ESWI Chairman Dr Albert Osterhaus speaks to HEQ about the burden of influenza and the role of education in infection control.
The European Scientific Working Group on Influenza (ESWI) was founded in 1992 to improve public health protection against influenza. ESWI Chairman Dr Albert Osterhaus, a leading virologist and influenza expert who was instrumental in identifying the SARS coronavirus (SARS-CoV-1) in 2003, speaks to HEQ about the burden of influenza and the role of education in infection control.
What is the role of ESWI within the broader public health landscape?
ESWI is a European foundation with 12 members and a number of advisors. The members of ESWI are all experts in different medical specialities – we have biologists, epidemiologists and general practitioners (GPs), among others – with a focus on speciality fields where there is an external risk for influenza infections, such as in older adults, people with underlying health conditions and young children; there is a whole range of people who suffer more from influenza or who are more at risk of infection. In the last few years ESWI has gradually expanded to cover respiratory syncytial virus (RSV) as an entity, as well as COVID-19, because the groups which are at risk, as well as the relevant clinical specialities, overlap to a large extent.
The purpose of ESWI is to stimulate collaboration and exchange information between stakeholders, and in doing so to facilitate the adoption of new measures to combat influenza, RSV and COVID-19. There are good vaccines and good antivirals available, which are not currently being exploited to their full extent; and that means that people in Europe have suffered too much from influenza as a result of not reaping the full benefit of the intervention strategies that we have today.
Has the COVID-19 pandemic had a significant impact on influenza treatment and research?
ESWI has been shouting that influenza pandemics may be a big risk in the future since around the turn of the century, voicing that message vigorously to all the stakeholders involved, including all kinds of organisations dealing with at-risk groups, in addition to medical specialists and GPs. We reached out to all the people who could make the difference in order to convince them that they have a very important task to play, to reduce and prevent the serious side effects and mortality arising from influenza – and latterly RSV, the second most important respiratory disease in people with the same risk factors – using all the means we have at our disposal today. Then, when COVID-19 came about, we already had all the expertise on those at-risk groups in place; we had access to all the different organisations that we were working with; and we had access to hundreds of thousands of people who are in the field and able to make a difference, so we were able to organise meetings and webinars to keep the stakeholders informed.
What we have seen during the COVID-19 pandemic is that, due to all the non-pharmaceutical intervention measures that were taken to protect the populace against COVID-19, we have been able to mitigate or even break the circulation of influenza. In the last season in Europe, we have seen virtually no influenza; and this primarily has to do with the measures that were taken to prevent to prevent or reduce the spread of COVID-19. That does mean, however, that we have to be even better prepared for next season: once we have COVID-19 under control, it may be expected that flu will come back. We did not really have a flu season in 2020, and we know that if there is a particularly mild flu season, the following season will usually be quite severe; so we will not reduce the amount of attention we pay to influenza.
In addition to informing stakeholders directly of developments and best practice in influenza, we also have a ‘Science Policy Interface’ track. We have two scientific tracks which meet in parallel: one which covers science generally, and a parallel track which is completely devoted to the interface between science and policy. We have the top policymakers from Europe and further afield, as well as specialist experts from Europe, the US, Japan, and all over the world.
The significance of the Science Policy Interface is that it brings together all these specialists in the field of respiratory infectious disease and translates the information they deliver into messages to policymakers, to enable them to use the latest information to form their policy decisions – do we need to buy vaccines, do we need to invest in diagnostics, what intervention methods do we need and how can we implement them, where do the viruses come from, where do they go, what can we expect in the future? – the interface helps to answer those kinds of questions.
What should be the key priorities in preparing for a potential new epidemic of influenza or a similar virus? How important is collaboration between regions and sectors?
I recently gave a presentation for a group of scientists, setting out the crucial elements for pandemic prevention which must be established in the inter-pandemic period. The first of these is an early warning system: we have to identify warning signs as soon as possible, as soon as we begin to see manifestations in humans of a new respiratory disease that is spreading rapidly we need to have a system to alert the world; we have seen during the COVID-19 pandemic that this took some time. Then, of course, it is important to immediately discover the cause: is it a virus? What kind of virus is it?
Then we would need immediately to establish a diagnostic platform. Once we know what the virus looks like and its basic genetic information, it is possible to develop new diagnostics quite rapidly and to spread this information worldwide. We have to immediately develop mathematical models, to see how the virus is spreading; and we also need to adopt animal models in which we can test intervention strategies, like the use of antivirals and vaccines as they are developed. We need clinical trials to be ready to launch as soon as we have candidate vaccines, candidate antivirals and candidate treatments, to test them out in humans as fast as possible. Meanwhile, we have to prepare for the implementation of non-pharmaceutical interventions and treatment strategies: this entails simple actions like stockpiling masks and protective gear for people working in hospitals in inter-pandemic periods.
