Epidemiology of seasonal influenza in the Middle East and North Africa regions, 2010-2016: Circulating influenza A and B viruses and spatial timing of epidemics

Knowledge, attitudes, concern, behaviors, and barriers associated with the readiness to receive seasonal influenza vaccine among healthcare workers in oncology setting during the COVID-19 pandemic

This study examines the knowledge, attitudes, concerns, behaviors, and barriers related to seasonal influenza vaccination among healthcare workers (HCWs) in the oncology setting during the COVID-19 pandemic. The objective is to assess the readiness of HCWs to receive the influenza vaccine. A cross-sectional study was conducted at the King Hussein Cancer Center (KHCC) in Amman, Jordan. HCWs were surveyed using a self-administered web-based questionnaire between October 2021 and November 2021. Among 223 participants, the coverage rates for seasonal influenza vaccination ranged from 65% to 81% during the autumns of 2019 and 2020, respectively. These vaccination rates showed a significant increase despite the challenges posed by the COVID-19 pandemic. Furthermore, 89.1% of the participants expressed their intention to receive the vaccine in the autumn of 2021. The analysis revealed a significant association between receiving the influenza vaccine in 2020 and the participants' work experience (P < .001, respectively). Additionally, receiving the influenza vaccination was significantly associated with higher knowledge levels (P = .036, 0.015). Although knowledge about the influenza vaccine was generally high, concerns and barriers were identified. This study demonstrates a high rate of influenza vaccination among HCWs during the COVID-19 pandemic. The participants also expressed a strong willingness to receive the vaccine in the post-pandemic season and exhibited good knowledge about it. However, concerns and barriers related to vaccination remain. These findings emphasize the importance of addressing these concerns and barriers to further enhance influenza vaccination rates among HCWs.

Timing of seasonal influenza epidemics for 25 countries in Africa during 2010-19: a retrospective analysis

BACKGROUND

Using country-specific surveillance data to describe influenza epidemic activity could inform decisions on the timing of influenza vaccination. We analysed surveillance data from African countries to characterise the timing of seasonal influenza epidemics to inform national vaccination strategies.

METHODS

We used publicly available sentinel data from African countries reporting to the WHO Global Influenza Surveillance and Response FluNet platform that had 3-10 years of data collected during 2010-19. We calculated a 3-week moving proportion of samples positive for influenza virus and assessed epidemic timing using an aggregate average method. The start and end of each epidemic were defined as the first week when the proportion of positive samples exceeded or went below the annual mean, respectively, for at least 3 consecutive weeks. We categorised countries into five epidemic patterns: northern hemisphere-dominant, with epidemics occurring in October-March; southern hemisphere-dominant, with epidemics occurring in April-September; primarily northern hemisphere with some epidemic activity in southern hemisphere months; primarily southern hemisphere with some epidemic activity in northern hemisphere months; and year-round influenza transmission without a discernible northern hemisphere or southern hemisphere predominance (no clear pattern).

FINDINGS

Of the 34 countries reporting data to FluNet, 25 had at least 3 years of data, representing 46% of the countries in Africa and 89% of Africa's population. Study countries reported RT-PCR respiratory virus results for a total of 503 609 specimens (median 12 971 [IQR 9607-20 960] per country-year), of which 74 001 (15%; median 2078 [IQR 1087-3008] per country-year) were positive for influenza viruses. 248 epidemics occurred across 236 country-years of data (median 10 [range 7-10] per country). Six (24%) countries had a northern hemisphere pattern (Algeria, Burkina Faso, Egypt, Morocco, Niger, and Tunisia). Eight (32%) had a primarily northern hemisphere pattern with some southern hemisphere epidemics (Cameroon, Ethiopia, Mali, Mozambique, Nigeria, Senegal, Tanzania, and Togo). Three (12%) had a primarily southern hemisphere pattern with some northern hemisphere epidemics (Ghana, Kenya, and Uganda). Three (12%) had a southern hemisphere pattern (Central African Republic, South Africa, and Zambia). Five (20%) had no clear pattern (Côte d'Ivoire, DR Congo, Madagascar, Mauritius, and Rwanda).

