High variation expected in the pace and burden of SARS-CoV-2 outbreaks across sub-Saharan Africa

A surprising feature of the SARS-CoV-2 pandemic to date is the low burdens reported in sub-Saharan Africa (SSA) countries relative to other global regions. Potential explanations (e.g., warmer environments1, younger populations2-4) have yet to be framed within a comprehensive analysis accounting for factors that may offset the effects of climate and demography. Here, we synthesize factors hypothesized to shape the pace of this pandemic and its burden as it moves across SSA, encompassing demographic, comorbidity, climatic, healthcare and intervention capacity, and human mobility dimensions of risk. We find large scale diversity in probable drivers, such that outcomes are likely to be highly variable among SSA countries. While simulation shows that extensive climatic variation among SSA population centers has little effect on early outbreak trajectories, heterogeneity in connectivity is likely to play a large role in shaping the pace of viral spread. The prolonged, asynchronous outbreaks expected in weakly connected settings may result in extended stress to health systems. In addition, the observed variability in comorbidities and access to care will likely modulate the severity of infection: We show that even small shifts in the infection fatality ratio towards younger ages, which are likely in high risk settings, can eliminate the protective effect of younger populations. We highlight countries with elevated risk of 'slow pace', high burden outbreaks. Empirical data on the spatial extent of outbreaks within SSA countries, their patterns in severity over age, and the relationship between epidemic pace and health system disruptions are urgently needed to guide efforts to mitigate the high burden scenarios explored here.

Reconciling early-outbreak estimates of the basic reproductive number and its uncertainty: framework and applications to the novel coronavirus (SARS-CoV-2) outbreak

A novel coronavirus (SARS-CoV-2) emerged as a global threat in December 2019. As the epidemic progresses, disease modellers continue to focus on estimating the basic reproductive number [Formula: see text]-the average number of secondary cases caused by a primary case in an otherwise susceptible population. The modelling approaches and resulting estimates of [Formula: see text] during the beginning of the outbreak vary widely, despite relying on similar data sources. Here, we present a statistical framework for comparing and combining different estimates of [Formula: see text] across a wide range of models by decomposing the basic reproductive number into three key quantities: the exponential growth rate, the mean generation interval and the generation-interval dispersion. We apply our framework to early estimates of [Formula: see text] for the SARS-CoV-2 outbreak, showing that many [Formula: see text] estimates are overly confident. Our results emphasize the importance of propagating uncertainties in all components of [Formula: see text], including the shape of the generation-interval distribution, in efforts to estimate [Formula: see text] at the outset of an epidemic.

Structure, space and size: competing drivers of variation in urban and rural measles transmission

A key concern in public health is whether disparities exist between urban and rural areas. One dimension of potential variation is the transmission of infectious diseases. In addition to potential differences between urban and rural local dynamics, the question of whether urban and rural areas participate equally in national dynamics remains unanswered. Specifically, urban and rural areas may diverge in local transmission as well as spatial connectivity, and thus risk for receiving imported cases. Finally, the potential confounding relationship of spatial proximity with size and urban/rural district type has not been addressed by previous research. It is rare to have sufficient data to explore these questions thoroughly. We use exhaustive weekly case reports of measles in 954 urban and 468 rural districts of the UK (1944–1965) to compare both local disease dynamics as well as regional transmission. We employ the time-series susceptible–infected–recovered model to estimate disease transmission, epidemic severity, seasonality and import dependence. Congruent with past results, we observe a clear dependence on population size for the majority of these measures. We use a matched-pair strategy to compare proximate urban and rural districts and control for possible spatial confounders. This analytical strategy reveals a modest difference between urban and rural areas. Rural areas tend to be characterized by more frequent, smaller outbreaks compared to urban counterparts. The magnitude of the difference is slight and the results primarily reinforce the importance of population size, both in terms of local and regional transmission. In sum, urban and rural areas demonstrate remarkable epidemiological similarity in this recent UK context.

