Abstract
BackgroundTwo subtypes of influenza A currently circulate in humans: seasonal H3N2 (sH3N2, emerged in 1968) and pandemic H1N1 (pH1N1, emerged in 2009). While the epidemiological characteristics of the initial wave of pH1N1 have been studied in detail, less is known about its infection dynamics during subsequent waves or its severity relative to sH3N2. Even prior to 2009, few data was available to estimate the risk of severe outcomes following infection with one circulating influenza strain relative to another.MethodsWe analyzed antibodies in quadruples of sera from individuals in Hong Kong collected between July 2009 and December 2011, a period that included three distinct influenza virus epidemics. We estimated infection incidence using these assay data and then estimated rates of severe outcomes per infection using population-wide clinical data.ResultsCumulative incidence of infection was high among children in the first epidemic of pH1N1. There was a change towards the older age group in the age distribution of infections for pH1N1 from the first to the second epidemic, with the age distribution of the second epidemic of pH1N1 more similar to that of sH3N2. We found no serological evidence that individuals were infected in both waves of pH1N1. The risks of excess mortality conditional on infection were higher for sH3N2 than for pH1N1, with age-standardized risk ratios of 2.6 [95% CI: 1.8, 3.7] for all causes and 1.5 [95% CI: 1.0, 2.1] for respiratory causes throughout the study period.ConclusionsOverall increase in clinical incidence of pH1N1 and higher rates of severity in older adults in post pandemic waves were in line with an age-shift in infection towards the older age groups. The absence of repeated infection is good evidence that waning immunity did not cause the second wave. Despite circulating in humans since 1968, sH3N2 is substantially more severe per infection than the pH1N1 strain. Infection-based estimates of individual-level severity have a role in assessing emerging strains; updating seasonal vaccine components; and optimizing of vaccination programs.
Highlights
IntroductionTwo subtypes of influenza A currently circulate in humans: seasonal H3N2 (sH3N2, emerged in 1968) and pandemic H1N1 (pH1N1, emerged in 2009)
Two subtypes of influenza A currently circulate in humans: seasonal H3N2 and pandemic H1N1
Since the emergence of the novel influenza A Pandemic influenza A H1N1 (pH1N1) strain in 2009, subsequent waves of infection have exhibited two intriguing characteristics: they have generated epidemics of similar size to the initial waves in some countries [5], despite no apparent antigenic change; and the distribution of clinical cases was skewed towards the older age groups [6]
Summary
Two subtypes of influenza A currently circulate in humans: seasonal H3N2 (sH3N2, emerged in 1968) and pandemic H1N1 (pH1N1, emerged in 2009). While the epidemiological characteristics of the initial wave of pH1N1 have been studied in detail, less is known about its infection dynamics during subsequent waves or its severity relative to sH3N2. Even prior to 2009, few data was available to estimate the risk of severe outcomes following infection with one circulating influenza strain relative to another. Since the emergence of the novel influenza A pH1N1 strain in 2009 (pH1N1), subsequent waves of infection have exhibited two intriguing characteristics: they have generated epidemics of similar size to the initial waves in some countries [5], despite no apparent antigenic change; and the distribution of clinical cases was skewed towards the older age groups [6]. Serological studies were used to confirm that differences in numbers of cases of adults compared with children were being driven by differences in infection but not by differences in pathogenicity [11, 12]
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