H5N1

Pandemics disable people — the history lesson that policymakers ignore

Via Nature, an excellent article by Laura Spinney: Pandemics disable people — the history lesson that policymakers ignore. Excerpt:

When Ashley Shew turned up for an appointment at a medical centre in spring 2020, a member of staff told her she could remove her mask because only people with pre-existing conditions were vulnerable to COVID-19. Shew was surprised. “A hard-of-hearing amputee battered by chemotherapy and more”, as she describes herself, she is a regular at the centre — the appointment that day concerned her prosthetic leg. Who, she wondered, did the staff member think counted as a person with pre-existing conditions?  

The invisibility of disability is not new, says Shew, a 38-year-old philosopher who explores the intersection of technology and disability at Virginia Polytechnic Institute and State University in Blacksburg. “But it is particularly deadly that we don’t frame COVID-19 as a disability issue,” she says. “Even linguistically we’re pointed away from it. ‘Pre-existing conditions’ is a way of not saying ‘disability’.”  

From the beginning of this pandemic, people with disabilities understood that the disease would target them and would swell their ranks. Disability historians knew that there was a penumbra of ill health to previous mass-death events. Health economists warned that, as with tuberculosis, HIV and other diseases, morbidity would stalk mortality. Too many others have clung stubbornly to a belief that COVID-19 is something from which a minority of people die, and that most bounce back quickly and intact, with only their immune system updated. The longer the pandemic drags on, the harder it is to maintain that fiction.  

Two years in, the debilitating tail of the pandemic has revealed itself in the form of tens of millions of people living with long COVID1. It is high time to ask whether attitudes to disability will change as a result. Will society grasp that the body can be altered for a long period — even permanently — by infectious disease, just as it seems to have accepted that the body politic will never be the same again? And will it make the necessary accommodations?  

These questions have been asked before.  

Long influenza  

Consider the ‘mother of all pandemics’ — the 1918 Spanish influenza outbreak. Even in the 1920s, scientists understood that this flu had neurological and other effects. The most notorious and debated of those — still — is the overlapping pandemic of encephalitis lethargica (EL) or ‘sleepy sickness’. Eighty per cent of EL survivors went on to develop a Parkinson’s-like disease. According to cell biologist Richard Smeyne at the Jefferson Hospital for Neuroscience in Philadelphia, Pennsylvania, it has never been proved biologically that flu caused both EL and this post-encephalitic parkinsonism — at least not in the sense of catching the virus in flagrante in the brain tissue of people who had died. Yet the statistical case for it seems strong. 

The neurological tails of two subsequent flu pandemics, in 1957 and 1968, were less pronounced, but both were followed by rises in cases of encephalitis (brain inflammation), among other conditions. Once again, researchers failed to demonstrate a clear causal link with an earlier flu infection, but it has since been established that the flu virus can infect the brain and trigger inflammation there and elsewhere in the body. Clinicians see this after every flu season, in a wave of strokes and heart attacks predominantly among older people. And flu can cause encephalitis in children. It’s rare, but it can kill, and those who survive can be left with long-term brain damage.

Circulation of influenza, RSV, and SARS-CoV-2: an uncertain season ahead

Via The Lancet Respiratory Medicine: Circulation of influenza, RSV, and SARS-CoV-2: an uncertain season ahead.

A new report by the Academy of Medical Sciences has warned that the UK could face exceptionally large outbreaks of respiratory syncytial virus (RSV) and influenza during the autumn and winter of 2021–22. The surge in infections could overlap with the spike in cases of COVID-19 that is expected to follow the lifting of lockdown restrictions across the country. “It is clear that the health-care system must plan for a high burden of respiratory diseases”, wrote the authors of the new report. They urged the government to rollout point-of-care joint testing for influenza, SARS-CoV-2, and RSV, and to ensure that the influenza vaccine is widely taken-up by eligible populations. 

The warning partly reflects the success of the precautions that have been deployed against SARS-CoV-2. Mask-wearing, social distancing, and sharply constrained population movements have dramatically reduced transmission of respiratory pathogens such as RSV and influenza. Hospitals in Italy and France reported drops of more than 80% in the number of paediatric patients treated for acute bronchiolitis during the 2020–21 season, compared with previous years. Australia, Chile, and South Africa registered just 51 cases of influenza between them over the entire 2020 southern hemisphere winter. In the USA, the 2020–21 influenza season was the mildest since at least 1997, the earliest year for which records are available. 