Reconciling early-outbreak estimates of the basic reproductive number and its uncertainty: framework and applications to the novel coronavirus (SARS-CoV-2) outbreak

A novel coronavirus (SARS-CoV-2) emerged as a global threat in December 2019. As the epidemic progresses, disease modellers continue to focus on estimating the basic reproductive number [Formula: see text]-the average number of secondary cases caused by a primary case in an otherwise susceptible population. The modelling approaches and resulting estimates of [Formula: see text] during the beginning of the outbreak vary widely, despite relying on similar data sources. Here, we present a statistical framework for comparing and combining different estimates of [Formula: see text] across a wide range of models by decomposing the basic reproductive number into three key quantities: the exponential growth rate, the mean generation interval and the generation-interval dispersion. We apply our framework to early estimates of [Formula: see text] for the SARS-CoV-2 outbreak, showing that many [Formula: see text] estimates are overly confident. Our results emphasize the importance of propagating uncertainties in all components of [Formula: see text], including the shape of the generation-interval distribution, in efforts to estimate [Formula: see text] at the outset of an epidemic.

Implications of localized charge for human influenza A H1N1 hemagglutinin evolution: Insights from deep mutational scans

Seasonal influenza A viruses of humans evolve rapidly due to strong selection pressures from host immune responses, principally on the hemagglutinin (HA) viral surface protein. Based on mouse transmission experiments, a proposed mechanism for immune evasion consists of increased avidity to host cellular receptors, mediated by electrostatic charge interactions with negatively charged cell surfaces. In support of this, the HA charge of the globally circulating H3N2 has increased over time since its pandemic. However, the same trend was not seen in H1N1 HA sequences. This is counter-intuitive, since immune escape due to increased avidity (due itself to an increase in charge) was determined experimentally. Here, we explore whether patterns of local charge of H1N1 HA can explain this discrepancy and thus further associate electrostatic charge with immune escape and viral evolutionary dynamics. Measures of site-wise functional selection and expected charge computed from deep mutational scan data on an early H1N1 HA yield a striking division of residues into three groups, separated by charge. We then explored evolutionary dynamics of these groups from 1918 to 2008. In particular, one group increases in net charge over time and consists of sites that are evolving the fastest, that are closest to the receptor binding site (RBS), and that are exposed to solvent (i.e., on the surface). By contrast, another group decreases in net charge and consists of sites that are further away from the RBS and evolving slower, but also exposed to solvent. The last group consists of those sites in the HA core, with no change in net charge and that evolve very slowly. Thus, there is a group of residues that follows the same trend as seen for the entire H3N2 HA. It is possible that the H1N1 HA is under other biophysical constraints that result in compensatory decreases in charge elsewhere on the protein. Our results implicate localized charge in HA interactions with host cells, and highlight how deep mutational scan data can inform evolutionary hypotheses.

The hemagglutinin (HA) surface protein of influenza A viruses evolves rapidly to evade host immunity, leading to sizable yearly epidemics in human populations. Previous transmission experiments with H1N1 in mice have tied immune escape to an increase in HA avidity for cellular receptors, mediated by electrostatic charge. Furthermore, retrospective sequence analyses from a previous study confirmed that the HA of circulating global H3N2 has increased in net charge, yet surprisingly, that of H1N1 has not varied significantly. How is a stable net charge related to local patterns of H1N1 HA charge in response to selection? To elucidate the role of local electrostatic charge in host-virus interactions, we investigate characteristics of local charge on the H1N1 HA using functional data from deep mutational scan experiments. Combining measures of functional selection and expected charge at each site on DMS data from a 1933 H1N1 HA yields a striking visual pattern that identifies three groups of sites that have different biophysical properties and that prove to have distinct evolutionary patterns in natural human sequences. Essentially, we find evidence for an increase in charge near the receptor binding site and for compensatory changes elsewhere on the protein. Thus, our findings may reconcile disparate results from transmission experiments and natural sequence analyses, and highlight the importance of local properties of the HA protein. Overall, our findings further support the hypothesis of immune escape due to increased HA avidity to cellular receptors mediated by electrostatic charge. More generally, our work illustrates a novel method of leveraging deep mutational scans in conjunction with natural sequences to shed light on virus-host interactions.

