Pandemic Influenza Research Articles

The extensive impact of the COVID-19 pandemic on various aspects of people's lives: A literature review

This literature review investigates the extensive impact of the COVID-19 pandemic on various aspects of people's lives. Key themes identified include healthcare, economics, livelihood, and mental health during the pandemic. However, gaps and limitations in existing research on the pandemic's impact have been revealed. Notably, the majority of studies focused on the population directly affected by the pandemic, such as the negative impact on mental health during lock-downs, the strain on healthcare systems, and the global economic downturn. This knowledge gap is not unique to the current pandemic but has also been observed in similar studies on the Great Influenza Pandemic and its influence. This study differs from the existing literature in the following way. It would provide further research that examines mental health challenges and stressors faced by healthcare providers, local businesses, and the cascading effects experienced by these affected groups. By addressing the flaws in the global response to the pandemic, this review contributes to the field, facilitating learning from mistakes and enhancing future preparedness. In summary, this literature review highlights the multifaceted impacts of the COVID-19 pandemic on various aspects of people's lives, emphasizing the negative consequences experienced by affected groups. It emphasizes the necessity of addressing these impacts to ensure they are no longer neglected.

Gravitational Ischemia in the Brain: How Interfering with Its Release May Predispose to Either Alzheimer’s- or Parkinson’s-like Illness, Treatable with Hyperbaric Oxygen

The physiological mechanisms for releasing and resolving gravitational ischemia in the brain, and their susceptibility to malfunction, may play an important role in a variety of neurological illnesses. An astronaut on a space walk in a micro-gravity environment may be susceptible to neuro-ocular symptoms associated with unopposed gravity-resistance mechanisms for partially preventing gravitational ischemia in the brain, and for attenuating its impact—mechanisms which may be required for normal brain physiology on Earth. Astronauts on the International Space Station typically breathe a mixture of gasses similar in composition to what they breathed on Earth, following the 1967 death of three astronauts, including Ed White, by fire on the Apollo 1 spacecraft, which was carrying 100% oxygen. For the last decade, astronauts have been studied extensively by flight physicians regarding the commonly experienced symptoms of VIIP, or ‘visual impairment and intracranial pressure’ syndrome. In this paper, we compare VIIP syndrome to the neuro-ocular and Parkinson’s-like symptoms which occurred during and after the 1918–1919 influenza pandemic. The common denominator may be gravitational ischemia in the brain, and the mirror-imaging failed mechanisms for its release (in influenza) versus unopposed gravity-resistance mechanisms (in astronauts). Some research has suggested that astronauts may benefit from breathing oxygen concentrations somewhat higher than 20%, and under slightly elevated pressure. These may possibly prevent maladaptive mechanisms leading to Alzheimer’s- or Parkinson’s-like illness by compensating for impaired mechanisms for releasing and resolving gravitational ischemia in the brain.

Etiology of placental insufficiency in women in the second trimester of gestation during the epidemic of influenza A(H3N2) and pandemic influenza(H1N1)pdm