 The vast majority of children contract RSV before the age of 2 years. “We now have a whole bunch of children who have not been exposed to the virus for 18 months to 2 years”, points out Charlotte Summers, reader in intensive care medicine at the University of Cambridge, UK, and member of the expert advisory group for the Academy of Medical Sciences report. The larger the susceptible population, the greater the risk of a sizeable outbreak once a virus starts circulating. 

England discontinued nearly all of its lockdown restrictions on July 19, 2021. Scotland and Wales are scheduled to do the same by mid-August. Even though there are several weeks of summer remaining, cases of RSV are on the rise (the USA is also seeing an out-of-season increase in RSV detections). Whether this will translate to increased hospitalisations remains to be seen. The Academy of Medical Sciences report recommended that children's wards and paediatric intensive care units should be ready for a potential influx of patients with RSV, otherwise they could find themselves overwhelmed. Modelling studies undertaken for the report suggested that a reasonable worst-case scenario for RSV would entail an outbreak somewhere in the region of 1·5–2 times greater than during a typical year, assuming the UK stays out of lockdown. 

The results for the modelling studies for influenza were similar. “There has probably been a waning of immunity to influenza, plus we have not had enough cases elsewhere in the world to offer a strong idea of what needs to go into the vaccine”, said Summers. The mildness of the 2019–20 influenza season in the UK might have further reduced population immunity. 

Much is uncertain. “We do not know what the influenza virus is going to look like when it returns”, said Rachel Baker, associate research scholar in the department of ecology and evolutionary biology at Princeton University, USA, “How much did the virus evolve during the period of low case numbers? Will we see a strain that people have been exposed to or vaccinated against in the past?” It is unclear how the British will respond to the easing of the lockdown restrictions. “Without national mandates for things like mask-wearing and distancing, a lot will come down to individual behaviour, and no-one really knows how people's behaviour will change”, said Summers. Baker suggested that vulnerable populations should continue wearing masks in crowded public places. 

Hospitals will have to quickly identify which patients have influenza and which ones have COVID-19, and ensure the two sets of patients are kept separate from each other and from vulnerable patients who do not have any respiratory symptoms. No small task, particularly if the viruses are surging at the same time.

However, risk for all-cause dementia was reduced for those who engaged in low (odds ratio [OR], 0.30; 95% CI, 0.25 – 0.36) and moderate to high (OR, 0.13; 95% CI, 0.10 – 0.16) levels of physical activity compared with their inactive peers.

Feter said it is particularly noteworthy that adults aged 80 and older who engaged in moderate to high levels of physical activity were at lower risk for dementia than inactive adults aged 50 to 69 years.

"In our opinion, this is the study's main finding," he said.

Although aging is the strongest risk factor for dementia, "we showed that moderate-intensity physical activity once per week can attenuate, or even eliminate, the risk of dementia associated with aging," Feter noted. "In fact, older adults engaging in regular physical activity have a lower risk of dementia than adults aged up to 30 years younger."

However, he noted several study limitations, including the way that physical activity and dementia were assessed and that reverse causality and residual confounding "might not be ruled out from our findings."

Los Angeles: Our century-old mask wars

Via The Los Angeles Times: Coronavirus Today: Our century-old mask wars. Excerpt:

Good evening. I’m Amina Khan, and it’s Tuesday, Dec. 29. Here’s what’s happening with the coronavirus in California and beyond. 

The pitched political battle over masks may feel like a quintessentially 2020 kind of conflict. But as it turns out, the anti-mask movement is more than a century old. Columnist Gustavo Arellano takes us back to 1919, when the world was facing another devastating global outbreak: the so-called Spanish flu, which is estimated to have infected a third of the world’s population and killed at least 50 million.  

Back then, more than 700 concerned citizens and doctors signed a petition asking the Los Angeles City Council to enact a mask mandate to combat the pandemic, or “the disease will come back again, and will exact a heavier toll than ever.” 

But councilmembers wouldn’t budge. One said the masks left the wearer “breathing in the foul air which they exhale.” Another snarked that he might have been more sympathetic “if the doctors would come through and agree on some one thing, or if any of them could agree at all.” A third said he would “not propose to take the advice of a lot of outsiders.”  

L.A. weathered the flu pandemic better than most major American cities, largely thanks to City Health Commissioner Dr. Luther Powers, who shut down businesses and schools early on, even when others did not. But Powers had a chance to save even more lives by implementing a mask ordinance — and he didn’t. 

If Powers had required everyone to wear masks in public, that “would’ve had an impact,” said J. Alexander Navarro, a medical historian at the University of Michigan.