INTERPRETATION

Most countries had identifiable influenza epidemic periods that could be used to inform authorities of non-seasonal and seasonal influenza activity, guide vaccine timing, and promote timely interventions.

FUNDING

None.

TRANSLATIONS

For the Berber, Luganda, Xhosa, Chewa, Yoruba, Igbo, Hausa and Afan Oromo translations of the abstract see Supplementary Materials section.

Subtypes specified environmental dependence of seasonal influenza virus

Understanding the role of meteorological factors in the transmission dynamics of respiratory infectious diseases remains challenging. Our study was to comprehensively investigate the nonlinear effects of environmental factors on influenza transmission, based on multi-region surveillance data from mainland China. An approach related to time-varying reproduction number (R_t) was proposed, which extracts the environment-related components from R_t to estimate the relationship between environmental factors and influenza transmission based on a mixed-effects regression model. Nonlinear relationships for absolute humidity (the lowest transmission was observed at absolute humidity of 12 g/m³) and mean temperature (the lowest transmission was observed at the mean temperature of 18 ^°C) with influenza transmission were observed. Influenza transmission holds almost constant with the average precipitation below 1 mm or sunshine hour below 9 h/day, but increases for the precipitation and decreases for the sunshine hour afterward. The environmental dependence varies across subtypes: A(H3N2) maintains relatively higher transmission in high temperature and humidity conditions, compared with other influenza subtypes. Overall, the subtypes specified environmental dependence of influenza transmission could explain 23.1 %, 29.2 % and 27.1 % of the variations for A(H1N1)pdm09, A(H3N2) and B-lineage in China. The projected seasonal transmission rates based on our approach could be used as a valuable seasonal proxy to model the influenza dynamics under various meteorological spaces. Finally, our approach is also applicable to obtain novel insights into the impact of environmental factors on other respiratory infectious diseases.

Geospatial epidemiology of hospitalized patients with a positive influenza assay: A nationwide study in Iran, 2016-2018

INTRODUCTION

Seasonal influenza is a significant public health challenge worldwide. This study aimed to investigate the epidemiological characteristics and spatial patterns of severe hospitalized influenza cases confirmed by polymerase chain reaction (PCR) in Iran.

METHODS

Data were obtained from Iran's Ministry of Health and Medical Education and included all hospitalized lab-confirmed influenza cases from January 1, 2016, to December 30, 2018 (n = 9146). The Getis-Ord Gi* and Local Moran's I statistics were used to explore the hotspot areas and spatial cluster/outlier patterns of influenza. We also built a multivariable logistic regression model to identify covariates associated with patients' mortality.

RESULTS

Cumulative incidence and mortality rate were estimated at 11.44 and 0.49 (per 100,000), respectively, and case fatality rate was estimated at 4.35%. The patients' median age was 40 (interquartile range: 22-63), and 55.5% (n = 5073) were female. The hotspot and cluster analyses revealed high-risk areas in northern parts of Iran, especially in cold, humid, and densely populated areas. Moreover, influenza hotspots were more common during the colder months of the year, especially in high-elevated regions. Mortality was significantly associated with older age (adjusted odds ratio [aOR]: 1.01, 95% confidence interval [CI]: 1.01-1.02), infection with virus type-A (aOR: 1.64, 95% CI: 1.27-2.15), male sex (aOR: 1.77, 95% CI: 1.44-2.18), cardiovascular disease (aOR: 1.71, 95% CI: 1.33-2.20), chronic obstructive pulmonary disease (aOR: 1.82, 95% CI: 1.40-2.34), malignancy (aOR: 4.77, 95% CI: 2.87-7.62), and grade-II obesity (aOR: 2.11, 95% CI: 1.09-3.74).

CONCLUSIONS

We characterized the spatial and epidemiological heterogeneities of severe hospitalized influenza cases confirmed by PCR in Iran. Detecting influenza hotspot clusters could inform prioritization and geographic specificity of influenza prevention, testing, and mitigation resource management, including vaccination planning in Iran.