Aim. To study the etiology of placental insufficiency in women in the second trimester of gestation during the influenza A(H3N2) epidemic and the A(H1N1)pdm pandemic.Materials and methods. In 1865 patients in the second trimester of pregnancy, uncomplicated and complicated by exacerbation of chronic ENT pathology leading to the development of placental insufficiency, using laboratory methods in the blood, nasal epithelium and biological fluids, pathogens of monoand mixed infections (influenza A(H1N1)pdm), A(H3N2), influenza B, parainfluenza type 1-3, adenovirus, respiratory syncytial virus (RS), cytomegalovirus (CMV), herpes simplex virus type 1 and type 2 (HSV-1,2 type), candida infection (Candida albicans), chlamydia (Chlamydia trachomatis), mycoplasmosis (Mycoplasma hominis) and ureaplasmosis (Ureaplasma urealyticum) were detected. The first group consisted of 873 women with placental insufficiency diagnosed during the influenza A(H3N2) epidemic, the second group consisted of 890 patients with placental insufficiency diagnosed during circulation of the influenza A(H1N1)pdm in the population. The control group were 42 women without ENT diseases and placental insufficiency caused by monoand mixed viral infections during influenza A(H3N2) and 60 women with similar somatic, infectious and obstetric status, examined during pandemic influenza A(H1N1)pdm.Results. With the development of placental insufficiency in women of the second group, compared with the first one, mono-influenza B and parainfluenza types 1-3 are diagnosed less frequently, as well as a combination of influenza A(H1N1) pdm and influenza B; influenza A(H1N1)pdm and parainfluenza types 1-3; influenza A(H1N1)pdm and RS virus; CMV and Chlamydia trachomatis; Mycoplasma hominis and Ureaplasma urealyticum; HSV-1,2 type, Candida albicans and Chlamydia trachomatis; as well as HSV-1,2 type, Candida albicans and Ureaplasma urealyticum. At the same time, exacerbations of mono-CMV, mono-HSV-1,2 type and Candida albicans are more common, as well as combinations of CMV+HSV-1,2 type; CMV+Candida albicans; CMV+Ureaplasma urealyticum; and CMV+Mycoplasma hominis; CMV+HSV-1,2 type+Candida albicans.Conclusion. In the etiology of placental insufficiency in acute diseases of the ENT organs in women in the second trimester of gestation against the background of circulation of the A(H1N1)pdm influenza in the population, compared with placental dysfunction in pregnant women with a similar ENT pathology during the influenza A(H3N2) epidemic, there is an increase in the proportion of monocytomegalovirus, herpesvirus and candida infections, as well as mixed cytomegalovirus infection, the reactivation of which may be due to more pronounced virusinduced immunosuppression and hormonal status disorders, leading to local dysbiosis.

Global Health Security

To reduce the risk and effect of sudden incidents of public health that put people at risk across national and international boundaries, it is necessary to take both preventive and reactive measures. These measures are referred to as global health security. Discussions on health security in scientific gatherings have become more prevalent in recent years after the Covid pandemic. Health security is for the whole world, irrespective of age, race, gender, or financial stability. However, it has been noted that there are many different concepts of health security, that the whole purpose of this is to accommodate only the upper-class societies. The disturbed equilibrium of the microbial world due to rapid urbanization, population increase, environmental deterioration, and the improper use of antimicrobials makes people realize the importance of health security that requires a collaborative approach focused on preparedness for any future pandemics and equal access to health care products. 
 The covid-19 pandemic has had a great influence on people’s lives and their ability to think. Now the main race is not about defence systems; it has shifted towards more and better health security and the ability to deal with any future pandemics. The coronavirus outbreak was associated with severe acute respiratory syndrome, the Middle East respiratory syndrome coronavirus outbreak in 2012, the swine flu pandemic in 2009, and the West African Ebola virus disease epidemic in 2013–2016. All these epidemics are primarily caused by the significant travel of infected people across borders. This highlights the need for global health security, which helps coordinate surveillance and policymaking. This limits disease transmission and reduces the damage.
 While infectious diseases have no limits, inadequate health systems in poor nations make them worse and more out of control. Africa and other third-world states face many problems in securing global security. The spread of infectious diseases among susceptible areas is due to inadequate public healthcare fundings, vaccine coverage, poverty, armed conflict, and climate-related disasters, which damage developing countries. This only serves to increase susceptibility to the disease. The continuous transmission of polio and measles in different parts of Africa and Asia, as well as recent Ebola outbreaks in West Africa, highlights the need to overcome this in order to stop the spread of diseases to other areas. No nation can be completely protected from the spread of diseases due to a lack of social services and a strong health infrastructure; hence, global security demands global equality and progress towards health for everyone. 
 To advance global health security in all nations, there is a need for multi-stakeholders and governance, justifiable finance through the proposed pandemic funds, and common goods for health. Future outbreaks can be efficiently managed by funding basic healthcare and enhancing the response systems. Equity in pandemic preparedness and response measures depends on high-level political commitment and global leadership irrespective of colour and gender. False contradictions between countries can be dismissed by focused investments in strengthening health emergency infrastructure, particularly through primary healthcare, ensuring that the world is better prepared to handle complex public health emergencies.

Influenza: Searching for Pandemic Origins.