Widespread mask use in L.A. seemed imminent when the Spanish flu hit California in the fall of 1918, Arellano writes. San Francisco issued an order for people to wear them outside their homes, and San Diego required them for anyone serving the public. Gov. William D. Stephens urged Californians to wear masks, saying they offered “but little discomfort and means a service rendered to our fellow-men and to our country.” 

These messages appear to have had an effect: The Times reported on Oct. 23 that masks in L.A. “were quite common in large offices ... where the general public is coming and going all day in numbers.” 

Mayor Frederick Woodman even brought a resolution to the City Council to enforce mask wearing, but Powers balked and the enforcement measure failed. Instead, the council passed a measure advising the public to wear masks, but not requiring it.  

The window of opportunity, it seemed, had closed. The council soon became hostile to a mask mandate. This paper openly called masks “muzzles” and published editorial cartoons mocking their advocates. In a Dec. 1, 1918, editorial titled “Adios ‘Flu’ Scare!” the paper’s editorial board wrote that “the real sufferers are the men and women whose incomes have been stopped, whose businesses have been all but ruined.” Sound familiar? 

Little did they know that the city was about to be overwhelmed by a second wave of influenza. In January, Powers finally wrote up a mask mandate but ultimately did not back its passage.

Comparison of the characteristics, morbidity, and mortality of COVID-19 and seasonal influenza: A nationwide, population-based retrospective cohort study

Via The Lancet Respiratory Medicine: Comparison of the characteristics, morbidity, and mortality of COVID-19 and seasonal influenza: a nationwide, population-based retrospective cohort study. The summary:

Background 

To date, influenza epidemics have been considered suitable for use as a model for the COVID-19 epidemic, given that they are respiratory diseases with similar modes of transmission. However, data directly comparing the two diseases are scarce. 

Methods 

We did a nationwide retrospective cohort study using the French national administrative database (PMSI), which includes discharge summaries for all hospital admissions in France. All patients hospitalised for COVID-19 from March 1 to April 30, 2020, and all patients hospitalised for influenza between Dec 1, 2018, and Feb 28, 2019, were included. The diagnosis of COVID-19 (International Classification of Diseases [10th edition] codes U07.10, U07.11, U07.12, U07.14, or U07.15) or influenza (J09, J10, or J11) comprised primary, related, or associated diagnosis. Comparisons of risk factors, clinical characteristics, and outcomes between patients hospitalised for COVID-19 and influenza were done, with data also stratified by age group. 

Findings 

89 530 patients with COVID-19 and 45 819 patients with influenza were hospitalised in France during the respective study periods. The median age of patients was 68 years (IQR 52–82) for COVID-19 and 71 years (34–84) for influenza. Patients with COVID-19 were more frequently obese or overweight, and more frequently had diabetes, hypertension, and dyslipidaemia than patients with influenza, whereas those with influenza more frequently had heart failure, chronic respiratory disease, cirrhosis, and deficiency anaemia. 

Patients admitted to hospital with COVID-19 more frequently developed acute respiratory failure, pulmonary embolism, septic shock, or haemorrhagic stroke than patients with influenza, but less frequently developed myocardial infarction or atrial fibrillation. In-hospital mortality was higher in patients with COVID-19 than in patients with influenza (15 104 [16·9%] of 89 530 vs 2640 [5·8%] of 45 819), with a relative risk of death of 2·9 (95% CI 2·8–3·0) and an age-standardised mortality ratio of 2·82. 

Of the patients hospitalised, the proportion of paediatric patients (<18 years) was smaller for COVID-19 than for influenza (1227 [1·4%] vs 8942 [19·5%]), but a larger proportion of patients younger than 5 years needed intensive care support for COVID-19 than for influenza (14 [2·3%] of 613 vs 65 [0·9%] of 6973). In adolescents (11–17 years), the in-hospital mortality was ten-times higher for COVID-19 than for influenza (five [1·1% of 458 vs one [0·1%] of 804), and patients with COVID-19 were more frequently obese or overweight. 

Interpretation 

The presentation of patients with COVID-19 and seasonal influenza requiring hospitalisation differs considerably. Severe acute respiratory syndrome coronavirus 2 is likely to have a higher potential for respiratory pathogenicity, leading to more respiratory complications and to higher mortality. In children, although the rate of hospitalisation for COVID-19 appears to be lower than for influenza, in-hospital mortality is higher; however, low patient numbers limit this finding. These findings highlight the importance of appropriate preventive measures for COVID-19, as well as the need for a specific vaccine and treatment.

