'In the Bleak Midwinter'

Kari Tveito About the author

This year’s influenza has thrown the UK into its worst hospital crisis in decades.

Photo: Einar Nilsen

Influenza is raging in Europe – this winter as in previous ones. The outbreak here in Norway appears to be somewhat milder than that of last year, and is dominated by type B influenza (1). In the UK, on the other hand, the onslaught of patients with ‘Aussie flu’, the moniker that the Britons have given to this year’s influenza, has overwhelmed the primary health services and the hospitals. The emergency departments have been filled to the rafters, an extra 5 000 beds had to be provided in the first week of January alone, and thousands of planned consultations and operations have been cancelled (2).

The influenza season in the southern hemisphere often provides an indication of the kind of influenza virus that will cause problems in northern latitudes six months later. In 2017, type A(H3 N2) influenza caused the worst outbreak in Australia since the 2009 pandemic, with uncommonly high mortality rates, especially among children and the elderly (3). It is a little unfair, however, by the British to blame the Australians for this year’s influenza, because the same virus made the rounds in Europe last winter as well. This may be the reason why we have not seen such high numbers of people infected with the H3 N2 virus this year in Norway; many have become immune from last year’s exposure (4).

Approximately one billion people become infected with influenza each year (5). Between three and five million become seriously ill, and half a million die. The societal costs in the form of lost production and increased consumption of health services are huge. We should therefore not take ‘ordinary’ influenza lightly – even though it cannot be compared to a pandemic. The Spanish Flu in 1918–19, the worst influenza pandemic of the 20th century, is estimated to have caused at least 50 million deaths (6). Such pandemics may occur – as it did in 2009 with the swine flu and H1 N1 virus – when a lot of people become infected with a new virus against which nobody is immune.

Starting from March this year, employees in the health and social sector in Finland who are working with especially vulnerable patients will be required to take vaccines against measles, whooping cough, chickenpox and influenza, pursuant to new legislation on infection control (7). Many have argued that Norway should enact similar laws. For health personnel to have completed the paediatric vaccination programme appears to be a reasonable requirement. But should they be vaccinated against influenza as well? Yes, because annual influenza vaccination is the most effective way to prevent influenza in health personnel and protect the patients (8). Norway and most other western European countries follow the recommendations from the World Health Organization on annual vaccination of health personnel and care workers for the elderly. This notwithstanding, the proportion that actually takes the vaccine is worryingly low in several of these countries. Legal amendments and statutory requirements are one way to raise the vaccination rate, but it is as important or better to implement other measures that have proven their effectiveness: information and reminders, encouragement to take the vaccine and easily available vaccination services that are free of charge.

The winter crisis in the British health services can be understood against the background of understaffing, fewer hospital beds and constant cuts in health budgets in recent years (9). The working conditions in the National Health Service (NHS) in recent weeks – described by doctors as working in a war zone – are an important reminder that cutting close to the bone is not necessarily cost-effective. Rationalisation and cutbacks are sometimes called for. However, we also need to have the contingency plans and resources required to handle variations in patient inflow through different seasons and from one year to the next – and in extraordinary circumstances. Today, people move across borders and between continents like never before. There is little to indicate that this will change any time soon. It is easy to envisage that new viruses and epidemics – and pandemics – suddenly can arise and rapidly spread.

Influenza viruses mutate constantly, and it is difficult to predict which kinds will predominate in the next season. This makes developing influenza vaccines a challenging task. Some years we succeed, in other years the vaccine provided is not as effective. For example, this year’s vaccine provides relatively little protection against type A (H3 N2) influenza (4). A global effort to develop new and better methods for immunisation against influenza is called for. In parallel, the efforts to encourage people to protect themselves against infection must continue. For many years, health authorities in the UK have run the campaign ‘Catch it. Bin it. Kill it.’ on radio and TV in the winter months (10). Its objective is to remind people that the best way to avoid infecting others with influenza is not to sneeze on anybody, maintain good hand hygiene and stay at home if you are ill. We also need to know more about who are especially vulnerable to influenza and why they become so ill. In this respect, monitoring of influenza patients admitted to intensive care wards, which started in 2016 under the auspices of the Norwegian Intensive Care Registry, is an important measure (4).

‘If I were a wise man, I would do my part’ says the last verse of In the bleak midwinter, the song that the British people voted ‘Best Christmas Carol’ in 2008 (11). Influenza is an annual reminder of the importance of undertaking preventive work and having sufficient resources in our health services. Budgets and staffing must be planned so as to make us adequately equipped to handle influenza and other communicable diseases ‘in the bleak midwinter’. And we must remember to take our vaccines.

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