Circulation and seasonality of influenza viruses in different transmission zones in Africa

Background

Influenza is responsible for more than 5 million severe cases and 290,000 to 650,000 deaths every year worldwide. Developing countries account for 99% of influenza deaths in children under 5 years of age. This paper aimed to determine the dynamics of influenza viruses in African transmission areas to identify regional seasonality for appropriate decision-making and the development of regional preparedness and response strategies.

Methods

We used data from the WHO FluMart website collected by National Influenza Centers for seven transmission periods (2013–2019). We calculated weekly proportions of positive influenza cases and determined transmission trends in African countries to determine the seasonality.

Results

From 2013 to 2019, influenza A(H1N1)pdm2009, A(H3N2), and A(H5N1) viruses, as well as influenza B Victoria and Yamagata lineages, circulated in African regions. Influenza A(H1N1)pdm2009 and A(H3N2) highly circulated in northern and southern Africa regions. Influenza activity followed annual and regional variations. In the tropical zone, from eastern to western via the middle regions, influenza activities were marked by the predominance of influenza A subtypes despite the circulation of B lineages. One season was identified for both the southern and northern regions of Africa. In the eastern zone, four influenza seasons were differentiated, and three were differentiated in the western zone.

Conclusion

Circulation dynamics determined five intense influenza activity zones in Africa. In the tropics, influenza virus circulation waves move from the east to the west, while alternative seasons have been identified in northern and southern temperate zones. Health authorities from countries with the same transmission zone, even in the absence of local data based on an established surveillance system, should implement concerted preparedness and control activities, such as vaccination.

Exploring the active ingredients and pharmacological mechanisms of the oral intake formula Huoxiang Suling Shuanghua Decoction on influenza virus type A based on network pharmacology and experimental exploration

Objective

To investigate the active ingredients, underlying anti-influenza virus effects, and mechanisms of Huoxiang Suling Shuanghua Decoction (HSSD).

Materials and methods

The therapeutic effect of HSSD were confirmed through the survival rate experiment of H1N1-infected mice. Then, the HSSD solution and the ingredients absorbed into the blood after treatment with HSSD in rats were identified by UPLC/Q-TOF MS, while the main contents of ingredients were detected by high performance liquid chromatography (HPLC). Next, a systems pharmacology approach incorporating target prediction, gene ontology (GO) enrichment, kyoto encyclopedia of genes and genomes (KEGG) pathway analysis, and molecular docking were performed to screen out the active compounds and critical pathways of HSSD in treating influenza. According to prediction results, real-time quantitative polymerase chain reaction (RT-qPCR) and immunohistochemistry assay were used to detect the mRNA and protein expression levels of critical targets in H1N1-infected mice lungs.

Results

Huoxiang Suling Shuanghua Decoction improved the survival rate of H1N1-infected mice and prolonged the mice’s lifespan. Besides, HSSD exerts an antivirus effect by decreasing the levels of hemagglutinin (HA) and nucleoprotein (NP) to inhibit the replication and proliferation of H1N1, reducing the lung pathological state, inhibiting the cell apoptosis in the lung, and regulating the abnormal responses of peripheral blood, including GRA, LYM, white blood cell (WBC), PLT, and hemoglobin (HGB). Then, 87 compounds in the HSSD solution and 20 ingredients absorbed into the blood after treatment with HSSD were identified. Based on this, combined with the network analysis and previous research on antivirus, 16 compounds were screened out as the active components. Moreover, 16 potential targets were predicted by network pharmacology analysis. Next, molecular docking results showed stable binding modes between compounds and targets. Furthermore, experimental validation results indicated that HSSD regulates the contents of Immunoglobulin A (IgA), Immunoglobulin M (IgM), and Immunoglobulin G (IgG) in serum, modulating the levels of IFN-γ, IL-6, IL-10, MCP-1, MIP-1α, and IP-10 in the lung tissue, and significantly decreasing the mRNA and protein expressions of TLR4, CD14, MyD88, NF-κB p65, HIF1 α, VEGF, IL17A, and IL6 in the lung tissue.

Conclusion

Huoxiang Suling Shuanghua Decoction exerts an anti-influenza effect by affecting the expressions of mRNA and protein including TLR4, CD14, MyD88, NF-kB p65, HIF-1α, VEGF, IL17A, IL6, and inhibiting the accumulation of inflammation. Our study provided experimental pieces of evidence about the practical application of HSSD in treating influenza.

