Influenza

For other uses, see Influenza (disambiguation).

Not to be confused with Haemophilus influenzae.

"Flu" and "Grippe" redirect here. For other uses, see Flu (disambiguation) and Grippe (disambiguation).

Influenza

Other names: Flu, the flu, Grippe
Influenza virus, magnified approximately 100,000 times
Specialty| Infectious disease
Symptoms| Fever, runny nose, sore throat, muscle and joint pain, headache, coughing, feeling tired[1]
Usual onset| 1–4 days after exposure[1]
Duration| ~1 week[1]
Causes| Influenza viruses[2]
Prevention| Hand washing, influenza vaccine, surgical masks[1][3]
Medication| Antiviral medications such as oseltamivir[1]
Frequency| 3–5 million severe cases per year[1]
Deaths| Up to 650,000 respiratory deaths per year[1][4]

Influenza, commonly known as "the flu", is an infectious disease caused by an influenza virus.[1] Symptoms can be mild to severe.[5] The most common symptoms include: high fever, runny nose, sore throat, muscle and joint pain, headache, coughing, and feeling tired.[1] These symptoms typically begin two days after exposure to the virus and most last less than a week.[1] The cough, however, may last for more than two weeks.[1] In children, there may be diarrhea and vomiting, but these are not common in adults.[6] Diarrhea and vomiting occur more commonly in gastroenteritis, which is an unrelated disease and sometimes inaccurately referred to as "stomach flu" or the "24-hour flu".[6] Complications of influenza may include viral pneumonia, secondary bacterial pneumonia, sinus infections, and worsening of previous health problems such as asthma or heart failure.[2][5]

Three of the four types of influenza viruses affect humans: Type A, Type B, and Type C.[2][7] Type D has not been known to infect humans, but is believed to have the potential to do so.[7][8] Usually, the virus is spread through the air from coughs or sneezes.[1] This is believed to occur mostly over relatively short distances.[9] It can also be spread by touching surfaces contaminated by the virus and then touching the eyes, nose, or mouth.[5][9][10] A person may be infectious to others both before and during the time they are showing symptoms.[5] The infection may be confirmed by testing the throat, sputum, or nose for the virus.[2] A number of rapid tests are available; however, people may still have the infection even if the results are negative.[2] A type of polymerase chain reaction that detects the virus's RNA is more accurate.[2]

Frequent hand washing reduces the risk of viral spread, as does wearing a surgical mask.[3] Yearly vaccinations against influenza are recommended by the World Health Organization (WHO) for those at high risk,[1] and by the Centers for Disease Control and Prevention (CDC) for those six months of age and older.[11] The vaccine is usually effective against three or four types of influenza.[1] It is usually well tolerated.[1] A vaccine made for one year may not be useful in the following year, since the virus evolves rapidly.[1] Antiviral medications such as the neuraminidase inhibitor oseltamivir, among others, have been used to treat influenza.[1] The benefit of antiviral medications in those who are otherwise healthy do not appear to be greater than their risks.[12] No benefit has been found in those with other health problems.[12][13]

Influenza spreads around the world in yearly outbreaks, resulting in about three to five million cases of severe illness and about 290,000 to 650,000 deaths.[1][4] About 20% of unvaccinated children and 10% of unvaccinated adults are infected each year.[14] In the northern and southern parts of the world, outbreaks occur mainly in the winter, while around the equator, outbreaks may occur at any time of the year.[1] Death occurs mostly in high risk groups—the young, the old, and those with other health problems.[1] Larger outbreaks known as pandemics are less frequent.[2] In the 20th century, three influenza pandemics occurred: Spanish influenza in 1918 (17–100 million deaths), Asian influenza in 1957 (two million deaths), and Hong Kong influenza in 1968 (one million deaths).[15][16][17] The World Health Organization declared an outbreak of a new type of influenza A/H1N1 to be a pandemic in June 2009.[18] Influenza may also affect other animals, including pigs, horses, and birds.[19]

Video summary (script)

## Contents

* 1 Signs and symptoms
* 2 Virology
* 2.1 Types of virus
* 2.1.1 Influenzavirus A
* 2.1.2 Influenzavirus B
* 2.1.3 Influenzavirus C
* 2.1.4 Influenzavirus D
* 2.2 Structure, properties, and subtype nomenclature
* 2.3 Replication
* 3 Mechanism
* 3.1 Transmission
* 3.2 Pathophysiology
* 4 Prevention
* 4.1 Vaccination
* 4.2 Infection control
* 5 Diagnosis
* 6 Treatment
* 6.1 Antivirals
* 6.1.1 Neuraminidase inhibitors
* 6.1.2 M2 inhibitors
* 7 Prognosis
* 7.1 Neurological
* 8 Epidemiology
* 8.1 Seasonal variations
* 8.2 Mortality
* 8.3 Outbreaks
* 9 History
* 9.1 Etymology
* 9.2 Pandemics
* 10 Society and culture
* 11 Research
* 12 Other animals
* 12.1 Bird flu
* 12.2 Swine flu
* 13 References
* 14 Further reading
* 15 External links

## Signs and symptoms[edit | edit source]

Most sensitive symptoms for diagnosing influenza[20] Symptom: | Sensitivity | Specificity

|
|

Fever  | 68–86% | 25–73%
Cough  | 84–98% | 7–29%
Nasal congestion  | 68–91% | 19–41%

* All three findings, especially fever, were less sensitive in people over 60 years of age.

Symptoms of influenza,[21][22] with fever and cough the most common symptoms[20]

The time between exposure to the virus and development of symptoms, called the incubation period, is 1–4 days, most commonly 1–2 days. Many infections, however, are asymptomatic.[23] The onset of symptoms is sudden, and initial symptoms are predominately non-specific, including fever, chills, headaches, muscle pain or aching, a feeling of discomfort, loss of appetite, lack of energy/fatigue, and confusion. These symptoms are usually accompanied by respiratory symptoms such as a dry cough, sore or dry throat, hoarse voice, and a stuffy or runny nose. Coughing is the most common symptom.[24] Gastrointestinal symptoms may also occur, including nausea, vomiting, diarrhea,[25] and gastroenteritis,[26] especially in children. The standard influenza symptoms typically last for 2–8 days.[27] A 2021 study suggests influenza can cause long lasting symptoms in a similar way to long COVID.[28]

Symptomatic infections are usually mild and limited to the upper respiratory tract, but progression to pneumonia is relatively common. Pneumonia may be caused by the primary viral infection or by a secondary bacterial infection. Primary pneumonia is characterized by rapid progression of fever, cough, labored breathing, and low oxygen levels that cause bluish skin. It is especially common among those who have an underlying cardiovascular disease such as rheumatic heart disease. Secondary pneumonia typically has a period of improvement in symptoms for 1–3 weeks[29] followed by recurrent fever, sputum production, and fluid buildup in the lungs,[24] but can also occur just a few days after influenza symptoms appear.[29] About a third of primary pneumonia cases are followed by secondary pneumonia, which is most frequently caused by the bacteria Streptococcus pneumoniae and Staphylococcus aureus.[23][24]

## Virology[edit | edit source]

### Types of virus[edit | edit source]

Structure of the influenza virion. The hemagglutinin (HA) and neuraminidase (NA) proteins are shown on the surface of the particle. The viral RNAs that make up the genome are shown as red coils inside the particle and bound to ribonucleoproteins (RNP).

In virus classification, influenza viruses are RNA viruses that make up four of the seven genera of the family Orthomyxoviridae:[30]

* Influenzavirus A
* Influenzavirus B
* Influenzavirus C
* Influenzavirus D

These viruses are only distantly related to the human parainfluenza viruses, which are RNA viruses belonging to the paramyxovirus family that are a common cause of respiratory infections in children such as croup,[31] but can also cause a disease similar to influenza in adults.[32]

The fourth family of influenza viruses – Influenza D – was identified in 2016.[33][34][35][36][37][38][39] The type species for this family is Influenza D virus, which was first isolated in 2011.[8]

#### Influenzavirus A[edit | edit source]

This digitally-colorized, negative-stained transmission electron microscopic (TEM) image depicted a number of Influenza A virions.

