a>, a type of white blood cell that fights infection. Sometimes, they are even called “soldier” cells. When T cells specifically recognize influenza virus proteins, they then begin to proliferate in the lymph nodes around the lungs and throat. This causes swelling and pain in these lymph nodes. </p>
<p>After a few days, these T cells move to the lungs and begin to kill the virus-infected cells. This process creates a great deal of lung damage similar to bronchitis, which can worsen existing lung disease and make breathing difficult. In addition, the buildup of mucous in the lungs, as a result of this immune response to infection, induces <a href="https://www.medicalnewstoday.com/articles/320190.php">coughing as a reflex</a> to try to clear the airways. Normally, this damage triggered by arrival of T cells in the lungs is reversible in a healthy person, but when it advances, it is bad news and can lead to death.</p>
<p>The proper functioning of influenza-specific T cells is critical for efficient clearance of the virus from the lungs. When T cell function declines, such as with increasing age or during use of immunosuppressive drugs, viral clearance is delayed. This results in a prolonged infection and greater lung damage. This can also set the stage for complications including secondary <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5481322/#B24">bacterial pneumonia</a>, which can often be deadly.</p>
<h2>Why your head hurts so much</h2>
<p>While the influenza virus is wholly contained in the lungs under normal circumstances, several symptoms of influenza are systemic, including fever, headache, fatigue and <a href="https://www.cdc.gov/flu/consumer/symptoms.htm">muscle aches</a>. In order to properly combat influenza infection, the cytokines and chemokines produced by the innate immune cells in the lungs become systemic – that is, they enter the bloodstream, and contribute to these systemic symptoms. When this happens, a cascade of complicating biological events occur.</p>
<p>One of the things that happens is that <a href="https://www.ncbi.nlm.nih.gov/pubmed/9620641">Interleukin-1</a>, an inflammatory type of cytokine, is activated. Interleukin-1 is important for developing the killer T cell response against the virus, but it also affects the part of the brain in the hypothalamus that regulates body temperature, resulting in fever and headaches. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/205743/original/file-20180209-51713-1rkawok.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/205743/original/file-20180209-51713-1rkawok.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/205743/original/file-20180209-51713-1rkawok.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/205743/original/file-20180209-51713-1rkawok.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/205743/original/file-20180209-51713-1rkawok.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/205743/original/file-20180209-51713-1rkawok.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/205743/original/file-20180209-51713-1rkawok.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A healthy human T cell.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Healthy_Human_T_Cell.jpg">Flickr/NIAID.com</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
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</figure>
<p>Another important cytokine that fights influenza infection is something called “<a href="https://www.webmd.com/rheumatoid-arthritis/how-does-tnf-cause-inflammation#1">tumor necrosis factor alpha</a>.” This cytokine can have<a href="http://jvi.asm.org/content/76/3/1071.full"> direct antiviral effects</a> in the lungs, and that’s good. But it can also cause fever and appetite loss, fatigue and weakness during influenza and other types of infection.</p>
<h2>Why your muscles ache</h2>
<p>Our research has also uncovered another aspect of <a href="http://www.aging-us.com/article/100882/text">how influenza infection affects our bodies</a>. </p>
<p>It is well-known that muscle aches and weakness are prominent symptoms of influenza infection. Our study in an animal model found that influenza infection leads to an increase in the expression of muscle-degrading genes and a decrease in expression of muscle-building genes in skeletal muscles in the legs. </p>
<p>Functionally, influenza infection also hinders walking and leg strength. Importantly, in young individuals, these effects are transient and return to normal once the infection was cleared. </p>
<p>In contrast, these effects can linger significantly longer in older individuals. This is important, since a decrease in leg stability and strength could result in older folks being more prone to falls during recovery from influenza infection. It could also result in long-term disability and lead to the need for a cane or walker, limiting mobility and independence. </p>
<p>Researchers in my lab think that this impact of influenza infection on muscles is another unintended consequence of the immune response to the virus. We are currently working to determine what specific factors produced during the immune response are responsible for this and if we can find a way to prevent it. </p>