One particularly important aspect of this is pharmaceutical interventions: especially in terms of vaccines, as we have seen with COVID-19, it took less than a year to develop a functional, patient-ready vaccine. Given that normally it takes about 10 years or more to get to that point, this was a fantastic achievement, but when we look at this situation – and this is true for COVID-19, but also for the influenza virus and for other virus groups which could potentially be the source of the next pandemic – what we need is broadly reactive vaccines that not only recognise one strain of a pandemic virus, but which also give much broader protection against all the strains of, say, the influenza or COVID-19 viruses; although that is probably a utopian goal.
I am chairing and co-ordinating a large project between a number of groups in India and Europe, funded by both European money and Indian money, where we look at the possibilities of developing a more universal influenza vaccine; it is obviously a very expensive project, but I think this investment in broadly reactive vaccines is quite important. If we were to have a vaccine that could already cover the potential pandemic viruses available at the beginning of a pandemic, then we would save billions – as an insurance policy, that would be a good thing to do. We have been advocating that for a long time, and I hope that after the pandemic is under control, we will be investing more money in this direction. The same could be said for antiviral medicines which cover, for instance, all the influenza viruses, all the coronaviruses or all the flaviviruses. Investment is necessary before a pandemic begins: you cannot wait to take out an insurance policy for your house until the house is on fire.
The last essential point is communication, not only between scientists, but also with policymakers and industry: not one of the vaccines which we are currently using for COVID-19 has been produced solely by a university or an academic group; they have all been developed or co-developed by teams from within the health industry. Again, these bonds and collaborations have to be established before a pandemic even begins.
ESWI provides information around the newest science that is emerging, particularly to policymakers, but also to other stakeholders and organisations, so that they can disseminate the key messages about how to deal with a pandemic. We are not only working to prevent the morbidity and mortality of epidemics, but also for pandemics. There is a quite an extensive set of actions which must be taken in peacetime, and on the one hand many of those actions will be expensive in the short term; but on the other hand, if they are not implemented it will become much more expensive in the long term, because we will have new pandemics in the future.
It is important to realise that in the inter-pandemic period, the total number of people who have died of influenza, for instance, between the pandemics is just as high as the number people who are dying during the pandemic. It is a universal problem; and ESWI is working to build up and disseminate the knowledge to those people who need it, by organising meetings, bringing people together, doing webinars – whatever is needed.
Should more action be taken to implement education on the risks and treatment of influenza, both for healthcare providers and patients? Do influenza vaccination programmes need to be more widely implemented?
The uptake of influenza vaccination in Europe is definitely suboptimal – a lot of medical professionals are still not even convinced that vaccination is a useful thing to do or that it reduces morbidity and mortality – so education of the professionals in the field is necessary. The World Health Organization (WHO) and the European Commission have recommended that at least 70% of people at risk should be vaccinated; and those figures are barely being achieved in Western European countries like the Netherlands, Belgium, France, and the UK, but the rates are even lower in much of Eastern Europe, with vaccination rates of 5% or 10% in some countries. It is an enormous missed opportunity, and the same is true for antiviral medications: the uptake of antivirals in Europe, compared to countries like Japan and the US, is appalling. There is still a lot of work to be done.
Are there any notable developments or current issues in influenza research or treatment which you think our readers should be more aware of?
There have been some very good antiviral drugs developed in the last couple of years; it is important for GPs, as well as for clinicians who specialise in at-risk groups, to know that those drugs are available now and what their key benefits are. Alongside this, vaccines are getting better all the time – there will always be stories claiming that influenza vaccines do not work properly, but the big problem with influenza vaccination is that people who need it the most are older adults above 65 or 70 years of age. As people age their immune systems deteriorate, which that means that they do not benefit as much from vaccination: where younger adults or adolescents who have been vaccinated would have almost 100% protection, in older people that protection may be reduced to less than 50%, depending on their age and health status. However, if you asked me as an older person if I would take the vaccine knowing that it could only offer 60% protection for my age group, of course I would still take it – 60% reduction of risk is still fantastic, and if I get the flu anyway then it will be much less severe and have a much lower risk of death.
It is important that we disseminate the facts about flu vaccinations and antivirals. It is important that people do not regard flu as trivial; especially since, as I said before, because we did not have a real flu season last year, we must be well prepared for it this year as it may be more severe than it has been in the past. This year has been a record year in vaccination uptake for vulnerable populations all over Europe: all the vaccines that were produced have been delivered. This has been primarily because people fear the risk of double infection; ESWI has done a great deal of promotional work urging people to get vaccinated because if someone is infected with influenza and COVID-19 at the same time, they will run a much higher risk of getting severely ill and dying.
Dr Albert Osterhaus
European Scientific Working Group on Influenza