This genus has one species, influenza A virus. Wild aquatic birds are the natural hosts for a large variety of influenza A.[40] Occasionally, viruses are transmitted to other species and may then cause devastating outbreaks in domestic poultry or give rise to human influenza pandemics.[40] The influenza A virus can be subdivided into different serotypes based on the antibody response to these viruses.[41] The serotypes that have been confirmed in humans are:

* H1N1, which caused Spanish flu in 1918, and Swine Flu in 2009
* H2N2, which caused Asian Flu in 1957
* H3N2, which caused Hong Kong Flu in 1968
* H5N1, which caused Bird Flu in 2004[42][43]
* H7N7, which has unusual zoonotic potential[44]
* H1N2, endemic in humans, pigs and birds
* H9N2
* H7N2
* H7N3
* H10N7
* H7N9, rated in 2018 as having the greatest pandemic potential among the Type A subtypes[45]
* H6N1, which only infected one person, who recovered[46]

#### Influenzavirus B[edit | edit source]

Influenza virus nomenclature (for a Fujian flu virus)

This genus has one species, influenza B virus. Influenza B almost exclusively infects humans[41] and is less common than influenza A. The only other animals known to be susceptible to influenza B infection are seals[47] and ferrets.[48] This type of influenza mutates at a rate 2–3 times slower than type A[49] and consequently is less genetically diverse, with only one influenza B serotype.[41] As a result of this lack of antigenic diversity, a degree of immunity to influenza B is usually acquired at an early age. However, influenza B mutates enough that lasting immunity is not possible.[50] This reduced rate of antigenic change, combined with its limited host range (inhibiting cross species antigenic shift), ensures that pandemics of influenza B do not occur.[51]

#### Influenzavirus C[edit | edit source]

This genus has one species, influenza C virus, which infects humans, dogs and pigs, sometimes causing both severe illness and local epidemics.[52][53] However, influenza C is less common than the other types and usually only causes mild disease in children.[54][55]

#### Influenzavirus D[edit | edit source]

This genus has only one species, influenza D virus, which infects pigs and cattle. The virus has the potential to infect humans, although no such cases have been observed.[8]

### Structure, properties, and subtype nomenclature[edit | edit source]

Influenzaviruses A, B, C, and D are very similar in overall structure.[8][56][57] The virus particle (also called the virion) is 80–120 nanometers in diameter such that the smallest virions adopt an elliptical shape.[58] The length of each particle varies considerably, owing to the fact that influenza is pleomorphic, and can be in excess of many tens of micrometers, producing filamentous virions.[59] However, despite these varied shapes, the viral particles of all influenza viruses are similar in composition.[60] These are made of a viral envelope containing the glycoproteins hemagglutinin and neuraminidase wrapped around a central core. The central core contains the viral RNA genome and other viral proteins that package and protect this RNA. RNA tends to be single stranded but in special cases it is double.[61] Unusually for a virus, its genome is not a single piece of nucleic acid; instead, it contains seven or eight pieces of segmented negative-sense RNA, each piece of RNA containing either one or two genes, which code for a gene product (protein).[60] For example, the influenza A genome contains 11 genes on eight pieces of RNA, encoding for 11 proteins: hemagglutinin (HA), neuraminidase (NA), nucleoprotein (NP), M1 (matrix 1 protein), M2, NS1 (non-structural protein 1), NS2 (other name is NEP, nuclear export protein), PA, PB1 (polymerase basic 1), PB1-F2 and PB2.[62]

Hemagglutinin (HA) and neuraminidase (NA) are the two large glycoproteins on the outside of the viral particles. HA is a lectin that mediates binding of the virus to target cells and entry of the viral genome into the target cell, while NA is involved in the release of progeny virus from infected cells, by cleaving sugars that bind the mature viral particles.[63] Thus, these proteins are targets for antiviral medications.[64] Furthermore, they are antigens to which antibodies can be raised. Influenza A viruses are classified into subtypes based on antibody responses to HA and NA. These different types of HA and NA form the basis of the H and N distinctions in, for example, H5N1.[65] There are 18 H and 11 N subtypes known, but only H 1, 2 and 3, and N 1 and 2 are commonly found in humans.[66][67]

### Replication[edit | edit source]

Pol II transcription cycle in cells infected with influenza virus[68] Host cell invasion and replication by the influenza virus. The steps in this process are discussed in the text.

Viruses can replicate only in living cells.[69] Influenza infection and replication is a multi-step process: First, the virus has to bind to and enter the cell, then deliver its genome to a site where it can produce new copies of viral proteins and RNA, assemble these components into new viral particles, and, last, exit the host cell.[60]

Influenza viruses bind through hemagglutinin onto sialic acid sugars on the surfaces of epithelial cells, typically in the nose, throat, and lungs of mammals, and intestines of birds (Stage 1 in infection figure).[70] After the hemagglutinin is cleaved by a protease, the cell imports the virus by endocytosis.[71]

The intracellular details are still being elucidated. It is known that virions converge to the microtubule organizing center, interact with acidic endosomes and finally enter the target endosomes for genome release.[72]

Once inside the cell, the acidic conditions in the endosome cause two events to happen: First, part of the hemagglutinin protein fuses the viral envelope with the vacuole's membrane, then the M2 ion channel allows protons to move through the viral envelope and acidify the core of the virus, which causes the core to disassemble and release the viral RNA and core proteins.[60] The viral RNA (vRNA) molecules, accessory proteins and RNA-dependent RNA polymerase are then released into the cytoplasm (Stage 2).[73] The M2 ion channel is blocked by amantadine drugs, preventing infection.[74]

These core proteins and vRNA form a complex that is transported into the cell nucleus, where the RNA-dependent RNA polymerase begins transcribing complementary positive-sense vRNA (Steps 3a and b).[75] The vRNA either is exported into the cytoplasm and translated (step 4) or remains in the nucleus. Newly synthesized viral proteins are either secreted through the Golgi apparatus onto the cell surface (in the case of neuraminidase and hemagglutinin, step 5b) or transported back into the nucleus to bind vRNA and form new viral genome particles (step 5a). Other viral proteins have multiple actions in the host cell, including degrading cellular mRNA and using the released nucleotides for vRNA synthesis and also inhibiting translation of host-cell mRNAs.[76]

Negative-sense vRNAs that form the genomes of future viruses, RNA-dependent RNA polymerase, and other viral proteins are assembled into a virion. Hemagglutinin and neuraminidase molecules cluster into a bulge in the cell membrane. The vRNA and viral core proteins leave the nucleus and enter this membrane protrusion (step 6). The mature virus buds off from the cell in a sphere of host phospholipid membrane, acquiring hemagglutinin and neuraminidase with this membrane coat (step 7).[77] As before, the viruses adhere to the cell through hemagglutinin; the mature viruses detach once their neuraminidase has cleaved sialic acid residues from the host cell.[70] After the release of new influenza viruses, the host cell dies.

Because of the absence of RNA proofreading enzymes, the RNA-dependent RNA polymerase that copies the viral genome makes an error roughly every 10 thousand nucleotides, which is the approximate length of the influenza vRNA. Hence, the majority of newly manufactured influenza viruses are mutants; this causes antigenic drift, which is a slow change in the antigens on the viral surface over time.[78] The separation of the genome into eight separate segments of vRNA allows mixing or reassortment of vRNAs if more than one type of influenza virus infects a single cell. The resulting rapid change in viral genetics produces antigenic shifts, which are sudden changes from one antigen to another. These sudden large changes allow the virus to infect new host species and quickly overcome protective immunity.[65] This is important in the emergence of pandemics, as discussed below in the section on epidemiology. Also, when two or more viruses infect a cell, genetic variation may be generated by homologous recombination.[79][80] Homologous recombination can arise during viral genome replication by the RNA polymerase switching from one template to another, a process known as copy choice.[80]

## Mechanism[edit | edit source]

### Transmission[edit | edit source]

When an infected person sneezes or coughs more than half a million virus particles can be spread to those close by.[81] In otherwise healthy adults, influenza virus shedding (the time during which a person might be infectious to another person) increases sharply one-half to one day after infection, peaks on day 2 and persists for an average total duration of 5 days—but can persist as long as 9 days.[82] In those who develop symptoms from experimental infection (only 67% of healthy experimentally infected individuals), symptoms and viral shedding show a similar pattern, but with viral shedding preceding illness by one day.[82] Children are much more infectious than adults and shed virus from just before they develop symptoms until two weeks after infection.[83] In immunocompromised people, viral shedding can continue for longer than two weeks.[84]

Influenza can be spread in three main ways:[85][86] by direct transmission (when an infected person sneezes mucus directly into the eyes, nose or mouth of another person); the airborne route (when someone inhales the aerosols produced by an infected person coughing, sneezing or spitting) and through hand-to-eye, hand-to-nose, or hand-to-mouth transmission, either from contaminated surfaces or from direct personal contact such as a handshake. The relative importance of these three modes of transmission is unclear, and they may all contribute to the spread of the virus.[9] In the airborne route, the droplets that are small enough for people to inhale are 0.5 to 5 μm in diameter and inhaling just one droplet might be enough to cause an infection.[85] Although a single sneeze releases up to 40,000 droplets,[87] most of these droplets are quite large and will quickly settle out of the air.[85] How long influenza survives in airborne droplets seems to be influenced by the levels of humidity and UV radiation, with low humidity and a lack of sunlight in winter aiding its survival;[85] ideal conditions can allow it to live for an hour in the atmosphere.[88]

As the influenza virus can persist outside of the body, it can also be transmitted by contaminated surfaces such as banknotes,[89] doorknobs, light switches and other household items.[90] The length of time the virus will persist on a surface varies, with the virus surviving for one to two days on hard, non-porous surfaces such as plastic or metal, for about fifteen minutes on dry paper tissues, and only five minutes on skin.[91] However, if the virus is present in mucus, this can protect it for longer periods (up to 17 days on banknotes).[85][89] Avian influenza viruses can survive indefinitely when frozen.[92] They are inactivated by heating to 56 °C (133 °F) for a minimum of 60 minutes, as well as by acids (at pH <2).[92]

### Pathophysiology[edit | edit source]

The different sites of infection (shown in red) of seasonal H1N1 versus avian H5N1. This influences their lethality and ability to spread.