<p>Thus, while you feel miserable when you have an influenza infection, you can rest assured that it is because your body is fighting hard. It’s combating the spread of the virus in your lungs and killing infected cells.</p><img src="https://counter.theconversation.com/content/91530/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Laura Haynes receives funding from the National Institutes of Health. </span></em></p>Anyone who’s had the flu can attest that it makes them feel horrible. But why? What is going on inside the body that brings such pain and malaise? An immunologist explains.Laura Haynes, Professor of Immunology, University of ConnecticutLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/913002018-02-09T12:46:11Z2018-02-09T12:46:11Z3 ways the US should prepare for the next flu pandemic<p>The flu is wreaking havoc globally this year. Influenza infections are on the rise, with <a href="https://www.cdc.gov/media/releases/2018/t0202-flu-update-activity.html">the Centers for Disease Control and Prevention predicting</a> that this year’s strain will cause the highest rate of hospitalizations and deaths in a decade. </p>
<p>This year also marks the 100th anniversary of the 1918 influenza pandemic. This pandemic was the worst flu outbreak in history, <a href="https://doi.org/10.1353/bhm.2002.0022">killing tens of millions of people</a> around the world. </p>
<p>As an expert in public health law, I can state two things with confidence. First, the U.S. has made enormous strides in preparing for and treating the flu. And second, we still are not nearly as prepared as we need to be for the next pandemic. </p>
<h2>A global scourge</h2>
<p>The 1918 influenza strain was unusually deadly because humans had not been exposed widely to the H1N1 strain of the virus. It overwhelmed our naive immune systems. What’s more, influenza vaccines and other modern medical treatments had not yet been developed and infection control strategies were poorly understood. The spread of the disease was also <a href="https://www.smithsonianmag.com/history/journal-plague-year-180965222">fueled by troop movements</a> connected with World War I. </p>
<p>Since 1918, flu outbreaks have <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5933a1.htm">fluctuated in size</a>, but overall become less severe. Scientific advances have made influenza more preventable and treatable. Public health officials now know better how to contain influenza outbreaks and minimize their harm. </p>
<p>Nevertheless, the flu remains a persistent global scourge. Each year, the disease kills an estimated 12,000 to 56,000 people <a href="https://www.cdc.gov/flu/about/disease/2015-16.htm">in the U.S.</a> and 291,000 to 646,000 people <a href="https://doi.org/10.1016/S0140-6736(17)33293-2">worldwide</a>. The influenza virus mutates rapidly and infects other animals in addition to humans, which allows <a href="https://doi.org/10.1073/pnas.0904991106">new viral combinations</a> to emerge and challenge our immune systems. </p>
<p>If the world were to face a new strain of flu similar in novelty and virulence to the 1918 virus, our capacity to prevent a pandemic would still fall short because we have not made sufficient progress in science, infrastructure or implementation of preparedness plans.</p>
<h2>1. Develop stronger vaccines</h2>
<p>So how can the U.S. improve its ability to stop a new flu pandemic, as well as to reduce the annual impact of influenza infections?</p>
<p>First, researchers need to improve the flu vaccine. Most flu vaccine production currently relies on <a href="https://www.niaid.nih.gov/diseases-conditions/influenza-vaccine-production-and-design">antiquated technology</a> that requires experts to predict the most likely strains early each flu season. Manufacturers must grow the vaccine in <a href="https://www.statnews.com/2017/11/07/flu-vaccine-egg-production/">chicken eggs</a>, a process that takes weeks and limits the ability to make adjustments to the vaccine during the flu season. </p>
<p>Efforts are underway to develop new technologies, including a <a href="https://doi.org/10.1016/j.vaccine.2015.08.053">universal flu vaccine</a> that could protect against multiple strains of influenza A, including novel strains, and last for several years. </p>
<p>But the federal government has only allocated <a href="https://www.nytimes.com/2018/01/08/opinion/flu-pandemic-universal-vaccine.html">US$75 million this year</a> toward flu vaccine research. This is not nearly enough. Ideally, there would be four or five times more federal money available for this research.</p>
<h2>2. Spot outbreaks early</h2>
<p>Second, to prevent flu pandemics, public health officials need more and better information about influenza outbreaks. </p>
<p>Right now, the World Health Organization collects data on <a href="http://www.who.int/influenza/gisrs_laboratory/en/">flu outbreaks</a> from multiple sources in 114 countries. But much of the data – and the funding – for global surveillance comes from the U.S. and other wealthy countries.</p>
<p>This is not sufficient to detect a pandemic strain quickly enough. New strains are most likely to emerge in <a href="https://doi.org/10.1016/S0140-6736(10)62004-1">developing countries</a> with dense populations and more frequent human-animal contact. In an increasingly interconnected world, emerging infections can spread rapidly through travel and trade, as with the <a href="https://doi.org/10.1016/j.vaccine.2010.05.031">2009 swine flu outbreak</a>.</p>