Differentiation of influenza B lineages circulating in different regions of Brazil, 2014 – 2016, using molecular assay

Background

Two antigenically and genetically distinct lineages of influenza B viruses (B/Victoria and B/Yamagata) have been co-circulating worldwide since 2002. Virological surveillance is essential to differentiate between both lineages with a view to the annual updating of the B component for the trivalent or quadrivalent influenza vaccine composition.

Methods

The samples analyzed in the present study were collected by influenza sentinel units located in the Southeast, Midwest, North, and Northeast regions of Brazil, part of the National Influenza Virus Surveillance Network, coordinated by the Ministry of Health of Brazil. A total of 870 influenza B positive samples by reverse transcription real – time polymerase chain reaction (RT-qPCR), collected during 2014, 2015, and 2016 influenza seasons, were submitted to the influenza B lineage genotyping panel for characterization as B/Yamagata or Victoria lineages using RT-qPCR.

Results

Of the 197 samples analyzed in 2014, a total of 160 (81 %) corresponded to the B/Yamagata lineage, 19 (10 %) to the B/Victoria lineage, and 18 (9 %) to indeterminate lineages. Of the 190 samples analyzed in 2015, a total of 124 (65 %) corresponded to the B/Yamagata lineage; 55 (29 %) to the B/Victoria lineage, whereas 11 (6 %) were of indeterminate lineages. Of the 483 samples analyzed in 2016, a total of 297 (62 %) corresponded to the B /Victoria lineage; 174 (36 %) to the B/Yamagata lineage and 12 (2 %) to indeterminate lineages. This cross-sectional study revealed influenza B virus (IBV) infection in all age groups, and among them, the highest prevalence was observed in individuals between 11 and 49 years of age Our findings demonstrate the match between influenza B virus lineages recommended by the World Health Organization (WHO) for the trivalent vaccine composition to be used in the Southern Hemisphere (SH) and the predominant circulating viruses during the 2014, 2015, and 2016 seasons.

Influenza circulating viruses, positivity rate and risk factors for influenza associated severe acute respiratory infection during 2018/2019 winter season, Yemen

BACKGROUND

The burden of seasonal influenza in conflict counties is exacerbated due to limited resource and collapse of health system. During 2018 /2019 season, two-fold increase in the incidence of influenza was reported in Yemen with 22% case fatality of severe acute respiratory infection (SARI). The aims are to analyze the influenza circulating viruses, positivity rate and risk factors for hospitalizing influenza associated-SARI.

METHODOLOGY

We used a retrospective analytical study based on surveillance data. All reported patients during 2018/2019 season, fulfilling the WHO cases definition for SARI or influenza like illness (ILI), and had laboratory result from the National Laboratory were included. Influenza positivity rate was calculated, all SARI and ILI patients with positive influenza were included for further analysis by univariate and multivariate binary logistic regression. Crude and adjusted Odds ratio (AOR), 95% confidence interval and P-value < 0.05 were used for statistically significant.

RESULTS

Out of 2186 patients enrolled, 768 patients were tested for influenza viruses,: 19% were children < 15 years, 15% were ≥ 65 years, 69% males and 18% had co-morbidity with chronic diseases. Patients with SARI were 37% and 63% were ILI patients. Influenza viruses were detected in 411 (53.5%), 68% were influenza A subtype (H1N1)pdm09, 27% influenza B and 5% was influenza A not subtyped. The influenza positivity was significantly higher in SARI compared to ILI for patients < 15 years (95% vs, 66%, p < 0.001), and patients ≥ 65 years (83% vs. 56%, p < 0.002), respectively. The highest positivity for influenza type A and B reached 44% and 33% for patients ≥ 65 years and < 15 years, respectively. The risk factors for influenza-associated SARI in multivariate analysis included age < 5 [AOR 2.8] and ≥ 65 years old [AOR 3.1] compared to age 5- < 25 years, diabetes [AOR 4.7], heart diseases [AOR 3.1] and chronic respiratory diseases [AOR 5.0].