Analysis: Could COVID-19 knock out flu in Europe this winter?

Via Reuters: Analysis: Could COVID knock out flu in Europe this winter? Excerpt:

PARIS (Reuters) - As Europeans brace for a grim winter with the threat of rising COVID-19 infections, minimal numbers of flu cases recorded so far point to a possible silver lining.

Data available for Europe since the beginning of October, when flu case numbers usually start to ramp up, mirror shallow figures seen in the Southern Hemisphere earlier this year. 

Some doctors say a combination of lockdowns, mask wearing and handwashing appear to have hampered transmission of the flu, while warning that the data should be treated with caution because the peak of the season is weeks or even months away.  

According to Flu News Europe, a joint monitoring platform of the European Centre for Disease Prevention and Control and the World Health Organization which collects samples in 54 European regions, only one person was diagnosed with flu out of 4,433 sentinel tests during Sept. 28-Nov. 22.  

This sentinel-source data -- case figures collated by national health authorities based on samples taken by a range of community doctors -- translates into a positivity rate of 0.02%, well below a 10% threshold that the WHO considers to be “epidemic” when it comes to flu. 

At the same time last year, this percentage stood at 15%. 

While scientists caution that the coronavirus pandemic has constrained testing for flu, the low sentinel rate so far will provide some relief to governments and health authorities, which had feared a potentially lethal “twindemic” of COVID-19 and flu that could overwhelm hospitals during the winter. 

“In any given typical year, we should be witnessing hundreds of influenza cases at this stage in Europe and beyond,” Bruno Lina, a senior virologist with Hospices Civils de Lyon, which runs 13 hospitals in France’s third-largest city, told Reuters. 

“Steps adopted to prevent transmission of COVID-19 are very efficient against influenza and other respiratory viruses.”

Virological surveillance of influenza viruses in the WHO European Region in 2019/20 – impact of the COVID-19 pandemic

Via Eurosurveillance: Virological surveillance of influenza viruses in the WHO European Region in 2019/20 – impact of the COVID-19 pandemic. The abstract:

The COVID-19 pandemic negatively impacted the 2019/20 WHO European Region influenza surveillance. Compared with previous 4-year averages, antigenic and genetic characterisations decreased by 17% (3,140 vs 2,601) and 24% (4,474 vs 3,403). Of subtyped influenza A viruses, 56% (26,477/47,357) were A(H1)pdm09, 44% (20,880/47,357) A(H3). Of characterised B viruses, 98% (4,585/4,679) were B/Victoria. Considerable numbers of viruses antigenically differed from northern hemisphere vaccine components. In 2020/21, maintaining influenza virological surveillance, while supporting SARS-CoV-2 surveillance, is crucial.

Double threat of COVID-19 and influenza

A news item in The Lancet Respiratory Medicine: Double threat of COVID-19 and influenza. Excerpt:

At the time of publication, it looks like the second wave of COVID-19 is well underway in Europe. The weekly tally of new cases has been steadily rising for more than 2 months, but the past few weeks have seen accelerated transmission. Cases have also been trending upwards in the USA. Oct 14, 2020, saw the nation register the highest number of new cases of COVID-19 since Aug 7. In general, countries are much better prepared than they were when severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) first exploded onto the scene. But October also marks the beginning of the flu season in the northern hemisphere. If both viruses surge simultaneously, even the best resourced health-care systems would be hard pressed to cope. 

The southern hemisphere avoided such an eventuality. Their recently concluded flu season was exceptionally mild. It is possible that behind the apparently low caseload lay thousands of undetected patients. Perhaps influenza testing fell away as countries concentrated their resources on COVID-19. Large numbers of people might have struggled through bouts of influenza at home, hidden from the statisticians. In a briefing to the media on June 15, 2020, WHO director-general Tedros Adhanom Ghebreyesus noted that “influenza surveillance has either been suspended or is declining in many countries, and there has been a sharp decline in sharing of influenza information and viruses because of the COVID-19 pandemic”. He added that “compared with the last 3 years, we've seen a dramatic decrease in the number of specimens tested for influenza globally”. 

Nonetheless, it is hard to imagine that the precautions against SARS-CoV-2 did not prove even more effective against influenza, a less contagious virus. By this time last year, Australia had confirmed 298 120 cases of influenza and 812 deaths. Thus far this year, the country has registered 21 156 cases and just 36 deaths. “While influenza testing in Australia and New Zealand is maintained or even increased, very few influenza viruses were detected”, stated WHO, in their most recent influenza update. 