From a farming family of 13 children in New Zealand, I graduated with a Master of Science degree in microbiology from the University of Otago (Dunedin, Otago, New Zealand). I established the first veterinary virology laboratory at Wallaceville Animal Research Station. I subsequently completed my PhD degree at Australian National University (Canberra, Australia) and a postdoctoral fellowship at the University of Michigan (Ann Arbor, Michigan). While in New South Wales, Australia, a walk on a beach littered with dead mutton birds (shearwaters) with Dr. Graeme Laver led to the surveillance of influenza in seabirds on the Great Barrier Reef Islands and my lifelong search for the origin of pandemic influenza viruses. Subsequent studies established that (a) aquatic birds are a natural reservoir of influenza A viruses, (b) these viruses replicate primarily in cells lining the intestinal tract, (c) reassortment in nature can lead to novel pandemic influenza viruses, and (d) live bird markets are one place where transmission of influenza virus from animals to humans occurs.

What Have We Learned by Resurrecting the 1918 Influenza Virus?

The 1918 Spanish influenza pandemic was one of the deadliest infectious disease events in recorded history, resulting in approximately 50-100 million deaths worldwide. The origins of the 1918 virus and the molecular basis for its exceptional virulence remained a mystery for much of the 20th century because the pandemic predated virologic techniques to isolate, passage, and store influenza viruses. In the late 1990s, overlapping fragments of influenza viral RNA preserved in the tissues of several 1918 victims were amplified and sequenced. The use of influenza reverse genetics then permitted scientists to reconstruct the 1918 virus entirely from cloned complementary DNA, leading to new insights into the origin of the virus and its pathogenicity. Here, we discuss some of the advances made by resurrection of the 1918 virus, including the rise of innovative molecular research, which is a topic in the dual use debate.

Elastomeric half-mask respirator disinfection practices among healthcare personnel.

Disposable N95 respirator shortages during the COVID-19 and 2009 H1N1 influenza pandemics highlighted the need for reusable alternatives, such as elastomeric half-mask respirators (EHMRs). Two US medical organizations deployed reusable EHMRs during the COVID-19 response. In addition to wipe-based disinfection following patient care episodes expected per local policies at both organizations, postshift centralized cleaning and disinfection (C&D) was expected at one site (A), permitting shared-pool EHMR use, and optional at the other (Site B), where EHMRs were issued to individuals. Using a survey, we evaluated disinfection practices reported by EHMR users and predictors of disinfection behaviors and perceptions. Surveys assessed EHMR disinfection practices, occupational characteristics, EHMR use frequency, training, and individual-issue versus shared-pool EHMR use. Of 1080 EHMR users completing the survey, 76% reported that they disinfect the EHMR after each patient encounter, which was the expected practice at both sites. Increasing EHMR use, recall of disinfection training, and work in intensive care or emergency settings significantly influenced higher reporting of this practice. 36% of respondents reported using centralized C&D, although reporting was higher at the site (A) where this was expected (53%). Confidence in cleanliness of the EHMR following centralized C&D was not influenced by individual versus shared-pool EHMR issue. Most EHMR users reported adherence with expected post-care individual-based disinfection of EHMRs but did not necessarily use standardized, centralized C&D. Future efforts to limit reliance on behavior related to respirator disinfection may improve EHMR implementation in healthcare to avert dependence on single-use, disposable N95 respirators.

Immunogenicity and Safety of MF59-Adjuvanted Quadrivalent Influenza Vaccine Compared with a Nonadjuvanted, Quadrivalent Influenza Vaccine in Adults 50-64 Years of Age.

Adults aged 50-64 years have a high incidence of symptomatic influenza associated with substantial disease and economic burden each year. We conducted a randomized, controlled trial to compare the immunogenicity and safety of an adjuvanted quadrivalent inactivated influenza vaccine (aIIV4; n = 1027) with a nonadjuvanted standard dose IIV4 (n = 1017) in this population. Immunogenicity was evaluated on Days 22, 181, and 271. On Day 22, upper limits (UL) of 95% confidence intervals (CI) for geometric mean titer (GMT) ratios (IIV4/aIIV4) were <1.5 and 95% CI ULs for the difference in seroconversion rate (SCR IIV4 - aIIV4) were <10% for all four vaccine strains, meeting primary endpoint noninferiority criteria. Protocol-defined superiority criteria (95% CI ULs < 1.0) were also met for A(H1N1) and A(H3N2). Immune responses following aIIV4 vaccination were more pronounced in persons with medical comorbidities and those not recently vaccinated against influenza. Safety data were consistent with previous studies of MF59 adjuvanted seasonal and pandemic influenza vaccines. These findings support the immunological benefit of aIIV4 for persons aged 50-64 years, especially those with comorbidities.