<p>Developing countries have the least resources for surveillance and treatment. They also face <a href="https://dx.doi.org/10.3201/eid1406.070839">disproportionately high rates</a> of flu deaths and infections. People in these countries will likely bear the brunt of a pandemic, which will be able to spread quickly in crowded megacities with inadequate public health services and limited capacity to track infections. </p>
<p>If the <a href="http://www.who.int/influenza/resources/documents/technical_consultation/en/">surveillance system were expanded</a> to include more humans and animals in less wealthy countries, it would allow officials to detect outbreaks earlier and better track an infection as it spreads.</p>
<p>The CDC has led efforts to coordinate global surveillance. But the Trump administration hopes to <a href="https://www.theatlantic.com/health/archive/2018/02/cdc-funding-pandemics/552224/">slash funding</a> for the CDC, as well as <a href="https://www.kff.org/global-health-policy/issue-brief/what-could-us-budget-cuts-mean-for-global-health/">global health programs</a>. If cuts are enacted, it would imperil these efforts. </p>
<h2>3. Make sure everyone is prepared</h2>
<p>Finally, government officials and other members of the health community need to pay more attention to plans for public health emergency preparedness. </p>
<p>On a federal and state level, many officials have prepared for a sudden upsurge in flu-related illness by conducting training exercises for health care workers and stockpiling resources, such as Tamiflu and <a href="https://www.apnews.com/c62970809845472cae7302125109399d">IV bags</a>. </p>
<p>But these efforts <a href="http://healthyamericans.org/assets/files/TFAH-2017-ReadyOrNot-FINAL.pdf">vary wildly</a> across the country. Laws in some states have streamlined the process to expand the health care workforce, implement measures to keep people apart during outbreaks, or enact other strategies that may help reduce the spread of influenza and lessen the impact of a severe outbreak.</p>
<p>However, many plans remain incomplete. Funding tends to go up after notable disasters and then <a href="https://doi.org/10.1089/hs.2016.0090">dissipate</a> when these events recede from memory. Plus, many of the resources available for public health emergencies depend on the discretion of executive officials. The recent reported difficulties of securing federal recovery resources for Puerto Rico <a href="https://www.reuters.com/article/us-puertorico-storm-loan/puerto-rico-fema-still-at-odds-on-terms-of-government-loan-idUSKBN1F705H">after Hurricane Maria</a> demonstrate that this is a real concern.</p>
<p>Despite progress over the past century, the world remains unprepared for an influenza pandemic. But, with a higher level of commitment and attention, we can greatly improve our pandemic response systems and save lives.</p><img src="https://counter.theconversation.com/content/91300/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lance Gable does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Science has come a long way in the 100 years since the worst flu pandemic in history. But that doesn’t mean that the country is ready for another health disaster.Lance Gable, Associate Professor of Law, Wayne State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/898412018-01-11T11:41:28Z2018-01-11T11:41:28ZThe ‘greatest pandemic in history’ was 100 years ago – but many of us still get the basic facts wrong<figure><img src="https://images.theconversation.com/files/201379/original/file-20180109-36019-q61srv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Influenza victims crowd into an emergency hospital near Fort Riley, Kansas in 1918.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Associated-Press-Domestic-News-Kansas-United-St-/78168a0d08f2da11af9f0014c2589dfb/4/0">AP Photo/National Museum of Health</a></span></figcaption></figure><p>This year marks the 100th anniversary of the great <a href="https://www.archives.gov/exhibits/influenza-epidemic/">influenza pandemic of 1918</a>. Between 50 and 100 million people are thought to have died, representing as much as 5 percent of the world’s population. Half a billion people were infected. </p>
<p>Especially remarkable was the 1918 flu’s predilection for taking the lives of otherwise healthy young adults, as opposed to children and the elderly, who usually suffer most. Some have called it the <a href="https://www.amazon.com/Great-Influenza-Deadliest-Pandemic-History/dp/0143036491">greatest pandemic in history</a>.</p>
<p>The 1918 flu pandemic has been a <a href="https://news.nationalgeographic.com/news/2014/04/140428-1918-flu-avian-swine-science-health-science/">regular subject</a> of speculation over the last century. Historians and scientists have advanced numerous hypotheses regarding its origin, spread and consequences. As a result, many of us harbor misconceptions about it. </p>
<p>By correcting these 10 myths, we can better understand what actually happened and learn how to prevent and mitigate such disasters in the future.</p>