But whether this will translate to an equivalently mild flu season in the northern hemisphere, where the public is becoming increasingly tired of control measures, remains to be seen. The UK, for example, is unlikely to replicate the kind of lockdown it enacted in the early part of the pandemic. 

“I think we are probably going to see a great deal more COVID-19 in the USA over the next few months, as people move indoors and we continue without any concerted approach to containment”, said Daniel Salmon, director of Johns Hopkins Institute for Vaccine Safety (Baltimore, USA). 

“But we should expect the social distancing and other measures to have some effect on influenza transmission, even if they are not followed across the board.”

Honigsbaum: How do pandemics end? In different ways, but it’s never quick and never neat

In The Guardian, Mark Honigsbaum writes: How do pandemics end? In different ways, but it’s never quick and never neat. Excerpt:

On 7 September 1854, in the middle of a raging cholera epidemic, the physician John Snow approached the board of guardians of St James’s parish for permission to remove the handle from a public water pump in Broad Street in London’s Soho. Snow observed that 61 victims of the cholera had recently drawn water from the pump and reasoned that contaminated water was the source of the epidemic. His request was granted and, even though it would take a further 30 years for the germ theory of cholera to become accepted, his action ended the epidemic. 

As we adjust to another round of coronavirus restrictions, it would be nice to think that Boris Johnson and Matt Hancock have a similar endpoint in sight for Covid-19. Unfortunately, history suggests that epidemics rarely have such neat endings as the 1854 cholera epidemic. Quite the opposite: as the social historian of medicine Charles Rosenberg observed, most epidemics “drift towards closure”. It is 40 years since the identification of the first Aids cases, for instance, yet every year 1.7 million people are infected with HIV. Indeed, in the absence of a vaccine, the World Health Organization does not expect to call time on it before 2030.  

However, while HIV continues to pose a biological threat, it does not inspire anything like the same fears as it did in the early 1980s when the Thatcher government launched its “Don’t Die of Ignorance” campaign, replete with scary images of falling tombstones. Indeed, from a psychological standpoint, we can say that the Aids pandemic ended with the development of antiretroviral drugs and the discovery that patients infected with HIV could live with the virus well into old age.  

The Great Barrington declaration, advocating the controlled spread of coronavirus in younger age groups alongside the sheltering of the elderly, taps into a similar desire to banish the fear of Covid-19 and bring narrative closure to this pandemic. Implicit in the declaration signed by scientists at Harvard and other institutions is the idea that pandemics are as much social as biological phenomena and that if we were willing to accept higher levels of infection and death we would reach herd immunity quicker and return to normality sooner. 

But other scientists, writing in the Lancet, say the Great Barrington strategy rests on a “dangerous fallacy”. There is no evidence for lasting “herd immunity” to the coronavirus following natural infection. Rather than ending the pandemic, they argue, uncontrolled transmission in younger people could merely result in recurrent epidemics, as was the case with numerous infectious diseases before the advent of vaccines.

It is no coincidence they have called their rival petition “the John Snow memorandum”. Snow’s decisive action in Soho may have ended the 1854 epidemic, but cholera returned in 1866 and 1892. It was only in 1893, when the first mass cholera vaccine trials got under way in India, that it became possible to envisage the rational scientific control of cholera and other diseases. The high point of these efforts came in 1980 with the eradication of smallpox, the first and still the only disease to be eliminated from the planet. However, these efforts had begun 200 years earlier with Edward Jenner’s discovery in 1796 that he could induce immunity against smallpox with a vaccine made from the related cowpox virus.

With more than 170 vaccines for Covid-19 in development, it is to be hoped we won’t have to wait that long this time. However, Professor Andrew Pollard, the head of the Oxford University vaccine trial, warns that we should not expect a jab in the near future. At an online seminar last week, Pollard said the earliest he thought a vaccine would be available was summer 2021 and then only for frontline health workers. The bottom line is that “we may need masks until July”, he said.

The other way the pandemic could be brought to a close is with a truly world-beating test-and-trace system. Once we can suppress the reproductive rate to below 1 and be confident of keeping it there, the case for social distancing dissolves. Sure, some local measures might be necessary from time to time, but there would no longer be a need for blanket restrictions in order to prevent the NHS being overwhelmed. Essentially, Covid-19 would become an endemic infection, like flu or the common cold, and fade into the background. This is what appears to have happened after the 1918, 1957 and 1968 influenza pandemics. In each case, up to a third of the world’s population was infected, but although the death tolls were high (50 million in the 1918-19 pandemic, about 1 million each in the 1957 and 1968 ones), within two years they were over, either because herd immunity was reached or the viruses lost their virulence.