Fitness Determinants of Influenza A Viruses.

Influenza A (IAV) is a major human respiratory pathogen that causes illness, hospitalizations, and mortality annually worldwide. IAV is also a zoonotic pathogen with a multitude of hosts, allowing for interspecies transmission, reassortment events, and the emergence of novel pandemics, as was seen in 2009 with the emergence of a swine-origin H1N1 (pdmH1N1) virus into humans, causing the first influenza pandemic of the 21st century. While the 2009 pandemic was considered to have high morbidity and low mortality, studies have linked the pdmH1N1 virus and its gene segments to increased disease in humans and animal models. Genetic components of the pdmH1N1 virus currently circulate in the swine population, reassorting with endemic swine viruses that co-circulate and occasionally spillover into humans. This is evidenced by the regular detection of variant swine IAVs in humans associated with state fairs and other intersections of humans and swine. Defining genetic changes that support species adaptation, virulence, and cross-species transmission, as well as mutations that enhance or attenuate these features, will improve our understanding of influenza biology. It aids in surveillance and virus risk assessment and guides the establishment of counter measures for emerging viruses. Here, we review the current understanding of the determinants of specific IAV phenotypes, focusing on the fitness, transmission, and virulence determinants that have been identified in swine IAVs and/or in relation to the 2009 pdmH1N1 virus.

Development of B-cell response during immunization with inactivated influenza vaccines "Grippol plus", "Sovigripp" and "Ultrix"

The worldwide circulating influenza viruses annually lead to serious medical and socio-economic consequences. It is generally recognized that vaccination is the most effective and safe strategy for preventing influenza and its complications. In order to reduce side effects when using live viruses, split and subunit influenza vaccines are widely used. To date, the characteristics of B cell response after immunization with influenza vaccines remain insufficiently studied. The aim of our study was to compare the effects of immunization with different influenza vaccines, i.e., “Sovigripp”, “Grippol plus” and “Ultrix”, on the B cell response. The study was conducted on the base of Clinical Department at the A.Smorodintsev Influenza Research Institute during the epidemic flu season of 2018-2019. For clinical studies, venous blood samples were obtained from 39 volunteers before vaccination, on the 7th and 21st days after vaccination. The subpopulations of B cells were analyzed by flow cytometry using fluorescently labeled antibodies to CD3, CD19, CD20, CD27, CD38, IgD, IgA surface antigens (BioLegend, USA). Cryopreserved mononuclear cells (1 × 106 cells/sample) were used for analysis. The processing of flow cytometry data was carried out with special software (H., Cytexpert, Beckman Coulter, Inc., USA) and Kaluza 2.0 (Beckman Coulter, Inc., USA). The differences with pre-vaccination data were evaluated using the Mann–Whitney U-test and being considered significant at p &lt; 0.05. As a result of the studies, the following subpopulations of B lymphocytes (CD3-CD19+) were specified: naive B cells (CD20+CD27-IgD+), non-switched memory B cells (CD20+CD27+IgD+), switched memory B cells (CD20+CD27+IgD-), effector memory B cells (CD20+CD27-IgD-), plasmablasts (CD20-CD38hiCD27hi). Activation of the B cell immune response was assessed by measuring the relative content of CD38+B cells belonging to subpopulations of naive, effector B lymphocytes, switched and non-switched memory B cells. The analysis of B cell response showed an increase in both the total number of B lymphocytes and their subpopulations including plasmablasts and activated switched memory B cells after immunization. With adjuvant vaccines “Grippol plus” and “Sovigripp”, as compared with the split “Ultrix” vaccine, an early increase in relative counts of plasmablasts was shown on the 7th day of the study. At the same time, all three vaccines equally contributed to an increase in the number of activated memory B cells with a switched antibody isotype. Thus, the assessment of B cell response revealed significant changes in contents of peripheral blood B cell subpopulations in response to vaccination with “Grippol plus”, “Sovigripp”, or “Ultrix”.