The mechanisms by which influenza infection causes symptoms in humans have been studied intensively. One of the mechanisms is believed to be the inhibition of adrenocorticotropic hormone (ACTH) resulting in lowered cortisol levels.[93] Knowing which genes are carried by a particular strain can help predict how well it will infect humans and how severe this infection will be (that is, predict the strain's pathophysiology).[53][94]

For instance, part of the process that allows influenza viruses to invade cells is the cleavage of the viral hemagglutinin protein by any one of several human proteases.[71] In mild and avirulent viruses, the structure of the hemagglutinin means that it can only be cleaved by proteases found in the throat and lungs, so these viruses cannot infect other tissues. However, in highly virulent strains, such as H5N1, the hemagglutinin can be cleaved by a wide variety of proteases, allowing the virus to spread throughout the body.[94]

Immune pathways triggered by influenza-virus infection.If proinflammatory cytokines are excessively created, then an uncontrolled cytokine storm is formed, which can cause organ damage and even death [95]

The viral hemagglutinin protein is responsible for determining both which species a strain can infect and where in the human respiratory tract a strain of influenza will bind.[96] Strains that are easily transmitted between people have hemagglutinin proteins that bind to receptors in the upper part of the respiratory tract, such as in the nose, throat and mouth. In contrast, the highly lethal H5N1 strain binds to receptors that are mostly found deep in the lungs.[97] This difference in the site of infection may be part of the reason why the H5N1 strain causes severe viral pneumonia in the lungs, but is not easily transmitted by people coughing and sneezing.[98][99]

Common symptoms of the flu such as fever, headaches, and fatigue are the result of the huge amounts of proinflammatory cytokines and chemokines (such as interferon or tumor necrosis factor) produced from influenza-infected cells.[100][101] In contrast to the rhinovirus that causes the common cold, influenza does cause tissue damage, so symptoms are not entirely due to the inflammatory response.[102] This massive immune response might produce a life-threatening cytokine storm. This effect has been proposed to be the cause of the unusual lethality of both the H5N1 avian influenza,[103] and the 1918 pandemic strain.[104][105] However, another possibility is that these large amounts of cytokines are just a result of the massive levels of viral replication produced by these strains, and the immune response does not itself contribute to the disease.[106] Influenza appears to trigger programmed cell death (apoptosis).[107]

## Prevention[edit | edit source]

### Vaccination[edit | edit source]

Main article: Influenza vaccine

Giving an influenza vaccination

The influenza vaccine is recommended by the World Health Organization (WHO) for high-risk groups, such as pregnant women, children aged less than five years, the elderly, health care workers, and people who have chronic illnesses such as HIV/AIDS, asthma, diabetes, heart disease, or are immunocompromised among others.[108][109] The United States Centers for Disease Control and Prevention (CDC) recommends the influenza vaccine for those aged six months or older who do not have contraindications.[110][11] In healthy adults it is modestly effective in decreasing the amount of influenza-like symptoms in a population.[111] In healthy children over the age of two years, the vaccine reduces the chances of getting influenza by around two-thirds, while it has not been well studied in children under two years.[112] In those with chronic obstructive pulmonary disease vaccination reduces exacerbations,[113] it is not clear if it reduces asthma exacerbations.[114] Evidence supports a lower rate of influenza-like illness in many groups who are immunocompromised such as those with: HIV/AIDS, cancer, and post organ transplant.[115] In those at high risk immunization may reduce the risk of heart disease.[116] Whether immunizing health care workers affects patient outcomes is controversial with some reviews finding insufficient evidence[117][118] and others finding tentative evidence.[119][120]

Due to the high mutation rate of the virus, a particular influenza vaccine usually confers protection for no more than a few years. Each year, the World Health Organization predicts which strains of the virus are most likely to be circulating in the next year (see Historical annual reformulations of the influenza vaccine), allowing pharmaceutical companies to develop vaccines that will provide the best immunity against these strains.[121] The vaccine is reformulated each season for a few specific flu strains but does not include all the strains active in the world during that season. It takes about six months for the manufacturers to formulate and produce the millions of doses required to deal with the seasonal epidemics; occasionally, a new or overlooked strain becomes prominent during that time.[122] It is also possible to get infected just before vaccination and get sick with the strain that the vaccine is supposed to prevent, as the vaccine takes about two weeks to become effective.[123] Vaccines can cause the immune system to react as if the body were actually being infected, and general infection symptoms (many cold and flu symptoms are just general infection symptoms) can appear, though these symptoms are usually not as severe or long-lasting as influenza. The most dangerous adverse effect is a severe allergic reaction to either the virus material itself or residues from the hen eggs used to grow the influenza; however, these reactions are extremely rare.[124]

A 2018 Cochrane review of children in good general health found that the live immunization seemed to lower the risk of getting influenza for the season from 18% to 4%. The inactivated vaccine seemed to lower the risk of getting flu for the season from 30% to 11%. Not enough data was available to draw definite conclusions about serious complications such as pneumonia or hospitalization.[112]

For healthy adults, a 2018 Cochrane review showed that vaccines reduced the incidence of lab-confirmed influenza from 2.3% to 0.9%, which constitutes a reduction of risk of approximately 60%. However, for influenza-like illness which is defined as the same symptoms of cough, fever, headache, runny nose, and bodily aches and pains, vaccine reduced the risk from 21.5% to 18.1%. This constitutes a much more modest reduction of risk of approximately 16%. The difference is most probably explained by the fact that over 200 viruses cause the same or similar symptoms as the flu virus.[111] Another review looked at the effect of short and long term exercise before the vaccine, however, no benefits or harms were recorded.[125]

The cost-effectiveness of seasonal influenza vaccination has been widely evaluated for different groups and in different settings.[126] It has generally been found to be a cost-effective intervention, especially in children[127] and the elderly,[128] however the results of economic evaluations of influenza vaccination have often been found to be dependent on key assumptions.[129][130]

### Infection control[edit | edit source]

Further information: Influenza prevention

These are the main ways that influenza spreads

* by direct transmission (when an infected person sneezes mucus directly into the eyes, nose or mouth of another person);
* the airborne route (when someone inhales the aerosols produced by an infected person coughing, sneezing or spitting);
* through hand-to-eye, hand-to-nose, or hand-to-mouth transmission, either from contaminated surfaces or from direct personal contact such as a hand-shake.

When vaccines and antiviral medications are limited, non-pharmaceutical interventions are essential to reduce transmission and spread. The lack of controlled studies and rigorous evidence of the effectiveness of some measures has hampered planning decisions and recommendations. Nevertheless, strategies endorsed by experts for all phases of flu outbreaks include hand and respiratory hygiene, self-isolation by symptomatic individuals and the use of face masks by them and their caregivers, surface disinfection, rapid testing and diagnosis, and contact tracing. In some cases, other forms of social distancing including school closures and travel restrictions are recommended.[131]

Reasonably effective ways to reduce the transmission of influenza include good personal health and hygiene habits such as: not touching the eyes, nose or mouth;[132] frequent hand washing (with soap and water, or with alcohol-based hand rubs);[133] covering coughs and sneezes with a tissue or sleeve; avoiding close contact with sick people; and staying home when sick. Avoiding spitting is also recommended.[131] Although face masks might help prevent transmission when caring for the sick,[134][135] there is mixed evidence on beneficial effects in the community.[131][136] Smoking raises the risk of contracting influenza, as well as producing more severe disease symptoms.[137][138]

Since influenza spreads through both aerosols and contact with contaminated surfaces, surface sanitizing may help prevent some infections.[139] Alcohol is an effective sanitizer against influenza viruses, while quaternary ammonium compounds can be used with alcohol so that the sanitizing effect lasts for longer.[140] In hospitals, quaternary ammonium compounds and bleach are used to sanitize rooms or equipment that have been occupied by people with influenza symptoms.[140] At home, this can be done effectively with a diluted chlorine bleach.[141]

Social distancing strategies used during past pandemics, such as quarantines, travel restrictions, and the closing of schools, churches and theaters, have been employed to slow the spread of influenza viruses. Researchers have estimated that such interventions during the 1918 Spanish flu pandemic in the US reduced the peak death rate by up to 50%, and the overall mortality by about 10–30%, in areas where multiple interventions were implemented. The more moderate effect on total deaths was attributed to the measures being employed too late, or lifted too early, most after six weeks or less.[142][143]

For typical flu outbreaks, routine cancellation of large gatherings or mandatory travel restrictions have received little agreement, particularly as they may be disruptive and unpopular. School closures have been found by most empirical studies to reduce community spread, but some findings have been contradictory. Recommendations for these community restrictions are usually on a case-by-case basis.[131]

## Diagnosis[edit | edit source]

29 yr old with H1N1

There are a number of rapid tests for the flu. One is called a Rapid Molecular Assay, when an upper respiratory tract specimen (mucus) is taken using a nasal swab or a nasopharyngeal swab.[144] It should be done within 3–4 days of symptom onset, as upper respiratory viral shedding takes a downward spiral after that.[145]

## Treatment[edit | edit source]

Main article: Influenza treatment

People with the flu are advised to get plenty of rest, drink plenty of liquids, avoid using alcohol and tobacco and, if necessary, take medications such as acetaminophen (paracetamol) to relieve the fever and muscle aches associated with the flu.[146][147] In contrast, there is not enough evidence to support corticosteroids as additional therapy for influenza.[148] It is advised to avoid close contact with others to prevent spread of infection.[146][147] Children and teenagers with flu symptoms (particularly fever) should avoid taking aspirin during an influenza infection (especially influenza type B), because doing so can lead to Reye's syndrome, a rare but potentially fatal disease of the liver.[149] Since influenza is caused by a virus, antibiotics have no effect on the infection; unless prescribed for secondary infections such as bacterial pneumonia. Antiviral medication may be effective, if given early (within 48 hours to first symptoms), but some strains of influenza can show resistance to the standard antiviral medications and there is concern about the quality of the research.[150] High-risk individuals such as young children, pregnant women, the elderly, and those with compromised immune systems should visit the doctor for antiviral medications. Those with the emergency warning signs should visit the emergency room at once.[151]