The nightmare scenario is that Sars-CoV-2 does not fade away but returns again and again. This was the case with the 14th-century Black Death, which caused repeated European epidemics between 1347 and 1353. Something similar happened in 1889-90 when the “Russian influenza” spread from central Asia to Europe and North America. Although an English government report gave 1892 as the official end date of the pandemic, in truth the Russian flu never went away. Instead, it was responsible for recurrent waves of illness throughout the closing years of Queen Victoria’s reign.

Flu News Europe, week 41

An update from Flu News Europe:

Weekly influenza overview

Week 41/2020 (5 October–11 October 2020)    

• Influenza activity remained at interseasonal levels.  

• None of 107 sentinel specimens tested for influenza viruses in week 41 were positive. 

• Of 4 673 non-sentinel specimens tested, 11 were positive (4 A unsubtyped, 3 A(H3), 2 A(H1)pdm09 and 2 type B viruses were not ascribed to a lineage). 

• There were no hospitalized laboratory-confirmed influenza cases for week 41/2020.   

• The novel coronavirus disease 2019 (COVID-19) pandemic has affected healthcare presentations and testing capacities of countries and areas in the Region, which negatively impacted reporting of influenza epidemiologic and virologic data during the 2019-2020 season. It is not unusual for influenza activity to be low at this time of year but, if the COVID-19 pandemic continues, influenza data we present, notably in terms of seasonal patterns, will need to be interpreted with caution.  

Taking pandemic sequelae seriously: From the Russian influenza to COVID-19 long-haulers

Via The Lancet, an important article: Taking pandemic sequelae seriously: from the Russian influenza to COVID-19 long-haulers.

In January, 1892, the English social reformer and women's rights campaigner Josephine Butler wrote to her son, Stanley, to complain of fatigue and a general declension of the spirits. Butler attributed her symptoms to an attack of “Russian influenza” the previous Christmas, which had left her with painful conjunctivitis and inflamed lungs. “I don't think I ever remember being so weak, not even after the malaria fever at Genoa”, she confessed. 3 months later there was little improvement. “I am so weak that if I read or write for half an hour I become so tired and faint that I have to lie down,” Butler informed a friend. 

Butler was one of the most prominent female sufferers to document the lingering after-effects of influenza following the pandemic of 1889–92—colloquially called the Russian influenza because the epidemic had broken out in St Petersburg in November, 1889. However, the best known and most widely reported influenza invalids in the UK were male and included the then British Prime Minister and Foreign Secretary Lord Salisbury, his nephew Alfred Balfour, the Secretary of State for Ireland, and Lord George Hamilton, the First Lord of the Admiralty. In February, 1895, the Liberal Party leader and Prime Minister, Lord Rosebery, also had Russian influenza and was confined to his home in Epsom, Surrey, for 6 weeks, with fatigue and insomnia, prompting intense commentary in Victorian newspapers and periodicals.  

As with COVID-19, the diversity of these post-influenza symptoms and their unpredictability baffled contemporary medical observers and provoked lengthy disquisitions in The Lancet and other medical journals. The neurological conditions observed after the Russian influenza were given many names: neuralgia, neurasthenia, neuritis, nerve exhaustion, “grippe catalepsy”, “post-grippal numbness”, psychoses, “prostration”, “inertia”, anxiety, and paranoia. The Victorian throat specialist Sir Morell Mackenzie described how influenza appeared to “run up and down the nervous keyboard stirring up disorder and pain in different parts of the body with what almost seems malicious caprice”. The German-born Harley Street neurologist Julius Althaus concurred, stating that “there are few disorders or diseases of the nervous system which are not liable to occur as consequences of grip”. 

The result was that by the middle 1890s Russian influenza was being blamed in England for everything from the suicide rate to the general sense of malaise that marked the fin de siècle, and the image of a nation of convalescents, too debilitated to work or return to daily routines, and plagued with mysterious and erratic symptoms and chronic illnesses, had become central to the period's medical and cultural iconography. Although H Franklin Parsons, the medical investigator for England's Local Government Board, completed his final report on the “1889–92 epidemic” in 1893, further severe recrudescences were observed in 1893, 1895, 1898, and 1899–1900. The official end of the pandemic, therefore, did not mean the end of illness but was merely the prelude to a longue durée of baffling sequelae. 