News Coverage of Covid-19 and Swine Flu: A Corpus-Assisted Study

The progression rate of Covid-19 and Swine Flu to the advanced pandemic level intensified the risk and damage to human fatalities. Since their outbreak, media outlets spared no effort in reporting news and updates about the two diseases. This study investigates the representations of Covid-19 and Swine Flu pandemics in The New York Times and The Guardian newspapers by utilizing a corpus linguistic quantitative approach. The most monthly read article was collected over one year since the two diseases were declared pandemics by the World Health Organization. The data were compiled in a corpus and analysed using Wordsmith software based on the concordances and the frequency list of the top 15 frequent words in each pandemic. The frequency lists generated 9 themes including: reporting verbs, titles, places, quantity expressions, people, disease name, prevention and control, impact and modal verbs. The study found that news tended to spread fear among people and highlight the governments' roles during Covid-19 pandemic more than Swine Flu.

Improved patient mortality predictions in emergency departments with deep learning data-synthesis and ensemble models

The triage process in emergency departments (EDs) relies on the subjective assessment of medical practitioners, making it unreliable in certain aspects. There is a need for a more accurate and objective algorithm to determine the urgency of patients. This paper explores the application of advanced data-synthesis algorithms, machine learning (ML) algorithms, and ensemble models to predict patient mortality. Patients predicted to be at risk of mortality are in a highly critical condition, signifying an urgent need for immediate medical intervention. This paper aims to determine the most effective method for predicting mortality by enhancing the F1 score while maintaining high area under the receiver operating characteristic curve (AUC) score. This study used a dataset of 7325 patients who visited the Yonsei Severance Hospital’s ED, located in Seoul, South Korea. The patients were divided into two groups: patients who deceased in the ED and patients who didn’t. Various data-synthesis techniques, such as SMOTE, ADASYN, CTGAN, TVAE, CopulaGAN, and Gaussian Copula, were deployed to generate synthetic patient data. Twenty two ML models were then utilized, including tree-based algorithms like Decision tree, AdaBoost, LightGBM, CatBoost, XGBoost, NGBoost, TabNet, which are deep neural network algorithms, and statistical algorithms such as Support Vector Machine, Logistic Regression, Random Forest, k-nearest neighbors, and Gaussian Naive Bayes, as well as Ensemble Models which use the results from the ML models. Based on 21 patient information features used in the pandemic influenza triage algorithm (PITA), the models explained previously were applied to aim for the prediction of patient mortality. In evaluating ML algorithms using an imbalanced medical dataset, conventional metrics like accuracy scores or AUC can be misleading. This paper emphasizes the importance of using the F1 score as the primary performance measure, focusing on recall and specificity in detecting patient mortality. The highest-ranked model for predicting mortality utilized the Gaussian Copula data-synthesis technique and the CatBoost classifier, achieving an AUC of 0.9731 and an F1 score of 0.7059. These findings highlight the effectiveness of machine learning algorithms and data-synthesis techniques in improving the prediction performance of mortality in EDs.

Unconjugated Multi-Epitope Peptides Adjuvanted with ALFQ Induce Durable and Broadly Reactive Antibodies to Human and Avian Influenza Viruses.

An unconjugated composite peptide vaccine targeting multiple conserved influenza epitopes from hemagglutinin, neuraminidase, and matrix protein and formulated with a safe and highly potent adjuvant, Army Liposome formulation (ALFQ), generated broad and durable immune responses in outbred mice. The antibodies recognized specific epitopes in influenza peptides and several human, avian, and swine influenza viruses. Comparable antibody responses to influenza viruses were observed with intramuscular and intradermal routes of vaccine administration. The peptide vaccine induced cross-reactive antibodies that recognized influenza virus subtypes A/H1N1, A/H3N2, A/H5N1, B/Victoria, and B/Yamagata. In addition, immune sera neutralized seasonal and pandemic influenza strains (Group 1 and Group 2). This composite multi-epitope peptide vaccine, formulated with ALFQ and administered via intramuscular and intradermal routes, provides a high-performance supra-seasonal vaccine that would be cost-effective and easily scalable, thus moving us closer to a viable strategy for a universal influenza vaccine and pandemic preparedness.

Global burden of influenza lower respiratory tract infections in older people from 1990 to 2019.

