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Australasian Journal of Neuroscience  Volume 30 ● Number 1 ● May 2020 
 4 
Pandemics and the neurological 
manifestations of viral respiratory 
illnesses including Covid-19.  
 
Editor: Linda Nichols 
  
Christie, Vicki and Dawn raise some really 
valid and pertinent thoughts and as I reflect 
on their guest editorial in our current Global 
crisis, the nexus between my two own areas 
of specialty becomes increasingly pellucid. 
After leaving clinical neuroscience practice 
for academia, immunisation and public health 
intervention is the mainstay of my clinical 
practice.  Preventative health care measures 
have never been so imperative. From hand 
hygiene, cough etiquette and the elusive 
Covid-19 (SARS-CoV2) vaccine we are ex-
posed to unparalleled and extraordinary me-
dia and social media coverage (Khan, Ali, 
Siddique, & Nabi, 2020). The current Covid-
19 health crisis is stretching our health re-
sources, nurses and medical staff to their 
absolute limits. Until recently it has been neu-
rotropic viruses such as the measles virus 
that have generally been associated with 
central nervous system pathologies. Howev-
er respiratory viruses including influenza and 
coronaviruses are emerging with neuropatho-
logical elements (Bohmwald, Gálvez, Ríos, & 
Kalergis, 2018). So what do we know about 
the history and impact of pandemics and how 
do novel respiratory viruses relate to neuro-
science? 
 
Viral respiratory illnesses and pandemics 
have been described since as early as 
412BC. We are all familiar with the 1918 
H1N1 (Spanish flu) influenza pandemic, but 
we often forget about the 1957 H2N2 (Asian 
flu) or the 1968 H3N2 (Hong Kong flu) influ-
enza pandemics that both resulted in millions 
of lives lost.  Our next influenza pandemic did 
not occur for another 51 years and caught 
many unaware. In early March 2009 cases of 
a novel H1N1 influenza strain (that is be-
lieved to have originated from pigs) emerged 
in California and Mexico (Broadbent & Sub-
barao, 2011). By May 2009 the first cases of 
the colloquially named “swine flu” were diag-
nosed in Australia (Australian Government 
Department of Health and Ageing, 2009; 
Eastwood, Durrheim, Jones, & Butler, 2010). 
Those like myself that were working during 
this time will remember being individually 
fitted for P3 masks and getting a sticker ones 
name badge that indicated size and fit, with  
shelves filled with different shapes and sizes 
of masks. This is such a contrast to this pan-
demic, where mask shortages and equip-
ment deprivations are being reported interna-
tionally. The H1N1/09 pandemic is described 
by some as being relatively benign 
(Kotsimbos et al., 2010). This in part is due to 
the launch of the H1N1 vaccination program 
using the Panvax® vaccine that became 
available a mere 6 months after the virus was 
first identified (Bishop, Murnane, & Owen, 
2009; Eastwood et al., 2010). However, vac-
cination is not an easy fix and various itera-
tions of the (H1N1)pdm09-like virus strain 
have been included internationally in the sea-
sonal flu vaccinations since 2010 to keep the 
spread in check. No pandemic is the same 
and each presents unique challenges for 
Governments, health care services and the 
community (Kotsimbos et al., 2010). We are 
only at the beginning of this current Covid-19 
journey and still in a phase where we are 
working to contain and sustain our resources. 
Protection through a potential vaccine is still 
a long way off and likely to take years before 
control is effective. 
 
Like influenza, coronaviruses are a group of 
related viruses that are zoonotic and primari-
ly cause respiratory symptoms in humans 
(Chen et al., 2020; Su et al., 2016). Unlike 
influenza, there are no antiviral drugs or vac-
cines to treat or prevent human coronavirus 
infections. Coronaviruses are relatively new, 
having been first discovered in animals in the 
1930’s, with the common cold the first human 
coronavirus discovered in the 1960’s 
(Kirkpatrick, 1996; Su et al., 2016).  Covid-19 
Pandemics and the neurological manifestations of viral 
respiratory illnesses including Covid-19.  
 