### Antivirals[edit | edit source]

Antiviral drugs[27] Drug | Route of administration | Approved age of use

|
|

Oseltamivir | By mouth | At least two weeks old
Zanamivir | Inhalation | At least five years old
Peramivir | Intravenous | At least 18 years old
Laninamivir | Inhalation[24] | 40 milligrams (mg) dose for people at least 10 years old,
20 mg for those under 10[152]
Baloxavir marboxil | By mouth[153] | At least 12 years old[154]

The two classes of antiviral medications used against influenza are neuraminidase inhibitors (oseltamivir, zanamivir, laninamivir and peramivir) and M2 protein inhibitors (adamantane derivatives).[155][156][157] In Russia, umifenovir is sold for treatment of influenza[158] and in the first quarter of 2020 had a 16 percent share in the antiviral market.[159]

#### Neuraminidase inhibitors[edit | edit source]

Overall the benefits of neuraminidase inhibitors in those who are otherwise healthy do not appear to be greater than the risks.[12] There does not appear to be any benefit in those with other health problems.[12] In those believed to have the flu, they decreased the length of time symptoms were present by slightly less than a day but did not appear to affect the risk of complications such as needing hospitalization or pneumonia.[13] Increasingly prevalent resistance to neuraminidase inhibitors has led researchers to seek alternative antiviral medications with different mechanisms of action.[160]

#### M2 inhibitors[edit | edit source]

The antiviral medications amantadine and rimantadine inhibit a viral ion channel (M2 protein), thus inhibiting replication of the influenza A virus.[74] These medications are sometimes effective against influenza A if given early in the infection but are ineffective against influenza B viruses, which lack the M2 drug target.[161] Measured resistance to amantadine and rimantadine in American isolates of H3N2 has increased to 91% in 2005.[162] This high level of resistance may be due to the easy availability of amantadines as part of over-the-counter cold remedies in countries such as China and Russia,[163] and their use to prevent outbreaks of influenza in farmed poultry.[164][165] The CDC recommended against using M2 inhibitors during the 2005–06 influenza season due to high levels of drug resistance.[166]

## Prognosis[edit | edit source]

Influenza's effects are much more severe and last longer than those of the common cold. Most people will recover completely in about one to two weeks, but others will develop life-threatening complications (such as pneumonia). Thus, influenza can be deadly, especially for the weak, young and old, those with compromised immune systems, or the chronically ill.[65] People with a weak immune system, such as people with advanced HIV infection or transplant recipients (whose immune systems are medically suppressed to prevent transplant organ rejection), suffer from particularly severe disease.[167] Pregnant women and young children are also at a high risk for complications.[168]

The flu can worsen chronic health problems. People with emphysema, chronic bronchitis or asthma may experience shortness of breath while they have the flu, and influenza may cause worsening of coronary heart disease or congestive heart failure.[169] Smoking is another risk factor associated with more serious disease and increased mortality from influenza.[137]

Even healthy people can be affected, and serious problems from influenza can happen at any age. People over 65 years old, pregnant women, very young children and people of any age with chronic medical conditions are more likely to get complications from influenza, such as pneumonia, bronchitis, sinus, and ear infections.[170]

### Neurological[edit | edit source]

Influenza encephalitis MRI

In some cases, an autoimmune response to an influenza infection may contribute to the development of Guillain–Barré syndrome.[171] However, as many other infections can increase the risk of this disease, influenza may only be an important cause during epidemics.[171][172] This syndrome has been believed to also be a rare side effect of influenza vaccines. One review gives an incidence of about one case per million vaccinations.[173] Getting infected by influenza itself increases both the risk of death (up to 1 in 10,000) and increases the risk of developing GBS to a much higher level than the highest level of suspected vaccine involvement (approx. 10 times higher by recent estimates).[171][174]

According to the Centers for Disease Control and Prevention (CDC), "Children of any age with neurologic conditions are more likely than other children to become very sick if they get the flu. Flu complications may vary and for some children, can include pneumonia and even death."[175]

Neurological conditions can include:

* Disorders of the brain and spinal cord
* Cerebral palsy
* Epilepsy (seizure disorders)
* Stroke
* Intellectual disability
* Moderate to severe developmental delay
* Muscular dystrophy
* Spinal cord injury

These conditions can impair coughing, swallowing, clearing the airways, and in the worst cases, breathing. Therefore, they worsen the flu symptoms.[175]

## Epidemiology[edit | edit source]

### Seasonal variations[edit | edit source]

Further information: Flu season

See also: United States influenza statistics by flu season

Seasonal risk areas for influenza: November–April (blue), April–November (red), and year-round (yellow).

Influenza reaches peak prevalence in winter, and because the Northern and Southern Hemispheres have winter at different times of the year, there are actually two different flu seasons each year. This is why the World Health Organization (assisted by the National Influenza Centers) makes recommendations for two different vaccine formulations every year; one for the Northern, and one for the Southern Hemisphere.[121]

A long-standing puzzle has been why outbreaks of the flu occur seasonally rather than uniformly throughout the year. One possible explanation is that, because people are indoors more often during the winter, they are in close contact more often, and this promotes transmission from person to person. Increased travel due to the Northern Hemisphere winter holiday season may also play a role.[176] Another factor is that cold temperatures lead to drier air, which may dehydrate mucus particles. Dry particles are lighter and can thus remain airborne for a longer period. The virus also survives longer on surfaces at colder temperatures and aerosol transmission of the virus is highest in cold environments (less than 5 °C) with low relative humidity.[177] The lower air humidity in winter seems to be the main cause of seasonal influenza transmission in temperate regions.[178][179]

However, seasonal changes in infection rates also occur in tropical regions, and in some countries these peaks of infection are seen mainly during the rainy season.[180] Seasonal changes in contact rates from school terms, which are a major factor in other childhood diseases such as measles and pertussis, may also play a role in the flu. A combination of these small seasonal effects may be amplified by dynamical resonance with the endogenous disease cycles.[181] H5N1 exhibits seasonality in both humans and birds.[182][183]

An alternative hypothesis to explain seasonality in influenza infections is an effect of vitamin D levels on immunity to the virus.[184] This idea was first proposed by Robert Edgar Hope-Simpson in 1981.[185] He proposed that the cause of influenza epidemics during winter may be connected to seasonal fluctuations of vitamin D, which is produced in the skin under the influence of solar (or artificial) UV radiation. This could explain why influenza occurs mostly in winter and during the tropical rainy season, when people stay indoors, away from the sun, and their vitamin D levels fall.

### Mortality[edit | edit source]

Influenza mortality in symptomatic cases in the US for the 2018/2019 season. The Y axis goes to 1%.[186]

Every year about 290,000 to 650,000 people die due to influenza globally, with an average of 389,000.[187] In the developed world most of those who die are over the age of 65.[1] In the developing world the effects are less clear; however, it appears that children are affected to a greater degree.[1]

Although the number of cases of influenza can vary widely between years, approximately 36,000 deaths and more than 200,000 hospitalizations are directly associated with influenza a year in the United States.[188][189] One method of calculating influenza mortality produced an estimate of 41,400 average deaths per year in the United States between 1979 and 2001.[190] Different methods in 2010 by the Centers for Disease Control and Prevention (CDC) reported a range from a low of about 3,300 deaths to a high of 49,000 per year.[191]

### Outbreaks[edit | edit source]

Further information: Flu pandemic

As influenza is caused by a variety of species and strains of viruses, in any given year some strains can die out while others create epidemics, while yet another strain can cause a pandemic. Typically, in a year's normal two flu seasons (one per hemisphere), there are between three and five million cases of severe illness,[1][4][192] which by some definitions is a yearly influenza epidemic.[1]

Roughly three times per century, a pandemic occurs, which infects a large proportion of the world's population and can kill tens of millions of people (see pandemics section). In 2006, a study estimated that if a strain with similar virulence to the 1918 influenza had emerged that year, it could have killed between 50 and 80 million people.[193]

Antigenic shift, or reassortment, can result in novel and highly pathogenic strains of human influenza

New influenza viruses are constantly evolving by mutation or by reassortment.[41] Mutations can cause small changes in the hemagglutinin and neuraminidase antigens on the surface of the virus. This is called antigenic drift, which slowly creates an increasing variety of strains until one evolves that can infect people who are immune to the pre-existing strains. This new variant then replaces the older strains as it rapidly sweeps through the human population, often causing an epidemic.[194] However, since the strains produced by drift will still be reasonably similar to the older strains, some people will still be immune to them. In contrast, when influenza viruses reassort, they acquire completely new antigens—for example by reassortment between avian strains and human strains; this is called antigenic shift. If a human influenza virus is produced that has entirely new antigens, everybody will be susceptible, and the novel influenza will spread uncontrollably, causing a pandemic.[195] In contrast to this model of pandemics based on antigenic drift and shift, an alternative approach has been proposed where the periodic pandemics are produced by interactions of a fixed set of viral strains with a human population with a constantly changing set of immunities to different viral strains.[196]

The generation time for influenza (the time from one infection to the next) is very short (only 2 days). This explains why influenza epidemics start and finish in a short time scale of only a few months.[197]

From a public health point of view, flu epidemics spread rapidly and are very difficult to control. Most influenza virus strains are not very infectious and each infected individual will only go on to infect one or two other individuals (the basic reproduction number for influenza is generally around 1.4). However, the generation time for influenza is extremely short: the time from a person becoming infected to when he infects the next person is only two days. The short generation time means that influenza epidemics generally peak at around 2 months and burn out after 3 months: the decision to intervene in an influenza epidemic, therefore, has to be taken early, and the decision is therefore often made on the back of incomplete data. Another problem is that individuals become infectious before they become symptomatic, which means that putting people in quarantine after they become ill is not an effective public health intervention.[197] For the average person, viral shedding tends to peak on day two, whereas symptoms peak on day three.[82]

## History[edit | edit source]

### Etymology[edit | edit source]

The word Influenza comes from the Italian language meaning "influence" and refers to the cause of the disease; initially, this ascribed illness to unfavorable astrological influences. It was introduced into English in the mid-eighteenth century during a pan-European epidemic.[198] Archaic terms for influenza include epidemic catarrh, la grippe (from the French, first used by Molyneaux in 1694; also used in German),[199] sweating sickness, and Spanish fever (particularly for the 1918 flu pandemic strain).[200]

### Pandemics[edit | edit source]

Further information: Influenza pandemic, Spanish flu, and Hong Kong flu

The difference between the influenza mortality age distributions of the 1918 epidemic and normal epidemics. Deaths per 100,000 persons in each age group, United States, for the interpandemic years 1911–1917 (dashed line) and the pandemic year 1918 (solid line).[201] Thermal imaging camera and screen, photographed in an airport terminal in Greece during the 2009 flu pandemic. Thermal imaging can detect elevated body temperature, one of the signs of swine flu.