Infections with influenza viruses cause severe illness, substantial number of hospitalization and death, especially in older adults. However, few studies have focused on the burden of influenza lower respiratory tract infections (LRTIs) solely in older adults, particularly in low-resource settings. We aimed to estimate the mortality and DALYs of influenza LRTIs for people aged 55years and older in 204 countries and territories from 1990 to 2019. The Global Burden of Disease (GBD) 2019 study was used to obtain data on mortality and DALYs of influenza LRTIs at the global, regional, and country levels. In 2019, the global rates for mortality and DALYs of influenza LRTIs were 6.46 per 100,000 [95% uncertainty interval (UI): 2.37-12.62] and 97.39 per 100,000 (95% UI: 34.70-187.03). Although the rates for mortality and DALYs in people aged 55years and older decreased from 1990 to 2019, the absolute numbers for both increased by 85.84% and 66.56%, respectively. Both the absolute numbers and rates of deaths and DALYs of influenza LRTIs were higher in male than in female in all age groups. Although low-socio-demographic index (SDI) regions experienced the largest declines for the rates of mortality and DALYs of influenza LRTIs over the past three decades, they still had the highest rates for mortality and DALYs in all age groups. Moreover, the absolute numbers and rates of deaths and DALYs of influenza LRTIs showed an increasing trend with age, reaching the peak in the people over 85years old. Burden of influenza LRTIs in older adults is still high and could continue to grow along with global aging. Efforts to improve vaccination for influenza are needed for preparedness of another influenza pandemic, especially in low-SDI regions.

Refined semi-lethal aerosol H5N1 influenza model in cynomolgus macaques for evaluation of medical countermeasures

Highly pathogenic avian influenza A H5N1 viruses cause high mortality in humans and have pandemic potential. Effective vaccines and treatments against this threat are urgently needed. Here, we have refined our previously established model of lethal H5N1 infection in cynomolgus macaques. An inhaled aerosol virus dose of 5.1 log10 plaque-forming unit (pfu) induced a strong febrile response and acute respiratory disease, with four out of six macaques succumbing after challenge. Vaccination with three doses of adjuvanted seasonal quadrivalent influenza vaccine elicited low but detectable neutralizing antibody to H5N1. All six vaccinated macaques survived four times the 50% lethal dose of aerosolized H5N1, while four of six unvaccinated controls succumbed to disease. Although vaccination did not protect against severe influenza, vaccinees had reduced respiratory dysfunction and lower viral load in airways compared to controls. We anticipate that our macaque model will play a vital role in evaluating vaccines and antivirals against influenza pandemics.

Vaccination acceptability in the French general population and related determinants, 2000–2021

BackgroundThis study describes the evolution of vaccination acceptability and associated determinants in the French general population between 2000 and 2021, and vaccinations with the highest vaccine hesitancy between 2010 and 2021. MethodsData were collected from the nine national ‘Health Barometer’ cross-sectional surveys conducted between 2000 and 2021. These surveys included French-speaking individuals aged 18–75 years old who were selected through randomly generated landline and mobile phone numbers. Participants were asked about their acceptability of vaccination in general and their vaccine hesitancy toward any particular vaccinations.Determinants of vaccination acceptability were studied using univariate and multivariate Poisson regressions. ResultsThe proportion of persons who found vaccination acceptable in general (i.e., answering “very” or “somewhat” favourable in the survey interview) decreased from 91.1% in 2000 to 61.2% in 2010 (the latter year coinciding with the 2009 H1N1 influenza pandemic), increased in 2014 (78.8%), slightly fluctuated until 2019 (74.2%), and increased again in both 2020 (80.0%) and 2021 (82.5%) during the COVID-19 pandemic. Irrespective of the year, acceptability was higher among persons with higher incomes, those with a higher education level, and individuals not living alone. In 2021, for the first time, vaccination acceptability was higher among persons over 44 years old (versus 18–24 year-olds) and among retired persons (versus workers). The highest hesitancy rate for a vaccine was for the 2009 H1N1 influenza virus in 2010 (41% answering “somewhat” or “very” unfavourable). In 2021, the highest rate was for the COVID-19 vaccine (21%). DiscussionUnlike the experience of the 2009 AH1N1 influenza pandemic, which led to a collapse in vaccination acceptability among the French general population, acceptability continued to increase during the COVID-19 pandemic. However, the pre-2010 level was not reached. Our results show a tendency towards a widening social and economic gap in terms of vaccine acceptability over time.

The emergence of a suburban penalty during the 1918/19 influenza pandemic in Malta: The role of a marketplace, railway, and measles.