Some 10 months into the pandemic sparked by the emergence of severe acute respiratory syndrome coronavirus 2, COVID-19 is revealing itself to be similarly protean, comprehensive, and persistent, and a new category of patients is emerging, colloquially known as COVID-19 “long-haulers”. These patients typically did not need critical care but on social media platforms and in interviews with journalists report “rolling waves of symptoms”, including fatigue, hallucinations, “brain fog”, delirium, memory loss, tachycardia, numbness and tingling, and shortness of breath. 

Some have joined social media survivor support groups and set up patient-led research forums. Others have shared their experiences on Twitter, where, in #LongCovid threads that resemble the epistolary dialogues of earlier influenza sufferers, they discuss their myriad symptoms and help each other navigate uncertainty about recurrence, debility, and dread of a new disease about which so much is still unknown. 

Medical literature is turning its attention to the long-term effects of COVID-19. One group of doctors in the UK, who have persisting symptoms of suspected or confirmed COVID-19, have called for research incorporating patients' perspectives to capture the “full spectrum” of this disease. Another group of long-haulers warn against comparing the symptoms observed after COVID-19 with those of other conditions or of treating the symptoms exclusively as a post-viral syndrome. 

Unfortunately, many COVID-19 long-haulers report having their experience of physiological suffering disbelieved or dismissed by medical practitioners. Such responses are potentially demoralising and might also impact racial and ethnic minorities, people living with disabilities, and other vulnerable groups, potentially worsening health disparities that became evident in some countries during the first months of the pandemic. As the world surpassed 1 million deaths from COVID-19, it is becoming increasingly clear that the coronavirus interacts with other social and biological phenomena—eg, non-communicable diseases, health resource strain, socioeconomic disparities, unequal housing, racism—a clustering known as a syndemic.

These medical attitudes can perhaps partly be traced to the initial phase of the pandemic when a priority was to identify acute cases at risk of severe respiratory and multiorgan failure. By contrast, non-urgent cases were generally designated mild to moderate. However, as mitigation strategies have provided some respite for critical care physicians ahead of a resurgence in infections, it appears that COVID-19 is a disease with a bewildering array of complications. Moreover, the designation of mild disease in some patients risks conflating self-resolving illnesses of short duration with persistent and, according to some long-hauler accounts, emotionally and psychologically debilitating morbid responses.

These accounts remind us of the limitations of narrow biomedical models and the importance of listening to patients' narratives of illness, which are shaped by pre-existing diagnostic categories, a patient's particular social setting, and the wider cultural context. According to Arthur Kleinman, Rita Charon, and other scholars, the task of the sympathetic physician is to contextualise these narratives within a broader web of biopsychosocial meanings. This can be particularly important in the case of chronic illnesses where patients may struggle to obtain adequate support, thus exacerbating the sense of a rift between the self and others.

In this respect, elements of the response to COVID-19 long-haulers contrast with the sympathy shown for Russian influenza convalescents during the 1890s and the engagement of a wide range of medical professionals with the influenza's nervous sequelae. This engagement can be partly explained by the fact that in the 1890s demarcations between the medical specialties, and family and hospital practice, were less rigid than they are today and an ear, nose, and throat physician could pronounce on nervous complaints which would now more properly be considered the province of neuropsychiatrists and other experts.

Furthermore, in the late Victorian period ideas of infectious disease causation were in a state of flux and laboratory medicine had yet to supplant older environmental and epidemiological understandings of disease and the close observation of patients' symptoms, particularly in the UK where physicians and medical researchers were suspicious of the “new” German bacteriological methods. A doctor's surgery was regarded as an important site for making and exploring new diagnostic categories and the physician–patient encounter was charged with the possibility of discovery. Little wonder then that the study of the psychoses of influenza came to be seen as a route to professional advancement and patient narratives and case histories became a popular subject for correspondents to medical journals and the emerging genre of the medical disease detective.

An association between influenza and CNS complications is established, even if the pathophysiology, the role of the host immunological response, and psychological stressors are not fully understood. For instance, the 1918–19 influenza pandemic was associated with parkinsonism, catatonia, and “encephalitis lethargica”, the so-called sleeping sickness that was reported in Europe in 1917 and persisted in Europe and North America until 1929. However, while the so-called Spanish influenza of 1918–19 is frequently invoked as an analogue for COVID-19, the Russian influenza might be a better cultural parallel.