Editor: Linda Nichols 
 
Australasian Journal of Neuroscience  Volume 30 ● Number 1 ● May 2020 
 5 
is the third serious coronavirus outbreak to 
occur in the last 20 years, following the 2003 
severe acute respiratory syndrome (SARS) 
and 2012 Middle East respiratory syndrome 
(MERS) outbreaks (LeDuc & Barry, 2004; 
Yang et al., 2020).  Influenza and corona-
viruses share many similarities, including the 
manifestation of neurological symptoms as-
sociated with poor outcomes (Li, Bai, & 
Hashikawa, 2020; Mao et al., 2020; Talan, 
2020). It is not clear whether these symp-
toms and subsequent neurological events 
are a direct cause of the virus entering the 
central nervous system, or an indirect re-
sponse to an overwhelming systemic viral 
storm (Fitzgerald, 2020). The most likely 
mode of infection is either a haematogenous 
or retrograde neuronal route (Mao et al., 
2020).  
 
Around 73% of Covid-19 cases are reported 
as being mild, however for the 18% of indi-
viduals who present with severe symptoms 
(Tian et al., 2020), the likelihood of neurologi-
cal symptoms and complications increases.  
Mao et al. (2020) were among the first to re-
port the prevalence of neurological symp-
toms associated with Covid-19, with 36% of 
individuals within their hospital-based cohort 
experiencing neurological symptoms. Clinical 
neurological manifestations include mild 
symptoms such as headache, dizziness and 
ataxia, myalgia (Lai, Shih, Ko, Tang, & 
Hsueh, 2020; Li et al., 2020; Mao et al., 
2020; Talan, 2020), as well as more signifi-
cant subsequent neurological events includ-
ing altered level of consciousness, stroke, 
seizures, encephalopathy and central respir-
atory failure (Chen et al., 2020; Mao et al., 
2020). Post-viral immune mediated complica-
tions such as acute disseminated encephalo-
myelitis and Guillain-Barré syndrome are al-
so reported (Talan, 2020). Hypoxic encepha-
lopathy associated with viral infections is of-
ten intractable and associated with an acute 
and rapid neurological deterioration 
(Achiriloaie et al., 2016). The spread of virus-
es via a synapse-connected route to the 
brainstem, including the medullary cardi-
orespiratory centre, is potentially partially 
responsible for acute respiratory failure 
(Khan et al., 2020; Li et al., 2020; Matsuda et 
al., 2004).  Rates of hypoxic encephalopathy, 
as high as 20% in hospitalised cohorts (Chen 
et al., 2020), are also similar to previous in-
fluenza studies (Newland et al., 2007). 
We are only just beginning to learn about 
Covid-19’s various manifestations and com-
plications. Whilst it is too early to make defi-
nite statements, the neuroinvasive propensity 
of Covid-19 has been well documented and 
not unexpected from our knowledge of influ-
enza and other coronaviruses. Defined as 
“the greatest medical holocaust in histo-
ry” (Waring, 1964), the 1918 pandemic of 
Spanish flu may yet be surpassed. Covid-19 
has resulted in a worst-case scenario where 
lives are dominated by not only loss but also 
by unimaginable social and economic priva-
tion. So, now is the time to advance our 
awareness and to share our nursing 
knowledge with each other. We are already 
seeing that Covid-19 does not limit infection 
to the cardiorespiratory system. While the 
overall mortality of Covid-19 is lower than 
that of both SARS and MERS, its atypical 
symptoms, rapid person to person transmis-
sion and international spread is making it 
more deadly (Chen et al., 2020). It will be our 
awareness and close attention to neurologi-
cal manifestations that will enable swift inter-
vention and the possible saving of lives.   
  
Linda 
 
Linda Nichols 
Editor 
 
DOI: 10.21307/ajon-2020-001a 
 
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Help determine the impact of COVID-19 on neurocritical care by participating in research.   
The Neuro Critical Care Society has developed an international collaborative using common 
data elements for a number of studies. If you are interested in collaborating with these efforts. 
Please see  https://www.neurocriticalcare.org/research/covid-19-research-opportunities   


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