CONCLUSION

The influenza positivity during 2018/2019 winter season was high in Yemen and varied by age distribution. Influenza subtype A (H1N1) pdm09 was the predominant and co circulated with influenza B. An influenza vaccination program for the risk group is necessary. Strengthening lab capacity to detect respiratory pathogens and further prospective study for more comprehensive picture are recommended.

A Systematic Review of Influenza Epidemiology and Surveillance in the Eastern Mediterranean and North African Region

Seasonal influenza represents a huge health burden, resulting in significant mortality and morbidity. Following the 2009 H1N1 pandemic, focus has been directed on the burden of influenza globally. Country and regional disease burden estimates play important roles in helping inform decisions on national influenza intervention programmes. Despite improvements in influenza surveillance following the 2009 pandemic, many opportunities remain unexplored in the Eastern Mediterranean and North African (EMNA) region, which has a high prevalence of patients with chronic disease and thus a population at high risk of influenza complications. We conducted a systematic literature review of Embase, Medline, Scopus and the Cochrane Database of Systematic Reviews from 1 January 1998 to 31 January 2020 covering the EMNA region with the aim to describe the epidemiology of influenza in the region and assess the influenza epidemiological surveillance research landscape. Relevant data on study characteristics, population, clinical/virology characteristics and epidemiology were extracted and summarised descriptively. Of the 112 studies identified for inclusion, 90 were conducted in the Eastern Mediterranean region, 19 in North Africa and three across the EMNA region. Data were reported on 314,058 laboratory-confirmed influenza cases, 96 of which were derived from surveillance systems. Amongst the surveillance studies, the percentage of positive cases reported ranged from 1% to 100%. The predominantly identified influenza strain was strain A; H1N1 was the most prominent circulating subtype. Typing was performed in approximately 75% and subtyping in 50% of studies, respectively. Data on those considered most at risk for influenza complications were collected in 21% of studies, highlighting a regional gap for these data. Our review reveals existing gaps in regional estimates of influenza health and economic burden, hospitalisation rates and duration, and highlights the need for robust and high-quality epidemiology data to help inform public health interventions.

Implementation of a Vaccination Program Based on Epidemic Geospatial Attributes: COVID-19 Pandemic in Ohio as a Case Study and Proof of Concept

Geospatial vaccine uptake is a critical factor in designing strategies that maximize the population-level impact of a vaccination program. This study uses an innovative spatiotemporal model to assess the impact of vaccination distribution strategies based on disease geospatial attributes and population-level risk assessment. For proof of concept, we adapted a spatially explicit COVID-19 model to investigate a hypothetical geospatial targeting of COVID-19 vaccine rollout in Ohio, United States, at the early phase of COVID-19 pandemic. The population-level deterministic compartmental model, incorporating spatial-geographic components at the county level, was formulated using a set of differential equations stratifying the population according to vaccination status and disease epidemiological characteristics. Three different hypothetical scenarios focusing on geographical subpopulation targeting (areas with high versus low infection intensity) were investigated. Our results suggest that a vaccine program that distributes vaccines equally across the entire state effectively averts infections and hospitalizations (2954 and 165 cases, respectively). However, in a context with equitable vaccine allocation, the number of COVID-19 cases in high infection intensity areas will remain high; the cumulative number of cases remained >30,000 cases. A vaccine program that initially targets high infection intensity areas has the most significant impact in reducing new COVID-19 cases and infection-related hospitalizations (3756 and 213 infections, respectively). Our approach demonstrates the importance of factoring geospatial attributes to the design and implementation of vaccination programs in a context with limited resources during the early stage of the vaccine rollout.

Impact of coinfection status and comorbidity on disease severity in adult emergency department patients with influenza B

Background

Influenza B accounts for approximately one fourth of the seasonal influenza burden. However, research on the importance of influenza B has received less attention compared to influenza A. We sought to describe the association of both coinfections and comorbidities with disease severity among adults presenting to emergency departments (ED) with influenza B.