Disease and healthcare burden of COVID-19 in the United States

As of 24 April 2020, the SARS-CoV-2 epidemic has resulted in over 830,000 confirmed infections in the United States¹. The incidence of COVID-19, the disease associated with this new coronavirus, continues to rise. The epidemic threatens to overwhelm healthcare systems, and identifying those regions where the disease burden is likely to be high relative to the rest of the country is critical for enabling prudent and effective distribution of emergency medical care and public health resources. Globally, the risk of severe outcomes associated with COVID-19 has consistently been observed to increase with age^2,3. We used age-specific mortality patterns in tandem with demographic data to map projections of the cumulative case burden of COVID-19 and the subsequent burden on healthcare resources. The analysis was performed at the county level across the United States, assuming a scenario in which 20% of the population of each county acquires infection. We identified counties that will probably be consistently, heavily affected relative to the rest of the country across a range of assumptions about transmission patterns, such as the basic reproductive rate, contact patterns and the efficacy of quarantine. We observed a general pattern that per capita disease burden and relative healthcare system demand may be highest away from major population centers. These findings highlight the importance of ensuring equitable and adequate allocation of medical care and public health resources to communities outside of major urban areas.

A Global lmmunological Observatory to meet a time of pandemics

SARS-CoV-2 presents an unprecedented international challenge, but it will not be the last such threat. Here, we argue that the world needs to be much better prepared to rapidly detect, define and defeat future pandemics. We propose that a Global Immunological Observatory and associated developments in systems immunology, therapeutics and vaccine design should be at the heart of this enterprise.

Climatological, virological and sociological drivers of current and projected dengue fever outbreak dynamics in Sri Lanka

The largest ever Sri Lankan dengue outbreak of 2017 provides an opportunity for investigating the relative contributions of climatological, epidemiological and sociological drivers on the epidemic patterns of this clinically important vector-borne disease. To do so, we develop a climatologically driven disease transmission framework for dengue virus using spatially resolved temperature and precipitation data as well as the time-series susceptible-infected-recovered (SIR) model. From this framework, we first demonstrate that the distinct climatological patterns encountered across the island play an important role in establishing the typical yearly temporal dynamics of dengue, but alone are unable to account for the epidemic case numbers observed in Sri Lanka during 2017. Using a simplified two-strain SIR model, we demonstrate that the re-introduction of a dengue virus serotype that had been largely absent from the island in previous years may have played an important role in driving the epidemic, and provide a discussion of the possible roles for extreme weather events and human mobility patterns on the outbreak dynamics. Lastly, we provide estimates for the future burden of dengue across Sri Lanka using the Coupled Model Intercomparison Phase 5 climate projections. Critically, we demonstrate that climatological and serological factors can act synergistically to yield greater projected case numbers than would be expected from the presence of a single driver alone. Altogether, this work provides a holistic framework for teasing apart and analysing the various complex drivers of vector-borne disease outbreak dynamics.

Dynamics in a simple evolutionary-epidemiological model for the evolution of an initial asymptomatic infection stage

Pathogens exhibit a rich variety of life history strategies, shaped by natural selection. An important pathogen life history characteristic is the propensity to induce an asymptomatic yet productive (transmissive) stage at the beginning of an infection. This characteristic is subject to complex trade-offs, ranging from immunological considerations to population-level social processes. We aim to classify the evolutionary dynamics of such asymptomatic behavior of pathogens (hereafter "latency") in order to unify epidemiology and evolution for this life history strategy. We focus on a simple epidemiological model with two infectious stages, where hosts in the first stage can be partially or fully asymptomatic. Immunologically, there is a trade-off between transmission and progression in this first stage. For arbitrary trade-offs, we derive different conditions that guarantee either at least one evolutionarily stable strategy (ESS) at zero, some, or maximal latency of the first stage or, perhaps surprisingly, at least one unstable evolutionarily singular strategy. In this latter case, there is bistability between zero and nonzero (possibly maximal) latency. We then prove the uniqueness of interior evolutionarily singular strategies for power-law and exponential trade-offs: Thus, bistability is always between zero and maximal latency. Overall, previous multistage infection models can be summarized with a single model that includes evolutionary processes acting on latency. Since small changes in parameter values can lead to abrupt transitions in evolutionary dynamics, appropriate disease control strategies could have a substantial impact on the evolution of first-stage latency.

Susceptible supply limits the role of climate in the early SARS-CoV-2 pandemic

Preliminary evidence suggests that climate may modulate the transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Yet it remains unclear whether seasonal and geographic variations in climate can substantially alter the pandemic trajectory, given that high susceptibility is a core driver. Here, we use a climate-dependent epidemic model to simulate the SARS-CoV-2 pandemic by probing different scenarios based on known coronavirus biology. We find that although variations in weather may be important for endemic infections, during the pandemic stage of an emerging pathogen, the climate drives only modest changes to pandemic size. A preliminary analysis of nonpharmaceutical control measures indicates that they may moderate the pandemic-climate interaction through susceptible depletion. Our findings suggest that without effective control measures, strong outbreaks are likely in more humid climates and summer weather will not substantially limit pandemic growth.