An overall lack of data up until 1500 precludes meaningful search for the influenza outbreaks in the more distant past.[202] Possibly the first influenza pandemic occurred around 6000 BC in China.[202] The symptoms of human influenza were clearly described by Hippocrates roughly 2,400 years ago.[203][204] Although the virus seems to have caused epidemics throughout human history, historical data on influenza are difficult to interpret, because the symptoms can be similar to those of other respiratory diseases.[199][205] The disease may have spread from Europe to the Americas as early as the European colonization of the Americas, since almost the entire indigenous population of the Antilles was killed by an epidemic resembling influenza that broke out in 1493, after the arrival of Christopher Columbus.[206][207]

The first convincing record of an influenza pandemic was a minor pandemic chronicled in 1510, which began in East Asia before spreading to North Africa and then Europe. During this pandemic, influenza killed about 1% of its victims.[208][209] The first pandemic of influenza to be reliably recorded as spreading worldwide was the 1557 influenza pandemic,[210][211][212][213] in which a reoccurring wave likely killed Queen Mary I of England and the Archbishop of Canterbury within 12 hours of each other.[214][215] One of the most well-chronicled pandemics of influenza in the 16th Century occurred in 1580, beginning in East Asia and spreading to Europe through Africa, Russia, and the Spanish and Ottoman Empires. In Rome, over 8,000 people were killed. Several Spanish cities saw large scale deaths, among the fatalities the Queen of Spain, Anna of Austria. Pandemics continued sporadically throughout the 17th and 18th centuries, with the pandemic of 1830–1833 being particularly widespread; it infected approximately a quarter of the people exposed.[199]

The most famous and lethal outbreak was the 1918 flu pandemic (Spanish flu) (type A influenza, H1N1 subtype), which lasted into 1920. It is not known exactly how many it killed, but estimates range from 17 million to 100 million people.[15][201][216][217] This pandemic has been described as "the greatest medical holocaust in history" and may have killed as many people as the Black Death.[199] This huge death toll was caused by an extremely high infection rate of up to 50% and the extreme severity of the symptoms, suspected to be caused by cytokine storms.[217] Symptoms in 1918 were so unusual that initially influenza was misdiagnosed as dengue, cholera, or typhoid. One observer wrote, "One of the most striking of the complications was hemorrhage from mucous membranes, especially from the nose, stomach, and intestine. Bleeding from the ears and petechial hemorrhages in the skin also occurred."[216] The majority of deaths were from bacterial pneumonia, a secondary infection caused by influenza, but the virus also killed people directly, causing massive hemorrhages and edema in the lung.[218]

The 1918 flu pandemic was truly global, spreading even to the Arctic and remote Pacific islands. The unusually severe disease killed between two and twenty percent of those infected, as opposed to the more usual flu epidemic mortality rate of 0.1%.[201][216] Another unusual feature of this pandemic was that it mostly killed young adults, with 99% of pandemic influenza deaths occurring in people under 65, and more than half in young adults 20 to 40 years old.[219] This is unusual since influenza is normally most deadly to the very young (under age 2) and the very old (over age 70). The total mortality of the 1918–1919 pandemic is not known, but it is estimated that 2.5% to 5% of the world's population was killed. As many as 25 million may have been killed in the first 25 weeks; in contrast, HIV/AIDS has killed 25 million in its first 25 years.[216]

Later flu pandemics were not so devastating. They included the 1957 Asian flu (type A, H2N2 strain) and the 1968 Hong Kong flu (type A, H3N2 strain), but even these smaller outbreaks killed millions of people. In later pandemics antibiotics were available to control secondary infections and this may have helped reduce mortality compared to the Spanish flu of 1918.[201]

Major modern influenza pandemics[220][221]

* v
* t
* e

Name  | Date  | World pop. | Subtype  | Reproduction number  | Infected (est.)  | Deaths worldwide  | Case fatality rate | Pandemic severity

|
|
|
|
|
|
|
|

1889–90 flu pandemic[222] | 1889–90  | 1.53 billion  | Likely H3N8 or H2N2 | 2.10 (IQR, 1.9–2.4)[222] | 20–60%[222] (300–900 million)  | 1 million[223] | 0.10–0.28%[222] | 2
1918 flu[224] | 1918–20  | 1.80 billion  | H1N1 | 1.80 (IQR, 1.47–2.27)[225] | 33% (500 million)[226] or >56% (>1 billion)[227] | 17[228]–100[229][230] million  | 2–3%,[227] or ~4%, or ~10%[231] | 5
Asian flu[232] | 1957–58  | 2.90 billion  | H2N2 | 1.65 (IQR, 1.53–1.70)[225] | >17% (>500 million)[227] | 1–4 million[227] | <0.2%[227] | 2
Hong Kong flu[233] | 1968–69  | 3.53 billion  | H3N2 | 1.80 (IQR, 1.56–1.85)[225] | >14% (>500 million)[227] | 1–4 million[227] | <0.1%[227][234] | 2
2009 flu pandemic[235][236] | 2009–10  | 6.85 billion  | H1N1/09 | 1.46 (IQR, 1.30–1.70)[225] | 11–21% (0.7–1.4 billion)[237] | 151,700–575,400[238] | 0.01%[239][240] | 1
Typical seasonal flu[t 1] | Every year  | 7.75 billion  | A/H3N2, A/H1N1, B, ...  | 1.28 (IQR, 1.19–1.37)[225] | 5–15% (340 million – 1 billion)[241]
3–11% or 5–20%[242][243] (240 million – 1.6 billion)  | 290,000–650,000/year[244] | <0.1%[245] | 1
Notes

1. ↑ Not necessarily pandemic, but included for comparison purposes.

It was incorrectly assumed that the cause of influenza was bacterial in origin from 1892 (with Haemophilus influenzae being discovered by and suggested as the origin of influenza by R. F. J. Pfeiffer).[246] The first influenza virus to be isolated was from poultry, when in 1901, the agent causing a disease called "fowl plague" was passed through Chamberland filters, which have pores that are too small for bacteria to pass through.[247] However, the conceptual differences between viruses and bacteria as different entities was not fully understood for some time, complicating preventative measures taken during the 1918 influenza pandemic.[246] The etiological cause of influenza, the virus family Orthomyxoviridae, was first discovered in pigs by Richard Shope in 1931.[248] This discovery was shortly followed by the isolation of the virus from humans by a group headed by Patrick Laidlaw at the Medical Research Council of the United Kingdom in 1933.[249] However, it was not until Wendell Stanley first crystallized tobacco mosaic virus in 1935 that the non-cellular nature of viruses was appreciated.

The main types of influenza viruses in humans. Solid squares show the appearance of a new strain, causing recurring influenza pandemics. Broken lines indicate uncertain strain identifications.[250]

The first significant step towards preventing influenza was the development in 1944 of a killed-virus vaccine for influenza by Thomas Francis, Jr. This built on work by Australian Frank Macfarlane Burnet, who showed that the virus lost virulence when it was cultured in fertilized hen's eggs.[251] Application of this observation by Francis allowed his group of researchers at the University of Michigan to develop the first influenza vaccine, with support from the U.S. Army.[252] The Army was deeply involved in this research due to its experience of influenza in World War I, when thousands of troops were killed by the virus in a matter of months.[216] In comparison to vaccines, the development of anti-influenza drugs has been slower, with amantadine being licensed in 1966 and, almost thirty years later, the next class of drugs (the neuraminidase inhibitors) being developed.[253]

## Society and culture[edit | edit source]

Further information: Social impact of H5N1

Influenza produces direct costs due to lost productivity and associated medical treatment, as well as indirect costs of preventive measures. In the United States, seasonal influenza is estimated to result in a total average annual economic cost of over $11 billion, with direct medical costs estimated to be over $3 billion annually.[254] It has been estimated that a future pandemic could cause hundreds of billions of dollars in direct and indirect costs.[255] However, the economic impacts of past pandemics have not been intensively studied, and some authors have suggested that the Spanish influenza actually had a positive long-term effect on per-capita income growth, despite a large reduction in the working population and severe short-term depressive effects.[256] Other studies have attempted to predict the costs of a pandemic as serious as the 1918 Spanish flu on the U.S. economy, where 30% of all workers became ill, and 2.5% were killed. A 30% sickness rate and a three-week length of illness would decrease the gross domestic product by 5%. Additional costs would come from medical treatment of 18 million to 45 million people, and total economic costs would be approximately $700 billion.[257]