<h2>1. The pandemic originated in Spain</h2>
<p>No one believes the so-called “Spanish flu” originated in <a href="https://doi.org/10.1086/590567">Spain</a>. </p>
<p>The pandemic likely acquired this nickname because of World War I, which was in full swing at the time. The major countries involved in the war were keen to avoid encouraging their enemies, so reports of the extent of the flu were suppressed in Germany, Austria, France, the United Kingdom and the U.S. By contrast, neutral Spain had no need to keep the flu under wraps. That created the false impression that Spain was bearing the brunt of the disease. </p>
<p>In fact, the geographic origin of the flu is debated to this day, though <a href="https://news.nationalgeographic.com/news/2014/01/140123-spanish-flu-1918-china-origins-pandemic-science-health/">hypotheses</a> have suggested East Asia, Europe and even Kansas.</p>
<h2>2. The pandemic was the work of a ‘super-virus’</h2>
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<a href="https://images.theconversation.com/files/201380/original/file-20180109-36028-cg8mlz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/201380/original/file-20180109-36028-cg8mlz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/201380/original/file-20180109-36028-cg8mlz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=899&fit=crop&dpr=1 600w, https://images.theconversation.com/files/201380/original/file-20180109-36028-cg8mlz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=899&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/201380/original/file-20180109-36028-cg8mlz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=899&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/201380/original/file-20180109-36028-cg8mlz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1130&fit=crop&dpr=1 754w, https://images.theconversation.com/files/201380/original/file-20180109-36028-cg8mlz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1130&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/201380/original/file-20180109-36028-cg8mlz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1130&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">A Chicago Public Health poster outlines flu regulations during the pandemic.</span>
<span class="attribution"><a class="source" href="https://origins.osu.edu/article/59/images">origins.osu.edu</a></span>
</figcaption>
</figure>
<p>The 1918 flu spread rapidly, killing 25 million people in just the first six months. This led some to fear the end of mankind, and has long fueled the supposition that the strain of influenza was particularly lethal. </p>
<p>However, more recent study suggests that the <a href="https://doi.org/10.1086/522355">virus itself</a>, though more lethal than other strains, was not fundamentally different from those that caused epidemics in other years.</p>
<p>Much of the high death rate can be attributed to crowding in military camps and urban environments, as well as poor nutrition and sanitation, which suffered during wartime. It’s now thought that many of the deaths were due to the development of bacterial pneumonias in lungs weakened by influenza.</p>
<h2>3. The first wave of the pandemic was most lethal</h2>
<p>Actually, the <a href="https://wwwnc.cdc.gov/eid/article/12/1/05-0979_article">initial wave</a> of deaths from the pandemic in the first half of 1918 was relatively low. </p>
<p>It was in the second wave, from October through December of that year, that the highest death rates were observed. A third wave in spring of 1919 was more lethal than the first but less so than the second. </p>
<p>Scientists now believe that the marked increase in deaths in the second wave was caused by conditions that favored the spread of a deadlier strain. People with mild cases stayed home, but those with severe cases were often crowded together in hospitals and camps, increasing transmission of a more lethal form of the virus.</p>
<h2>4. The virus killed most people who were infected with it</h2>
<p>In fact, the vast majority of the people who contracted the 1918 flu <a href="https://wwwnc.cdc.gov/eid/article/12/1/05-0979_article">survived</a>. National death rates among the infected generally did not exceed 20 percent. </p>
<p>However, death rates varied among different groups. In the U.S., deaths were particularly high among <a href="http://www.jstor.org/stable/10.5250/amerindiquar.38.4.0459">Native American populations</a>, perhaps due to lower rates of exposure to past strains of influenza. In some cases, entire Native communities were wiped out. </p>
<p>Of course, even a 20 percent death rate vastly exceeds <a href="https://www.cdc.gov/nchs/fastats/flu.htm">a typical flu</a>, which kills less than one percent of those infected. </p>
<h2>5. Therapies of the day had little impact on the disease</h2>
<p>No specific anti-viral therapies were available during the 1918 flu. That’s still largely true today, where most medical care for the flu aims to support patients, rather than cure them.</p>