The Russian influenza was the first influenza pandemic for 42 years. While veteran physicians recalled the diverse forms the disease had taken in 1847–48, in 1889 a standard classification was that found in Quain's Dictionary of Medicine, which emphasised the pulmonary and gastric forms of the disease. Influenza's nervous symptoms therefore came as a surprise to many practising physicians and discussion of typical cases soon became a hot topic, and not only in medical journals. “Influenza is the very Proteus of diseases, a malady which assumes so many different forms that it seems to be not one, but all diseases epitome”, Mackenzie informed readers of the Fortnightly Review during the second wave of the pandemic in 1891.

The Lancet's letter columns were full of correspondence from doctors in hospital and private practice attesting to unusual features of the disease. As in the first phase of COVID-19, men seemed more likely than women to suffer acute attacks of influenza and present at hospitals and doctors' surgeries—men were also reported to be more likely to suffer fatal outcomes. This might explain physicians' willingness to compare influenza to neurasthenia and, rather than characterise male patients' responses as a type of hysteria—a diagnosis generally reserved for women and which risked being gendered “feminine”—argue that the nervous sequelae were somatopsychic and the result of a primary focal infection.

By 1892 influenza nervosa had been classified as a type of fatigue neurosis that, like neurasthenia, could be traced to overwork and hypervigilance, key tropes of masculinity and modernity.

In the 1890s, a marked feature of the psychoses of influenza was a profound sense of dread accompanied by feelings of alienation, both from oneself and from others. Disembodiment or the mutiny of one's own facilities was a common description: “My powers of endurance” have been shaken by “a recent attack of influenza and its consequences”, wrote Speaker Peel to Henry Lucy in 1894. Not being able to trust one's mind or memories was another: influenza has left an “extraordinary sequel behind”, reported Dr Arthur Feveral in L T Meade and Clifford Halifax's short story "The Doctor's Dilemma," published in The Strand Magazine in 1895. In it, Feveral believes he may have poisoned a patient by mistake after an attack of influenza. Halifax was a pseudonym for the Harley Street physician Edgar Beaumont, and the story makes clear how seriously Victorian physicians regarded the Russian influenza and the psychosocial and economic consequences of its nervous sequelae. In his confusion, Feveral believes he has made a grave medical error. The influenza, we are told, has wrecked Feveral's memory and “the fear of it has made [him] thoroughly nervous and unfit for work”. In this way, the story makes explicit the supposed connection between overwork and mental debility at the heart of the influenza nervosa diagnosis and the social and economic pressures to which doctors and other bourgeois professionals were presumed to be subject, especially during the first months of the Russian influenza pandemic.

Will the COVID-19 pandemic elicit similar sympathy for COVID-19 long-haulers, three-quarters of whom, according to one patient survey, identify as female, an apparent reversal of the pattern seen in 1889–92 and prompting questions about whether women might be more likely than men to suffer long-term symptoms? Will doctors and medical researchers show the same enthusiasm for treating these patients and taking their symptoms seriously?

There are already some heartening signs. Post-COVID-19 rehabilitation and outpatient care is being rolled out in countries including India, Italy, and the USA. WHO has been pooling data about the long-term effects of COVID-19 and sharing advice on rehabilitation. In August, 2020, the UK's Department of Health and Social Care awarded a £2 million grant for a COVID-19 Symptom Study tracking app. To date initial findings from the Covid Symptom Study suggest that about 10% of those self-reporting symptoms to the tracker have had symptoms for 30 days and 1·5–2% for 90 days; patterns in the study also suggest that long COVID was about twice as common in women as in men. However, it is impossible to rule out sampling bias, hence the importance of rigorous studies measuring the long-term health impacts of this new disease. This is one of the aims of the Post-hospitalisation COVID-19 study (PHOSP-COVID) study in the UK, which is recruiting patients who were admitted to hospital with confirmed or suspected COVID-19.

Such refocusing is crucial now that the early, mysterious days of the pandemic are behind us and as it becomes clear that COVID-19, in one form or another, is here to stay. As they adjust to the pandemic's longue durée, physicians might find it helpful to look back to the Russian influenza and the historical accounts of the sequelae, even as COVID-19 long-haulers look to digital, patient-centred, and activist forums for support and validation in the present. Although such self-generated experiential accounts and communities do not offer certainty, they provide a narrative frame of reference and, as Sharrona Pearl writes, allow “individuals to emerge from behind the panic and spectacle of a plague”. For pandemics, like the illnesses they generate, linger not only in our bodies but also in our minds, culture, and communities. What we choose to make of this lingering, and how we interpret the pandemic's sequelae, will be the true measure of our care.