Preventive costs are also high. Governments worldwide have spent billions of U.S. dollars preparing and planning for a potential H5N1 avian influenza pandemic, with costs associated with purchasing drugs and vaccines as well as developing disaster drills and strategies for improved border controls.[258] On 1 November 2005, United States President George W. Bush unveiled the National Strategy to Safeguard Against the Danger of Pandemic Influenza[255] backed by a request to Congress for $7.1 billion to begin implementing the plan.[259] Internationally, on 18 January 2006, donor nations pledged US$2 billion to combat bird flu at the two-day International Pledging Conference on Avian and Human Influenza held in China.[260][261]

In an assessment of the 2009 H1N1 pandemic on selected countries in the Southern Hemisphere, data suggest that all countries experienced some time-limited and/or geographically isolated socioeconomic effects and a temporary decrease in tourism most likely due to fear of 2009 H1N1 disease. It is still too early to determine whether the H1N1 pandemic has had any long-term economic effects.[262][needs update]

## Research[edit | edit source]

Further information: Influenza research

Research on influenza includes studies on molecular virology, how the virus produces disease (pathogenesis), host immune responses, viral genomics, and how the virus spreads (epidemiology). These studies help in developing influenza countermeasures; for example, a better understanding of the body's immune system response helps vaccine development, and a detailed picture of how influenza invades cells aids the development of antiviral drugs. One important basic research program is the Influenza Genome Sequencing Project, which was initiated in 2004 to create a library of influenza sequences and help clarify which factors make one strain more lethal than another, which genes most affect immunogenicity, and how the virus evolves over time.[263]

The sequencing of the influenza genome and recombinant DNA technology may accelerate the generation of new vaccine strains by allowing scientists to substitute new antigens into a previously developed vaccine strain.[264] Growing viruses in cell culture also promises higher yields, less cost, better quality and surge capacity.[265] Research on a universal influenza A vaccine, targeted against the external domain of the transmembrane viral M2 protein (M2e), is being done at the University of Ghent by Walter Fiers, Xavier Saelens and their team[266][267][268] and has now successfully concluded Phase I clinical trials. There has been some research success towards a "universal flu vaccine" that produces antibodies against proteins on the viral coat which mutate less rapidly, and thus a single shot could potentially provide longer-lasting protection.[269][270][271]

A number of biologics, therapeutic vaccines and immunobiologics are also being investigated for treatment of infection caused by viruses. Therapeutic biologics are designed to activate the immune response to virus or antigens. Typically, biologics do not target metabolic pathways like anti-viral drugs, but stimulate immune cells such as lymphocytes, macrophages, and/or antigen-presenting cells, in an effort to drive an immune response towards a cytotoxic effect against the virus. Influenza models, such as murine influenza, are convenient models to test the effects of prophylactic and therapeutic biologics. For example, lymphocyte T-cell immunomodulator inhibits viral growth in the murine model of influenza.[272]

* Tetramer of influenza neuraminidase protein bound by variable domains of two new human antibodies targeting its dark side (1G01 and DA03E17)[273][274][275]

* Dr. Terrence Tumpey examining a laboratory-grown reconstruction of the 1918 Spanish flu virus in a biosafety level 3 environment.

## Other animals[edit | edit source]

H5N1

* Influenza A virus
* subtype H5N1
* Genetic structure
* Infection
* Human mortality
* Global spread
* in 2004
* in 2005
* in 2006
* in 2007
* Social impact
* Pandemic
* Vaccine

* v
* t
* e

Further information: Influenzavirus A, H5N1, and Transmission and infection of H5N1

Influenza infects many animal species, and transfer of viral strains between species can occur. Birds are thought to be the main animal reservoirs of influenza viruses.[276] Most influenza strains are believed to have originated after humans began their intensive domestication of animals about 10,000 years ago.[277] Sixteen forms of hemagglutinin and nine forms of neuraminidase have been identified. All known subtypes (HxNy) are found in birds, but many subtypes are endemic in humans, dogs, horses, and pigs; populations of camels, ferrets, cats, seals, mink, and whales also show evidence of prior infection or exposure to influenza.[50] Variants of flu virus are sometimes named according to the species the strain is endemic in or adapted to. The main variants named using this convention are: bird flu, human flu, swine flu, horse flu and dog flu. (Cat flu generally refers to feline viral rhinotracheitis or feline calicivirus and not infection from an influenza virus.) In pigs, horses and dogs, influenza symptoms are similar to humans, with cough, fever and loss of appetite.[50] The frequency of animal diseases are not as well-studied as human infection, but an outbreak of influenza in harbor seals caused approximately 500 seal deaths off the New England coast in 1979–1980.[278] However, outbreaks in pigs are common and do not cause severe mortality.[50] Vaccines have also been developed to protect poultry from avian influenza. These vaccines can be effective against multiple strains and are used either as part of a preventive strategy, or combined with culling in attempts to eradicate outbreaks.[279]

### Bird flu[edit | edit source]

Flu symptoms in birds are variable and can be unspecific.[280] The symptoms following infection with low-pathogenicity avian influenza may be as mild as ruffled feathers, a small reduction in egg production, or weight loss combined with minor respiratory disease.[281] Since these mild symptoms can make diagnosis in the field difficult, tracking the spread of avian influenza requires laboratory testing of samples from infected birds. Some strains such as Asian H9N2 are highly virulent to poultry and may cause more extreme symptoms and significant mortality.[282] In its most highly pathogenic form, influenza in chickens and turkeys produces a sudden appearance of severe symptoms and almost 100% mortality within two days.[283] As the virus spreads rapidly in the crowded conditions seen in the intensive farming of chickens and turkeys, these outbreaks can cause large economic losses to poultry farmers.[citation needed]

An avian-adapted, highly pathogenic strain of H5N1 (called HPAI A(H5N1), for "highly pathogenic avian influenza virus of type A of subtype H5N1") causes H5N1 flu, commonly known as "avian influenza" or simply "bird flu", and is endemic in many bird populations, especially in Southeast Asia. This Asian lineage strain of HPAI A(H5N1) is spreading globally. It is epizootic (an epidemic in non-humans) and panzootic (a disease affecting animals of many species, especially over a wide area), killing tens of millions of birds and spurring the culling of hundreds of millions of other birds in an attempt to control its spread. Most references in the media to "bird flu" and most references to H5N1 are about this specific strain.[284][285]

HPAI A(H5N1) is an avian disease and there is no evidence suggesting efficient human-to-human transmission of HPAI A(H5N1). In almost all cases, those infected have had extensive physical contact with infected birds.[286] H5N1 may mutate or reassort into a strain capable of efficient human-to-human transmission. The exact changes that are required for this to happen are not well understood.[287] Due to the high lethality and virulence of H5N1, its endemic presence, and its large and increasing biological host reservoir, the H5N1 virus was the world's major pandemic threat in the 2006–07 flu season, and billions of dollars are being raised and spent researching H5N1 and preparing for a potential influenza pandemic.[258]

Chinese inspectors checking airline passengers for fevers, a common symptom of swine flu

In March 2013, the Chinese government reported three cases of H7N9 influenza infections in humans, two of whom had died and the third became critically ill. Although the strain of the virus is not thought to spread efficiently between humans,[288][289] by mid-April, at least 82 persons had become ill from H7N9, of which 17 had died. These cases include three small family clusters in Shanghai and one cluster between a neighboring girl and boy in Beijing, raising at least the possibility of human-to-human transmission. The WHO points out that one cluster did not have two of the cases lab confirmed and further points out, as a matter of baseline information, that some viruses are able to cause limited human-to-human transmission under conditions of close contact but are not transmissible enough to cause large community outbreaks.[290][291][292]

### Swine flu[edit | edit source]

In pigs swine influenza produces fever, lethargy, sneezing, coughing, difficulty breathing and decreased appetite.[293] In some cases the infection can cause abortion. Although mortality is usually low, the virus can produce weight loss and poor growth, causing economic loss to farmers.[293] Infected pigs can lose up to 12 pounds of body weight over a three- to four-week period.[293] Direct transmission of an influenza virus from pigs to humans is occasionally possible (this is called zoonotic swine flu). In all, 50 human cases are known to have occurred since the virus was identified in the mid-20th century, which have resulted in six deaths.[294]

In 2009, a swine-origin H1N1 virus strain commonly referred to as "swine flu" caused the 2009 flu pandemic, but there is no evidence that it is endemic to pigs (i.e. actually a swine flu) or of transmission from pigs to people; instead, the virus spreads from person to person.[295][296] This strain is a reassortment of several strains of H1N1 that are usually found separately, in humans, birds, and pigs.[297]