The Malta 1918/19 influenza experience adds to our understanding of the pandemic by illustrating the importance of suburban populations, their vulnerabilities, and elevated mortality rates. Studies on the socio-geographical variation in the 1918/19 influenza mortality has largely overlooked the suburban experience, and thus the often-hidden heterogeneity of the disease experience is missing. A comparison of mortality rates across the three settlement types (urban, suburban, and rural) for the second wave of the pandemic revealed that there were significant differences across the settlement types (x2 = 22.67, 2df, p <0.0001). There was a statistically significant divide between suburban settlement type versus urban and rural communities. Further, the geographical division of the central suburban region had the highest mortality rate at 4.28 per 1000 living of all suburban regions. A closer examination of the central suburban communities revealed that the town of Birchicara was the driving force behind the elevated influenza mortality, with a rate of 5.28 per 1000 living. The exceedingly high rate of influenza mortality in Birchicara was significantly different from the other suburban communities (Z = 2.915, p = 0.004). Birchicara was notable as both a transmission and burden hotspot for influenza infection because of a unique conflation of factors not observed elsewhere on the island. Foremost, was the pitkali market, which was a produce wholesale distributing centre; second, was the fact that the train station was a central hub especially for Maltese labourers; third, was that the measles epidemic in 1916/17 contributed to elevated childhood influenza deaths because the presence of military personnel and their families. We argue that the interaction of the three factors, and in particular, the measles epidemic with childhood influenza, amounted to a syndemic. Factors associated with urbanization and high rates of infectious diseases, such as overcrowding and infant mortality, did not play a primary role in the syndemic.

"The Graves Cannot Be Dug Fast Enough": Excess Deaths Among US Amish and Mennonites During the 1918 Flu Pandemic.

Estimating the lethal impact of a pandemic on a religious community with significant barriers to outsiders can be exceedingly difficult. Nevertheless, Stein and colleagues (2021) developed an innovative means of arriving at such an estimate for the lethal impact of COVID-19 on the Amish community in 2020 by counting user-generated death reports in the widely circulated Amish periodical The Budget. By comparing monthly averages of reported deaths before and during the COVID-19 pandemic, Stein and colleagues were able to arrive at a rough estimate of "excess deaths" during the first year of the pandemic. Our research extends the same research method, applying it to the years during and immediately preceding the global influenza pandemic of 1918. Results show similarly robust findings, including three notable "waves" of excess deaths among Amish and conservative Mennonites in the USA in 1918, 1919, and 1920. Such results point to the promise of utilizing religious periodicals like The Budget as a relatively untapped trove of user-generated data on public health outcomes among religious minorities more than a century in the past.

Improvements and Persisting Challenges in COVID-19 Response Compared with 1918–19 Influenza Pandemic Response, New Zealand (Aotearoa)

Improvements and Persisting Challenges in COVID-19 Response Compared with 1918–19 Influenza Pandemic Response, New Zealand (Aotearoa)

Indigenous communities and influenza: protocol for a systematic review and meta-analysis

BackgroundSeveral studies have documented that specific Indigenous groups have been disproportionately affected by previous pandemics. The objective of this paper is to describe the protocol to be used in a review and meta-analysis of the literature on Indigenous groups and influenza. Using this protocol as a guide, a future study will provide a comprehensive historical overview of pre-COVID impact of influenza on Indigenous groups by combining data from the last five influenza pandemics and seasonal influenza up to date.Methods/principle findingsThe review will include peer-reviewed original studies published in English, Spanish, Portuguese, Swedish, Danish, and Norwegian. Records will be identified through systematic literature search in eight databases: Embase, MEDLINE, CINAHL, Web of Science, Academic Search Ultimate, SocINDEX, ASSIA, and Google Scholar. Results will be summarized narratively and using meta-analytic strategies.DiscussionTo our knowledge, there is no systematic review combining historical data on the impact of both seasonal and pandemic influenza on Indigenous populations. By summarizing results within and across Indigenous groups, different countries, and historical periods, as well as research in six different languages, we aim to provide information on how strong the risk for influenza is among Indigenous groups and how consistent this risk is across groups, regions, time, and seasonal versus the specific pandemic influenza strains.Systematic review registrationPROSPERO CRD42021246391