An influenza pandemic is caused by a virus that is either entirely new or has not circulated recently and widely in the human population, creating an almost universal vulnerability to infection. Although not all people ever become infected during a pandemic, nearly all people are susceptible to infection. How contagious the virus is also influences the severity of a pandemic’s impact, as it can increase the number of people falling ill and needing care within a short time frame in a given geographical area. On the positive side, not all parts of the world, or all parts of a country, are affected at the same time.
One of the major determinant(s) of the severity of an influenza pandemic is the number of cases of severe illness and deaths that occur, which indicates the inherent disease potential of the virus. However, many other factors influence the overall severity of a pandemic’s impact. A distinctive feature of influenza viruses is that mutations occur frequently and unpredictably in the eight gene segments, and especially in the so-called haemagglutinin gene, so the emergence of an inherently more virulent virus during the course of a pandemic can never be ruled out.
Different patterns of spread can also influence the severity of subsequent waves. For example, if schoolchildren are mainly affected in the first wave, the elderly can bear the brunt of illness during the second wave, with higher mortality seen because of the greater vulnerability of elderly people.
During the previous century, the 1918 pandemic began mild and returned, within six months, in a much more lethal form. The pandemic that began in 1957 started mild, and returned in a somewhat more severe form, though significantly less devastating than seen in 1918. The 1968 pandemic began relatively mild, with sporadic cases prior to the first wave, and remained mild in its second wave in most, but not all, countries.
Even a pandemic virus that initially causes mild symptoms in otherwise healthy people can be disruptive, especially under the conditions of today’s highly mobile and closely interdependent societies. Moreover, the same virus that causes mild illness in one country can result in much higher illness and death in another. In addition, the inherent virulence of the virus can change over time as the pandemic goes through subsequent waves of national and international spread.
Pandemics usually have a concentrated adverse impact in specific age groups. Concentrated illnesses and deaths in a young, economically productive age group will be more disruptive to societies and economies than when the very young or very old are most severely affected, as seen during epidemics of seasonal influenza. Indeed, the overall vulnerability of the population can play a major role. For example, people with underlying chronic conditions (such as cardiovascular disease, hypertension, asthma, diabetes, among others) are more likely to experience severe or lethal infections. The prevalence of these conditions, combined with other factors such as nutritional status, can significantly influence the severity of a pandemic.
Finally, the quality of health services influences the impact of any pandemic. The same virus that causes only mild symptoms in countries with strong health systems can be devastating in other countries where health systems are weak, supplies of medicines, including antibiotics, are limited or frequently interrupted, and hospitals are crowded, poorly equipped, and understaffed.
Assessment of the current situation
To date, the following observations can be made, specifically about the H1N1 virus (swine flu), and more generally about the vulnerability of the world population. Observations specific to H1N1 are preliminary, based on limited data in only a few countries.
The H1N1 virus strain causing the current outbreaks is a new virus that has not been seen previously in either humans or animals. Although firm conclusions cannot be reached at present, scientists anticipate that pre-existing immunity to the virus will be low or non-existent, or largely confined to older population groups.
In addition, H1N1 appears to be more contagious than seasonal influenza.
With the exception of the outbreak in Mexico, which is still not fully understood, the H1N1 virus tends to cause very mild illness in otherwise healthy people. Outside Mexico, nearly all cases of illness, and all deaths, have been detected in people with underlying chronic conditions.
In the two largest and best documented outbreaks to date, in Mexico and the U.S., a younger age group has been affected than seen during seasonal epidemics of influenza. Though cases have been confirmed in all age groups, from infants to the elderly, the youth of patients with severe or lethal infections is a striking feature of these early outbreaks.
For several reasons, the prevalence of chronic diseases has risen dramatically since 1968, when the last pandemic of the previous century occurred. Today, the World Health Organization (WHO) estimates that 85% of the burden of chronic diseases is now concentrated in low- and middle-income countries. In these countries, chronic diseases show an earlier average age of onset than seen in more affluent parts of the world.
In these early days of the outbreaks, some scientists speculate that the full clinical spectrum of disease caused by H1N1 will not become apparent until the virus is more widespread. This, too, could alter the current disease picture, which is overwhelmingly mild outside Mexico.
Apart from the intrinsic mutability of influenza viruses, other factors could alter the severity of current disease patterns, though in completely unknowable ways, if the virus continues to spread.
Scientists are concerned about possible changes that could take place as the virus spreads to the southern hemisphere and encounters currently circulating human viruses as the normal influenza season in that hemisphere begins.
The fact that the H5N1 avian influenza virus is firmly established in poultry in some parts of the world is another cause for concern. No one can predict how the H5N1 virus will behave under the pressure of a pandemic. At present, H5N1 is an animal virus that does not spread easily to humans and only very rarely transmits directly from one person to another.
(Adapted from the CDC and the WHO)