## References[edit | edit source]

1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 "Influenza (Seasonal)". World Health Organization (WHO). 6 November 2018. Archived from the original on 30 November 2019. Retrieved 30 November 2019.
2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 Longo, Dan L. (2012). "Chapter 187: Influenza". Harrison's principles of internal medicine (18th ed.). New York: McGraw-Hill. ISBN 978-0-07-174889-6.
3. ↑ 3.0 3.1 Jefferson T, Del Mar CB, Dooley L, Ferroni E, Al-Ansary LA, Bawazeer GA, et al. (July 2011). "Physical interventions to interrupt or reduce the spread of respiratory viruses" (PDF). Cochrane Database Syst Rev (7): CD006207. doi:10.1002/14651858.CD006207.pub4. PMC 6993921. PMID 21735402. Archived (PDF) from the original on 28 August 2021. Retrieved 1 August 2020.
4. ↑ 4.0 4.1 4.2 "Up to 650 000 people die of respiratory diseases linked to seasonal flu each year". World Health Organization (WHO) (Press release). 14 December 2017. Archived from the original on 18 April 2019. Retrieved 24 September 2019.
5. ↑ 5.0 5.1 5.2 5.3 "Key Facts About Influenza (Flu)". Centers for Disease Control and Prevention (CDC). 9 September 2014. Archived from the original on 2 December 2014. Retrieved 26 November 2014.
6. ↑ 6.0 6.1 Duben-Engelkirk, Paul G.; Engelkirk, Janet (2011). Burton's microbiology for the health sciences (9th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. p. 314\. ISBN 978-1-60547-673-5. Archived from the original on 28 August 2021. Retrieved 1 August 2020.
7. ↑ 7.0 7.1 "Types of Influenza Viruses Seasonal Influenza (Flu)". Centers for Disease Control and Prevention (CDC). 27 September 2017. Archived from the original on 21 January 2017. Retrieved 28 September 2018.
8. ↑ 8.0 8.1 8.2 8.3 Su S, Fu X, Li G, Kerlin F, Veit M (25 August 2017). "Novel Influenza D virus: Epidemiology, pathology, evolution and biological characteristics". Virulence. 8 (8): 1580–91. doi:10.1080/21505594.2017.1365216. PMC 5810478. PMID 28812422.
9. ↑ 9.0 9.1 9.2 Brankston G, Gitterman L, Hirji Z, Lemieux C, Gardam M (April 2007). "Transmission of influenza A in human beings". Lancet Infect Dis. 7 (4): 257–65. doi:10.1016/S1473-3099(07)70029-4. PMID 17376383.
10. ↑ "Influenza in children". Paediatr Child Health. 10 (8): 485–7. October 2005. doi:10.1093/pch/10.8.485. PMC 2722601. PMID 19668662.
11. ↑ 11.0 11.1 Grohskopf LA, Alyanak E, Broder KR, Walter EB, Fry AM, Jernigan DB (2019). "Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices – United States, 2019–20 Influenza Season" (PDF). MMWR Recomm Rep. 68 (3): 1–21. doi:10.15585/mmwr.rr6803a1. PMC 6713402. PMID 31441906. Archived (PDF) from the original on 25 December 2020. Retrieved 1 August 2020. This article incorporates text from this source, which is in the public domain.
12. ↑ 12.0 12.1 12.2 12.3 Michiels B, Van Puyenbroeck K, Verhoeven V, Vermeire E, Coenen S (2013). "The value of neuraminidase inhibitors for the prevention and treatment of seasonal influenza: a systematic review of systematic reviews". PLOS One. 8 (4): e60348. Bibcode:2013PLoSO...860348M. doi:10.1371/journal.pone.0060348. PMC 3614893. PMID 23565231.
13. ↑ 13.0 13.1 Ebell MH, Call M, Shinholser J (April 2013). "Effectiveness of oseltamivir in adults: a meta-analysis of published and unpublished clinical trials". Family Practice. 30 (2): 125–33. doi:10.1093/fampra/cms059. PMID 22997224.
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## Further reading[edit | edit source]

General

* Beigel JH, Farrar J, Han AM, Hayden FG, Hyer R, de Jong MD, et al. (September 2005). "Avian influenza A (H5N1) infection in humans". New England Journal of Medicine. 353 (13): 1374–85. CiteSeerX 10.1.1.730.7890. doi:10.1056/NEJMra052211. PMID 16192482.
* Kamps, Bernd Sebastian; Hoffmann, Christian; Preiser, Wolfgang (2006). "Influenza Report". Flying Publisher. p. 225\. Archived from the original on 1 April 2020. Retrieved 14 March 2022.
* Levine, Arnold J (1992). Viruses. New York: Scientific American Library. ISBN 978-0-7167-5031-4. Archived from the original on 28 August 2021. Retrieved 1 August 2020.
* Baron, Samuel (1996). Medical microbiology (4th ed.). Galveston, TX: University of Texas Medical Branch at Galveston. ISBN 978-0-9631172-1-2. PMID 21413252. Bookshelf ID: NBK7627. Archived from the original on 4 May 2021. Retrieved 1 August 2020.
* Cox NJ, Subbarao K (October 1999). "Influenza". Lancet. 354 (9186): 1277–82. doi:10.1016/S0140-6736(99)01241-6. PMID 10520648. Archived from the original on 1 August 2020. Retrieved 1 August 2020.
* ISBN 978-3-211-80892-4 The Influenza Viruses Hoyle L 1968 Springer Verlag

History

* Brown, Jeremy (2018). Influenza: The Hundred Year Hunt to Cure the Deadliest Disease in History. New York: Atria. ISBN 978-1501181245. Archived from the original on 28 August 2021. Retrieved 1 August 2020.
* Kilbourne ED (January 2006). "Influenza pandemics of the 20th century". Emerging Infectious Diseases. 12 (1): 9–14. doi:10.3201/eid1201.051254. PMC 3291411. PMID 16494710.
* Collier, Richard (1974). The plague of the Spanish lady: the influenza pandemic of 1918–1919. New York: Macmillan. ISBN 978-0-333-13864-9.
* Barry, John M (2004). The great influenza: the epic story of the deadliest plague in history. New York: Viking. ISBN 978-0-670-89473-4.
* Dehner, George (2012). Influenza: A Century of Science and Public Health Response. University of Pittsburgh Press. ISBN 978-0-8229-6189-5.

Microbiology

* Webster RG, Bean WJ, Gorman OT, Chambers TM, Kawaoka Y (March 1992). "Evolution and ecology of influenza A viruses". Microbiological Reviews. 56 (1): 152–79. doi:10.1128/MMBR.56.1.152-179.1992. PMC 372859. PMID 1579108.
* Steinhauer DA, Skehel JJ (2002). "Genetics of influenza viruses". Annual Review of Genetics. 36: 305–32. doi:10.1146/annurev.genet.36.052402.152757. PMID 12429695.

Pathogenesis

* García-Sastre A (January 2006). "Antiviral response in pandemic influenza viruses". Emerging Infectious Diseases. 12 (1): 44–47. doi:10.3201/eid1201.051186. PMC 3291409. PMID 16494716.
* Zambon MC (2001). "The pathogenesis of influenza in humans". Reviews in Medical Virology. 11 (4): 227–41. doi:10.1002/rmv.319. PMID 11479929.

Epidemiology

* Dowdle WR (January 2006). "Influenza pandemic periodicity, virus recycling, and the art of risk assessment". Emerging Infectious Diseases. 12 (1): 34–39. doi:10.3201/eid1201.051013. PMC 3291401. PMID 16494714.
* Horimoto T, Kawaoka Y (January 2001). "Pandemic threat posed by avian influenza A viruses". Clinical Microbiology Reviews. 14 (1): 129–49. doi:10.1128/CMR.14.1.129-149.2001. PMC 88966. PMID 11148006.
* World Health Organization (June 2006). "Epidemiology of WHO-confirmed human cases of avian influenza A(H5N1) infection". Wkly Epidemiol Rec. 81 (26): 249–57. hdl:10665/233137. PMID 16812929. Archived from the original on 2 August 2020. Retrieved 1 August 2020.

Treatment and prevention

* Harper SA, Fukuda K, Uyeki TM, Cox NJ, Bridges CB (July 2005). "Prevention and control of influenza. Recommendations of the Advisory Committee on Immunization Practices (ACIP)" (PDF). MMWR. Recommendations and Reports. 54 (RR-8): 1–40. PMID 16086456. Archived (PDF) from the original on 1 August 2020. Retrieved 1 August 2020.
* Monto AS (January 2006). "Vaccines and antiviral drugs in pandemic preparedness". Emerging Infectious Diseases. 12 (1): 55–60. doi:10.3201/eid1201.051068. PMC 3291404. PMID 16494718.

Research

* Palese P (January 2006). "Making better influenza virus vaccines?". Emerging Infectious Diseases. 12 (1): 61–65. doi:10.3201/eid1201.051043. PMC 3291403. PMID 16494719.
* World Health Organization (May 2007). "Antigenic and genetic characteristics of H5N1 viruses and candidate H5N1 vaccine viruses developed for potential use as pre-pandemic vaccines, March 2007". Weekly Epidemiological Record. 82 (19): 164–67. hdl:10665/240934. PMID 17500103. Archived from the original on 2 August 2020. Retrieved 1 August 2020.
* World Health Organization (September 2006). Influenza research at the human and animal interface : report of a WHO working group, Geneva, Switzerland 21–22 September 2006 (Report). World Health Organization (WHO). hdl:10665/69391. WHO/CDS/EPR/GIP/2006.3.

|

## External links[edit | edit source]

Classification|

* ICD-10: J10, J11
* ICD-9-CM: 487
* OMIM: 614680
* MeSH: D007251
* DiseasesDB: 6791

|

External resources|

* MedlinePlus: 000080
* eMedicine: med/1170 ped/3006

* "Seasonal Influenza". Centre for Health Protection. Hong Kong. Archived from the original on 2 August 2020. Retrieved 1 August 2020.
* "What you need to know about influenza (flu) from CDC". Centers for Disease Control and Prevention (CDC). 7 February 2020. Archived from the original on 23 May 2019. Retrieved 1 August 2020.