Methods

Nasopharyngeal samples from patients found to be influenza B positive in four US and three Taiwanese ED over four consecutive influenza seasons (2014–2018) were tested for coinfections with the ePlex RP RUO panel. Multivariable logistic regressions were fitted to model adjusted odds ratios (aOR) for two severity outcomes separately: hospitalization and pneumonia diagnosis. Adjusting for demographic factors, underlying health conditions, and the National Early Warning Score (NEWS), we estimated the association of upper respiratory coinfections and comorbidity with disease severity (including hospitalization or pneumonia).

Results

Amongst all influenza B positive individuals (n = 446), presence of another upper respiratory pathogen was associated with an increased likelihood of hospitalization (aOR = 2.99 [95% confidence interval (95% CI): 1.14–7.85, p = 0.026]) and pneumonia (aOR = 2.27 [95% CI: 1.25–4.09, p = 0.007]). Chronic lung diseases (CLD) were the strongest predictor for hospitalization (aOR = 3.43 [95% CI: 2.98–3.95, p < 0.001]), but not for pneumonia (aOR = 1.73 [95% CI: 0.80–3.78, p = 0.166]).

Conclusion

Amongst ED patients infected with influenza B, the presence of other upper respiratory pathogens was independently associated with both hospitalization and pneumonia; presence of CLD was also associated with hospitalization. These findings may be informative for ED clinician's in managing patients infected with influenza B.

Spatiotemporal Analysis of COVID-19 Pandemic and Predictive Models based on Artificial Intelligence for different States of India

Geographical and spatial diversities play important roles in dynamics of spread of COVID-19 virus. These phenomena are not properly addressed in the literature yet. In this paper, COVID data of various states of India are collected. The data had been processed and analysed using an open-source software. A framework based on Susceptible, Infectious, Hospitalised, Recovered and Deaths model to determine the effects of geographical diversities of Indian states on COVID-19 pandemic has been developed. The confirmed, cured and death cases due to the virus have been analysed for different state. Reasons behind the differences in number of cases in different states are identified. An improved Long-Short-Term-Memory algorithm has been developed to forecast the virus spread and recovery of patients for the next one month. Numerical results along with discussions are given.

The burden of Respiratory Syncytial Virus (RSV) infection in the Middle East and North Africa (MENA) region across age groups: A systematic review

Respiratory Syncytial Virus (RSV) is a common respiratory virus that generally causes a mild illness in children and adults or severe symptoms with complications in infants and the elderly, particularly in the presence of underlying comorbidities. While epidemiological data about this virus are available globally, data from the Middle East and North Africa (MENA) region are still scarce. For this reason, we conducted a systematic review to determine the burden of RSV disease in the MENA region by searching the available literature up until September 2018. A total of 1242 studies were retrieved of which 90 were included in the review. Most of the included studies were conducted in subjects aged 0-18 years with the majority being in children below 3 years of age, while only 2 studies included exclusively adults above 18 years of age. RSV infection rates varied greatly between different studies on hospitalized subjects and ranged between 4% and 82%, while the range was smaller in studies on outpatient subjects (between 6% and 36%). When calculating the RSV infection rates in the hospitalized subjects with different inclusion criteria, we found that it was 19%, 70%, and 33% among subjects admitted with Acute Respiratory Infections (ARIs), Acute Lower Respiratory Infections (ALRIs), and bronchiolitis, respectively. RSV infections were most common during the winter season. With regards to complications, intensive care unit admissions ranged between 1% and 15%, while the need for mechanical ventilation ranged between 1% and 10%. The overall RSV related mortality rate across all age groups in studies included in our review was 1.9%. This review identifies several limitations in the existing data and under-representation of the adult population. Future studies should be providing more evidence on the RSV burden in adults and children with comorbidities in order to better assess the potential impact of future preventive strategies in the MENA region.

