Abstract
Remarkably little is known definitively about the modes of influenza transmission. Thus, important health policy and infection control issues remain unresolved. These shortcomings have been exposed in national and international pandemic preparedness activities over recent years. Indeed, WHO, CDC, ECDC and the U.S. Institute of Medicine have prioritised understanding the modes of influenza transmission as a critical need for pandemic planning. Studying influenza transmission is difficult; seasonality, unpredictable attack rates, role of environmental parameters such as temperature and humidity, numbers of participants required and confounding variables all present considerable obstacles to the execution of definitive studies. A range of investigations performed to date have failed to provide definitive answers and key questions remain. Reasons for this include the fact that many studies have not sought to investigate routes of transmission as a primary objective (instead, they have evaluated specific interventions) and that fieldwork in natural settings, specifically assessing the dynamics and determinants of transmission between humans, has been limited. The available evidence suggests that all routes of transmission (droplet, aerosol and contact) have a role to play; their relative significance will depend on the set of circumstances acting at a given time. Dictating the process are factors related to the virus itself, the host and the environment.