<p>One hypothesis suggests that many flu deaths could actually be attributed to <a href="https://doi.org/10.1086/606060">aspirin poisoning</a>. Medical authorities at the time recommended large doses of aspirin of up to 30 grams per day. Today, about four grams would be considered the maximum safe daily dose. Large doses of aspirin can lead to many of the pandemic’s symptoms, including bleeding. </p>
<p>However, <a href="https://doi.org/10.1086/651472">death rates</a> seem to have been equally high in some places in the world where aspirin was not so readily available, so the debate continues. </p>
<h2>6. The pandemic dominated the day’s news</h2>
<p>Public health officials, law enforcement officers and politicians had reasons to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2862342/">underplay</a> the severity of the 1918 flu, which resulted in less coverage in the press. In addition to the fear that full disclosure might embolden enemies during wartime, they wanted to preserve public order and avoid panic. </p>
<p>However, officials did respond. At the height of the pandemic, <a href="https://virus.stanford.edu/uda/fluresponse.html">quarantines</a> were instituted in many cities. Some were forced to restrict essential services, including police and fire. </p>
<h2>7. The pandemic changed the course of World War I</h2>
<p>It’s unlikely that the flu changed the <a href="http://ww1centenary.oucs.ox.ac.uk/body-and-mind/the-spanish-influenza-pandemic-and-its-relation-to-the-first-world-war/">outcome</a> of World War I, because combatants on both sides of the battlefield were relatively equally affected. </p>
<p>However, there is little doubt that the war <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2862337/">profoundly influenced</a> the course of the pandemic. Concentrating millions of troops created ideal circumstances for the development of more aggressive strains of the virus and its spread around the globe. </p>
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<span class="caption">Patients receive care for the Spanish flu at Walter Reed Military Hospital, in Washington, D.C.</span>
<span class="attribution"><a class="source" href="https://origins.osu.edu/article/59/images">origins.osu.edu</a></span>
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<h2>8. Widespread immunization ended the pandemic</h2>
<p><a href="http://www.vaccination.english.vt.edu/wp-content/uploads/2015/04/updated-influenza-media-kit-4.pdf">Immunization against the flu</a> as we know it today was not practiced in 1918, and thus played no role in ending the pandemic. </p>
<p>Exposure to prior strains of the flu may have offered some protection. For example, soldiers who had served in the military for years suffered <a href="http://dx.doi.org/10.1111/irv.12267">lower rates of death</a> than new recruits.</p>
<p>In addition, the rapidly mutating virus likely evolved over time into less lethal strains. This is predicted by models of natural selection. Because highly lethal strains kill their host rapidly, they cannot spread as easily as less lethal strains. </p>
<h2>9. The genes of the virus have never been sequenced</h2>
<p>In 2005, researchers announced that they had successfully determined the <a href="http://www.sciencemag.org/news/2005/10/resurrecting-spanish-flu">gene sequence</a> of the 1918 influenza virus. The virus was recovered from the body of a flu victim buried in the permafrost of Alaska, as well as from samples of American soldiers who fell ill at the time. </p>
<p>Two years later, <a href="http://www.nature.com/articles/445237a">monkeys</a> infected with the virus were found to exhibit the symptoms observed during the pandemic. Studies suggest that the monkeys died when their immune systems overreacted to the virus, a so-called “cytokine storm.” Scientists now believe that a similar immune system overreaction contributed to high death rates among otherwise healthy young adults in 1918. </p>
<h2>10. The 1918 pandemic offers few lessons for 2018</h2>
<p>Severe influenza epidemics tend to occur every <a href="https://www.ncbi.nlm.nih.gov/pubmed/67988">few decades</a>. Experts believe that the next one is a question not of “if” but “when.” </p>
<p>While few living people can recall the great flu pandemic of 1918, we can continue to learn its lessons, which range from the commonsense value of handwashing and immunizations to the potential of anti-viral drugs. Today we know more about how to isolate and handle large numbers of ill and dying patients, and we can prescribe antibiotics, not available in 1918, to combat secondary bacterial infections. Perhaps the best hope lies in improving nutrition, sanitation and standards of living, which render patients better able to resist the infection.</p>
<p>For the foreseeable future, flu epidemics will remain an annual feature of the rhythm of human life. As a society, we can only hope that we have learned the great pandemic’s lessons sufficiently well to quell another such worldwide catastrophe.</p><img src="https://counter.theconversation.com/content/89841/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Richard Gunderman does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Don’t believe these 10 common myths about the 1918 Spanish flu.Richard Gunderman, Chancellor's Professor of Medicine, Liberal Arts, and Philanthropy, Indiana UniversityLicensed as Creative Commons – attribution, no derivatives.