An investigation of transmission control measures during the first 50 days of the COVID-19 epidemic in China

Responding to an outbreak of a novel coronavirus [agent of coronavirus disease 2019 (COVID-19)] in December 2019, China banned travel to and from Wuhan city on 23 January 2020 and implemented a national emergency response. We investigated the spread and control of COVID-19 using a data set that included case reports, human movement, and public health interventions. The Wuhan shutdown was associated with the delayed arrival of COVID-19 in other cities by 2.91 days. Cities that implemented control measures preemptively reported fewer cases on average (13.0) in the first week of their outbreaks compared with cities that started control later (20.6). Suspending intracity public transport, closing entertainment venues, and banning public gatherings were associated with reductions in case incidence. The national emergency response appears to have delayed the growth and limited the size of the COVID-19 epidemic in China, averting hundreds of thousands of cases by 19 February (day 50).

An investigation of transmission control measures during the first 50 days of the COVID-19 epidemic in China

Responding to an outbreak of a novel coronavirus [agent of coronavirus disease 2019 (COVID-19)] in December 2019, China banned travel to and from Wuhan city on 23 January 2020 and implemented a national emergency response. We investigated the spread and control of COVID-19 using a data set that included case reports, human movement, and public health interventions. The Wuhan shutdown was associated with the delayed arrival of COVID-19 in other cities by 2.91 days. Cities that implemented control measures preemptively reported fewer cases on average (13.0) in the first week of their outbreaks compared with cities that started control later (20.6). Suspending intracity public transport, closing entertainment venues, and banning public gatherings were associated with reductions in case incidence. The national emergency response appears to have delayed the growth and limited the size of the COVID-19 epidemic in China, averting hundreds of thousands of cases by 19 February (day 50).

An investigation of transmission control measures during the first 50 days of the COVID-19 epidemic in China

Responding to an outbreak of a novel coronavirus [agent of coronavirus disease 2019 (COVID-19)] in December 2019, China banned travel to and from Wuhan city on 23 January 2020 and implemented a national emergency response. We investigated the spread and control of COVID-19 using a data set that included case reports, human movement, and public health interventions. The Wuhan shutdown was associated with the delayed arrival of COVID-19 in other cities by 2.91 days. Cities that implemented control measures preemptively reported fewer cases on average (13.0) in the first week of their outbreaks compared with cities that started control later (20.6). Suspending intracity public transport, closing entertainment venues, and banning public gatherings were associated with reductions in case incidence. The national emergency response appears to have delayed the growth and limited the size of the COVID-19 epidemic in China, averting hundreds of thousands of cases by 19 February (day 50).

An investigation of transmission control measures during the first 50 days of the COVID-19 epidemic in China

Responding to an outbreak of a novel coronavirus [agent of coronavirus disease 2019 (COVID-19)] in December 2019, China banned travel to and from Wuhan city on 23 January 2020 and implemented a national emergency response. We investigated the spread and control of COVID-19 using a data set that included case reports, human movement, and public health interventions. The Wuhan shutdown was associated with the delayed arrival of COVID-19 in other cities by 2.91 days. Cities that implemented control measures preemptively reported fewer cases on average (13.0) in the first week of their outbreaks compared with cities that started control later (20.6). Suspending intracity public transport, closing entertainment venues, and banning public gatherings were associated with reductions in case incidence. The national emergency response appears to have delayed the growth and limited the size of the COVID-19 epidemic in China, averting hundreds of thousands of cases by 19 February (day 50).

Dynamic Perspectives on the Search for a Universal Influenza Vaccine

A universal influenza vaccine (UIV) could considerably alleviate the public health burden of both seasonal and pandemic influenza. Although significant progress has been achieved in clarifying basic immunology and virology relating to UIV, several important questions relating to the dynamics of infection, immunity, and pathogen evolution remain unsolved. In this study, we review these gaps, which span integrative levels, from cellular to global and timescales from molecular events to decades. We argue that they can be best addressed by a tight integration of empirical (laboratory, epidemiological) research and theory and suggest fruitful areas for this synthesis. In particular, quantifying natural and vaccinal limitations on viral transmission are central to this effort.

