Is Routine Flu Vaccination Key to Pandemic Preparedness?
The staggering loss of life that COVID-19 has wrought, by some estimates more than 3.8 million people at the time of this writing, almost defies comprehension. To say that every human on the planet is being impacted by this illness may not be an overstatement. At the same time, an alarming shift in public focus is taking place: seasonal influenza has all but disappeared as a subject of discussion in the global sphere. We see this disappearance as a grave risk to global public health. It complicates the ability of certain countries to, in the recent words of the G7 Health Ministers, "build back better and strengthen global health security and systems for the future." Stringent COVID-19 mitigation measures markedly reduced the spread and severity of the most recent influenza season. As welcome as that has been, we must not lose sight of the fact that under "normal" circumstances, influenza viruses are responsible for up to 650,000 deaths per year globally, according to World Health Organization (WHO) estimates. Seasonal Flu Will Boomerang Back and Into a New Frontier  When influenza boomerangs back, and it is only rational to predict that it will because population-level immunity is now lower, calculating risk to human health will be an entirely new frontier within the context of COVID-19. Particularly worrisome is that some low- and middle-income countries, all integral to global community health, may be in deepening peril if competing priorities continue to obscure routine flu vaccination programming. Public health experts agree that an influenza pandemic like that of 1918 could result in 62 million deaths, with 96% of those occurring in low- and middle-income countries. For years, WHO has recommended that all countries establish robust seasonal influenza programs as a vehicle to be ready to respond effectively to the large-scale emergence of a viral respiratory infection. During the 2009 H1N1 pandemic, countries with seasonal influenza vaccination programs had more effective pandemic responses than countries without such programs. Likewise, according to documented feedback received from representatives of Partnership for Influenza Vaccine Introduction (PIVI) countries, public health professionals in low- and middle-income countries such as Albania, Armenia, Bhutan, Laos, and Mongolia have gathered real-world evidence showing that existing influenza programs are currently reinforcing efficient COVID-19 responses. Even so, while influenza vaccine use has been increasing globally, it remains woefully underused in some low- and lower middle- income countries. An acute need for change looms large. A survey recently published in Vaccine provides the first in-depth exploration of barriers to and activities that expand influenza vaccination programs in low- and middle-income countries. We recommend grouping the most significant of those barriers into three priorities:  Assess the broader economic and public health impact of influenza (and not only the effectiveness of seasonal influenza vaccines in individuals)  Forge increased and sustained access to seasonal influenza vaccines  Drive influenza vaccine acceptance via effective community mobilization and communication campaigns  Other Adult Vaccination Programs Will Benefit, Too  While the COVID-19 pandemic feels like the most pressing public health issue at the moment, we cannot ignore the looming threat of influenza. Operational solutions must be designed such that low- and middle-income countries in need of flu vaccines can provide them in programs that are affordable within their national, economic, and cultural contexts. Improvements in this regard will be invaluable for other adult vaccination programs in the near term, too. These advances will improve response not only to annual epidemics of seasonal influenza, but also to the current COVID-19 pandemic and to future pandemics. First, however, we must collaborate to break down the barriers to influenza vaccination programs in low- and middle-income countries so as to raise equitable access to pandemic readiness, and thereby increase global health security. Marie Mazur, PharmD, MS, is director of Ready2Respond, a global coalition of stakeholders committed to augmenting low- and middle-income countries' responses to influenza and emerging respiratory viral pandemics. Angela Gentile, MD, PhD, is a professor of infectious disease and epidemiology at Ricardo Gutierrez Children Hospital in Buenos Aires, Argentina. Gagandeep Kang, MD, MBBS, PhD, is a professor of microbiology at the Wellcome Trust Research Laboratory in the Division of Gastrointestinal Sciences at the Christian Medical College (CMC) in Vellore, India. Rhoda Wanyenze, MBChB, MPH, PhD, is a professor and dean of Makerere University School of Public Health in Kampala, Uganda.