* v
* t
* e

Influenza

General topics|

* Research
* Vaccine
* Treatment
* Genome sequencing
* Reassortment
* Superinfection
* Flu season

Viruses|

* Orthomyxoviridae
* Influenza A
* Influenza B
* Influenza C
* Influenza D

Influenza A virus
subtypes

* H1N1
* H1N2
* H2N2
* H2N3
* H3N1
* H3N2
* H3N8
* H5N1
* H5N2
* H5N3
* H5N6
* H5N8
* H5N9
* H6N1
* H7N1
* H7N2
* H7N3
* H7N4
* H7N7
* H7N9
* H9N2
* H10N7
* H10N8
* H11N2
* H11N9

H1N1|

| Pandemics|

* 1918 (Spanish flu)
* 2009 (Swine flu)

|

Science|

* 2009 A/H1N1

H5N1|

| Outbreaks|

* Croatia (2005)
* India (2006)
* UK (2007)
* West Bengal (2008)

|

Science|

* Genetic structure
* Transmission and infection
* Global spread
* Vaccine
* clinical trials
* Human mortality
* Social impact
* Pandemic preparation

Treatments|

| Antiviral drugs|

* Adamantane derivatives
* Amantadine
* Rimantadine
* Neuraminidase inhibitor
* Oseltamivir
* Laninamivir
* Peramivir
* Zanamivir
* Peramivir (experimental)
* Umifenovir
* Baloxavir marboxil

|

Vaccines|

* Live attenuated influenza vaccine
* Brands
* Pandemrix
* Audenz

Pandemics and
epidemics

| Pandemics|

* Influenza pandemic (1510)
* Influenza pandemic (1557)
* "Russian flu" (1889-1890)
* "Spanish flu" (1918)
* "Asian flu" (1957)
* "Hong Kong flu" (1968)
* "Swine flu" (2009)

|

Epidemics|

* "Russian flu" (1977-1978)
* "Fujian flu" (H3N2)
* 1989–90 UK outbreak
* Central Luzon H5N6 (2017)

Non-human|

| Mammals|

* Canine
* Feline
* Equine
* 2007 Australian outbreak
* Swine

|

Non-mammals|

* Avian
* Fujian (H5N1)

Complications|

* Acute bronchitis
* Bronchiolitis
* Croup
* Otitis media
* Pharyngitis
* Pneumonia
* Sinusitis
* Strep throat

Related topics|

* Influenza-like illness
* 2017–2018 United States flu season
* US influenza statistics by flu season

* v
* t
* e

Diseases of the respiratory system

Upper RT
(including URTIs,
common cold)|

| Head|

sinuses

Sinusitis

nose

Rhinitis

Vasomotor rhinitis
Atrophic rhinitis
Hay fever
Nasal polyp
Rhinorrhea
nasal septum

Nasal septum deviation
Nasal septum perforation
Nasal septal hematoma

tonsil

Tonsillitis
Adenoid hypertrophy
Peritonsillar abscess

|

Neck|

pharynx

Pharyngitis

Strep throat
Laryngopharyngeal reflux (LPR)
Retropharyngeal abscess

larynx

Croup
Laryngomalacia
Laryngeal cyst
Laryngitis
Laryngopharyngeal reflux (LPR)
Laryngospasm

vocal cords

Laryngopharyngeal reflux (LPR)
Vocal fold nodule
Vocal fold paresis
Vocal cord dysfunction

epiglottis

Epiglottitis

trachea

Tracheitis
Laryngotracheal stenosis

Lower RT/lung disease
(including LRTIs)|

| Bronchial/
obstructive|

acute

Acute bronchitis

chronic

COPD

Chronic bronchitis
Acute exacerbation of COPD)
Asthma (Status asthmaticus
Aspirin-induced
Exercise-induced
Bronchiectasis
Cystic fibrosis

unspecified

Bronchitis
Bronchiolitis

Bronchiolitis obliterans
Diffuse panbronchiolitis

|

Interstitial/
restrictive
(fibrosis)|

| External agents/
occupational
lung disease|

Pneumoconiosis

Aluminosis
Asbestosis
Baritosis
Bauxite fibrosis
Berylliosis
Caplan's syndrome
Chalicosis
Coalworker's pneumoconiosis
Siderosis
Silicosis
Talcosis
Byssinosis

Hypersensitivity pneumonitis

Bagassosis
Bird fancier's lung
Farmer's lung
Lycoperdonosis

|

Other|

* ARDS
* Combined pulmonary fibrosis and emphysema
* Pulmonary edema
* Löffler's syndrome/Eosinophilic pneumonia
* Respiratory hypersensitivity
* Allergic bronchopulmonary aspergillosis
* Hamman-Rich syndrome
* Idiopathic pulmonary fibrosis
* Sarcoidosis
* Vaping-associated pulmonary injury

Obstructive / Restrictive|

| Pneumonia/
pneumonitis|

| By pathogen|

* Viral
* Bacterial
* Pneumococcal
* Klebsiella
* Atypical bacterial
* Mycoplasma
* Legionnaires' disease
* Chlamydiae
* Fungal
* Pneumocystis
* Parasitic
* noninfectious
* Chemical/Mendelson's syndrome
* Aspiration/Lipid

|

By vector/route|

* Community-acquired
* Healthcare-associated
* Hospital-acquired

By distribution|

* Broncho-
* Lobar

IIP|

* UIP
* DIP
* BOOP-COP
* NSIP
* RB

Other|

* Atelectasis
* circulatory
* Pulmonary hypertension
* Pulmonary embolism
* Lung abscess

Pleural cavity/
mediastinum|

| Pleural disease|

* Pleuritis/pleurisy

* Pneumothorax/Hemopneumothorax

Pleural effusion

Hemothorax
Hydrothorax
Chylothorax
Empyema/pyothorax
Malignant

Fibrothorax

|

Mediastinal disease|

* Mediastinitis
* Mediastinal emphysema

Other/general|

* Respiratory failure
* Influenza
* Common cold
* SARS
* COVID-19
* Idiopathic pulmonary haemosiderosis
* Pulmonary alveolar proteinosis

* v
* t
* e

Infectious diseases – viral systemic diseases

Oncovirus|

DNA virus
HBV

Hepatocellular carcinoma
HPV

Cervical cancer
Anal cancer
Penile cancer
Vulvar cancer
Vaginal cancer
Oropharyngeal cancer
KSHV

Kaposi's sarcoma
EBV

Nasopharyngeal carcinoma
Burkitt's lymphoma
Hodgkin lymphoma
Follicular dendritic cell sarcoma
Extranodal NK/T-cell lymphoma, nasal type
MCPyV

Merkel-cell carcinoma

RNA virus
HCV

Hepatocellular carcinoma
Splenic marginal zone lymphoma
HTLV-I

Adult T-cell leukemia/lymphoma

Immune disorders|

* HIV
* AIDS

Central
nervous system|

| Encephalitis/
meningitis|

DNA virus
Human polyomavirus 2

Progressive multifocal leukoencephalopathy

RNA virus
MeV

Subacute sclerosing panencephalitis
LCV

Lymphocytic choriomeningitis
Arbovirus encephalitis
Orthomyxoviridae (probable)

Encephalitis lethargica

Rabies
Chandipura vesiculovirus
Herpesviral meningitis
Ramsay Hunt syndrome type 2

|

Myelitis|

* Poliovirus
* Poliomyelitis
* Post-polio syndrome
* HTLV-I
* Tropical spastic paraparesis

Eye|

* Cytomegalovirus
* Cytomegalovirus retinitis
* HSV
* Herpes of the eye

Cardiovascular|

* CBV
* Pericarditis
* Myocarditis

Respiratory system/
acute viral
nasopharyngitis/
viral pneumonia|

| DNA virus|

* Epstein–Barr virus
* EBV infection/Infectious mononucleosis
* Cytomegalovirus

|

RNA virus|

* IV: Human coronavirus 229E/NL63/HKU1/OC43
* Common cold
* MERS coronavirus
* Middle East respiratory syndrome
* SARS coronavirus
* Severe acute respiratory syndrome
* SARS coronavirus 2
* COVID-19

* V, Orthomyxoviridae: Influenza virus A/B/C/D
* Influenza/Avian influenza

* V, Paramyxoviridae: Human parainfluenza viruses
* Parainfluenza
* Human orthopneumovirus
* hMPV

Human
digestive system|

| Pharynx/Esophagus|

* MuV
* Mumps
* Cytomegalovirus
* Cytomegalovirus esophagitis

|

Gastroenteritis/
diarrhea|

DNA virus
Adenovirus

Adenovirus infection

RNA virus
Rotavirus
Norovirus
Astrovirus
Coronavirus

Hepatitis|

DNA virus
HBV (B)

RNA virus
CBV
HAV (A)
HCV (C)
HDV (D)
HEV (E)
HGV (G)

Pancreatitis|

* CBV

Urogenital|

* BK virus
* MuV
* Mumps

Find out more on
Wikipedia's
Sister projects|

* Media
from Commons
* Species directories
from Wikispecies
* Travel guides
from Wikivoyage
* News stories
from Wikinews
* Definitions
from Wiktionary
* Textbooks
from Wikibooks
* Quotations
from Wikiquote
* Source texts
from Wikisource
* Learning resources
from Wikiversity
* Data
from Wikidata

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