Coexisting attractors in the context of cross-scale population dynamics: measles in London as a case study

Patterns of measles infection in large urban populations have long been considered the paradigm of synchronized nonlinear dynamics. Indeed, recurrent epidemics appear approximately mass-action despite underlying heterogeneity. However, using a subset of rich, newly digitized mortality data (1897–1906), we challenge that proposition. We find that sub-regions of London exhibited a mixture of simultaneous annual and biennial dynamics, while the aggregate city-level dynamics appears firmly annual. Using a simple stochastic epidemic model and maximum-likelihood inference methods, we show that we can capture this observed variation in periodicity. We identify agreement between theory and data, indicating that both changes in periodicity and epidemic coupling between regions can follow relatively simple rules; in particular we find local variation in seasonality drives periodicity. Our analysis underlines that multiple attractors can coexist in a strongly mixed population and follow theoretical predictions.

A competing-risks model explains hierarchical spatial coupling of measles epidemics en route to national elimination

Apart from its global health importance, measles is a paradigm for the low-dimensional mechanistic understanding of local nonlinear population interactions. A central question for spatio-temporal dynamics is the relative roles of hierarchical spread from large cities to small towns and metapopulation transmission among local small population clusters in measles persistence. Quantifying this balance is critical to planning the regional elimination and global eradication of measles. Yet, current gravity models do not allow a formal comparison of hierarchical versus metapopulation spread. We address this gap with a competing-risks framework, capturing the relative importance of competing sources of reintroductions of infection. We apply the method to the uniquely spatio-temporally detailed urban incidence dataset for measles in England and Wales, from 1944 to the infection's vaccine-induced nadir in the 1990s. We find that despite the regional influence of a few large cities (for example, London and Liverpool), metapopulation aggregation in neighbouring towns and cities played an important role in driving national dynamics in the prevaccination era. As vaccination levels increased in the 1970s and 1980s, the signature of spatially predictable spread diminished: increasingly, infection was introduced from unidentifiable random sources possibly outside regional metapopulations. The resulting erratic dynamics highlight the challenges of identifying shifting sources of infection and characterizing patterns of incidence in times of high vaccination coverage. More broadly, the underlying incidence and demographic data, accompanying this paper, will also provide an important resource for exploring nonlinear spatiotemporal population dynamics.

Potential roles of social distancing in mitigating the spread of coronavirus disease 2019 (COVID-19) in South Korea

On January 20, 2020, the first COVID-19 case was confirmed in South Korea. After a rapid outbreak, the number of incident cases has been consistently decreasing since early March; this decrease has been widely attributed to its intensive testing. We report here on the likely role of social distancing in reducing transmission in South Korea. Our analysis suggests that transmission may still be persisting in some regions.

Symbolic transfer entropy reveals the age structure of pandemic influenza transmission from high-volume influenza-like illness data

Existing methods to infer the relative roles of age groups in epidemic transmission can normally only accommodate a few age classes, and/or require data that are highly specific for the disease being studied. Here, symbolic transfer entropy (STE), a measure developed to identify asymmetric transfer of information between stochastic processes, is presented as a way to reveal asymmetric transmission patterns between age groups in an epidemic. STE provides a ranking of which age groups may dominate transmission, rather than a reconstruction of the explicit between-age-group transmission matrix. Using simulations, we establish that STE can identify which age groups dominate transmission even when there are differences in reporting rates between age groups and even if the data are noisy. Then, the pairwise STE is calculated between time series of influenza-like illness for 12 age groups in 884 US cities during the autumn of 2009. Elevated STE from 5 to 19 year-olds indicates that school-aged children were likely the most important transmitters of infection during the autumn wave of the 2009 pandemic in the USA. The results may be partially confounded by higher rates of physician-seeking behaviour in children compared to adults, but it is unlikely that differences in reporting rates can explain the observed differences in STE.

Changes in historical typhoid transmission across 16 U.S. cities, 1889-1931: Quantifying the impact of investments in water and sewer infrastructures

Investments in water and sanitation systems are believed to have led to the decline in typhoid fever in developed countries, such that most cases now occur in regions lacking adequate clean water and sanitation. Exploring seasonal and long-term patterns in historical typhoid mortality in the United States can offer deeper understanding of disease drivers. We fit modified Time-series Susceptible-Infectious-Recovered models to city-level weekly mortality counts to estimate seasonal and long-term typhoid transmission. We examined seasonal transmission separately by city and aggregated by water source. Typhoid transmission peaked in late summer/early fall. Seasonality varied by water source, with the greatest variation occurring in cities with reservoirs. We then fit hierarchical regression models to measure associations between long-term transmission and annual financial investments in water and sewer systems. Overall historical $1 per capita ($16.13 in 2017) investments in the water supply were associated with approximately 5% (95% confidence interval: 3-6%) decreases in typhoid transmission, while $1 increases in the overall sewer system investments were associated with estimated 6% (95% confidence interval: 4-9%) decreases. Our findings aid in the understanding of typhoid transmission dynamics and potential impacts of water and sanitation improvements, and can inform cost-effectiveness analyses of interventions to reduce the typhoid burden.

Accelerated viral dynamics in bat cell lines, with implications for zoonotic emergence

Bats host virulent zoonotic viruses without experiencing disease. A mechanistic understanding of the impact of bats’ virus hosting capacities, including uniquely constitutive immune pathways, on cellular-scale viral dynamics is needed to elucidate zoonotic emergence. We carried out virus infectivity assays on bat cell lines expressing induced and constitutive immune phenotypes, then developed a theoretical model of our in vitro system, which we fit to empirical data. Best fit models recapitulated expected immune phenotypes for representative cell lines, supporting robust antiviral defenses in bat cells that correlated with higher estimates for within-host viral propagation rates. In general, heightened immune responses limit pathogen-induced cellular morbidity, which can facilitate the establishment of rapidly-propagating persistent infections within-host. Rapidly-transmitting viruses that have evolved with bat immune systems will likely cause enhanced virulence following emergence into secondary hosts with immune systems that diverge from those unique to bats.

Bats can carry viruses that are deadly to other mammals without themselves showing serious symptoms. In fact, bats are natural reservoirs for viruses that have some of the highest fatality rates of any viruses that people acquire from wild animals – including rabies, Ebola and the SARS coronavirus.

Bats have a suite of antiviral defenses that keep the amount of virus in check. For example, some bats have an antiviral immune response called the interferon pathway perpetually switched on. In most other mammals, having such a hyper-vigilant immune response would cause harmful inflammation. Bats, however, have adapted anti-inflammatory traits that protect them from such harm, include the loss of certain genes that normally promote inflammation. However, no one has previously explored how these unique antiviral defenses of bats impact the viruses themselves.

Now, Brook et al. have studied this exact question using bat cells grown in the laboratory. The experiments made use of cells from one bat species – the black flying fox – in which the interferon pathway is always on, and another – the Egyptian fruit bat – in which this pathway is only activated during an infection. The bat cells were infected with three different viruses, and then Brook et al. observed how the interferon pathway helped keep the infections in check, before creating a computer model of this response.

The experiments and model helped reveal that the bats’ defenses may have a potential downside for other animals, including humans. In both bat species, the strongest antiviral responses were countered by the virus spreading more quickly from cell to cell. This suggests that bat immune defenses may drive the evolution of faster transmitting viruses, and while bats are well protected from the harmful effects of their own prolific viruses, other creatures like humans are not.

The findings may help to explain why bats are often the source for viruses that are deadly in humans. Learning more about bats' antiviral defenses and how they drive virus evolution may help scientists develop better ways to predict, prevent or limit the spread of viruses from bats to humans. More studies are needed in bats to help these efforts. In the meantime, the experiments highlight the importance of warning people to avoid direct contact with wild bats.

Surveillance data confirm multiyear predictions of rotavirus dynamics in New York City

Prediction skill is a key test of models for epidemic dynamics. However, future validation of models against out-of-sample data is rare, partly because of a lack of timely surveillance data. We address this gap by analyzing the response of rotavirus dynamics to infant vaccination. Syndromic surveillance of emergency department visits for diarrhea in New York City reveals a marked decline in diarrheal incidence among infants and young children, in line with data on rotavirus-coded hospitalizations and laboratory-confirmed cases, and a shift from annual to biennial epidemics increasingly affecting older children and adults. A published mechanistic model qualitatively predicted these patterns more than 2 years in advance. Future efforts to increase vaccination coverage may disrupt these patterns and lead to further declines in the incidence of rotavirus-attributable gastroenteritis.