Decline in influenza cases in Mexico after the implementation of public health measures for COVID-19

Mexico took swift action and has strictly followed mitigation measures to prevent the spread of coronavirus disease, COVID-19. In this study we compared influenza activity indicators in our country after the implementation of public health measures for COVID-19. We compared indicators of influenza activity in 2020 before and after public health measures were taken to reduce COVID-19 with the corresponding indicators from three preceding years and the immediate one, and the potential decrease in seasonal influenza cases/deaths. Nationwide surveillance data revealed a drastic decline in influenza diagnosis in outpatient clinics and public hospitals, influenza positivity rates of clinical specimens, and confirmed severe cases during the following 10 weeks of 2020 as lockdown activities and control measures were established compared with the same period of 2019. Our results suggest that the measures taken for COVID-19 were effective in reducing the spread of other viral respiratory diseases as influenza in our country.

Molecular Detection of Influenza A and B Viruses in Four Consecutive Influenza Seasons 2015-16 to 2018-19 in a Tertiary Center in Western Saudi Arabia

Introduction: Influenza infection poses a significant public health threat. The core for disease prevention and control relies on strengthened surveillance activities, particularly in Saudi Arabia, the country that hosts the largest annual mass gathering event worldwide. This study aimed to assess the molecular and seasonal pattern of influenza virus subtypes in western Saudi Arabia to inform policy decisions on influenza vaccine.

Methods: This cross-sectional study was conducted at King Abdulaziz Medical City, western Saudi Arabia. Medical records and surveillance database of laboratory-confirmed influenza cases were reviewed from October 2015 to 2019. A panel of real-time polymerase chain reactions was performed to detect influenza A and B. Extracted RNA from a subset of positive samples was used to determine influenza A subtypes and influenza B lineages.

Results: This study included a total of 1928 patients with laboratory-confirmed influenza infections. Influenza peaks were observed in October each season, with variant predominant strains. Influenza virus subtypes co-circulate with no reports of co-infection. Influenza A(H3N2) was reported in 42% of the cases, then influenza B (30.7%) and influenza A(H1N1)pdm09 (27.3%). Healthcare workers represented 9.4% of the cases. One-third of the cases (30.4%) were admitted to the hospital with a median admission duration of 4 days. The influenza B viruses were subtyped in 218 cases. Victoria lineage was predominant (64.1%) in 2015 and 2016; however, Yamagata was predominant in the next two consecutive seasons (94.4% and 85.4%, respectively).

Conclusion: The burden due to influenza B may be underestimated with an observed vaccine mismatch. A quadrivalent influenza vaccine is recommended to reduce the health impact associated with influenza B infections. Molecular surveillance of the influenza viruses should be enhanced continuously for a better understanding of the influenza activity and assessment of vaccine effectiveness.

Natural immunity to influenza A and B among Saudi blood donors in Al Madinah Al Munawarah, Saudi Arabia

Objectives:

To investigate the seroprevalence of influenza viruses (A and B) among blood donors in Kingdom of Saudi Arabia.

Methods:

The present investigation was conducted between April 2019 and July 2019. Participants were healthy adults recruited from the central blood bank Al Madinah Al Munawarah, Kingdom of Saudi Arabia. Immunoglobulin G (IgG) levels against influenza A and B were measured in serum samples using ELISA.

Results:

The results showed that 29.2% of the sample had significant concentrations of influenza A IgG antibody, whereas 38.6% had significant concentrations of influenza B IgG antibody. A strong correlation was found between the levels of influenza A and influenza B antibodies (r=0.708, p<0.001). The number of individuals identified as negative for influenza A IgG antibody increased with age (p<0.01). In addition, no correlations were identified between influenza A IgG and influenza B IgG and body mass index (BMI), (p>0.05). Finally, linear regression analysis showed that the level of influenza A antibody can be predicted by age (p<0.05) and body mass index (BMI) (p<0.05).

Conclusion:

Approximately one-third of Saudi Arabian adults presented significant levels of influenza A and B antibodies in our study. Demographic factors, including age and BMI, might contribute to influenza A antibody levels.

Assessing the epidemiology and seasonality of influenza among children under two hospitalized in Amman, Jordan, 2010-2013

Background

The disease burden of influenza‐associated hospitalizations among children in Jordan is not well established. We aimed to characterize hospitalizations attributed to influenza in a pediatric population.

Methods

We conducted a cross‐sectional study from our viral surveillance cohort in children under 2 years hospitalized with acute respiratory symptoms and/or fever from March 2010 to March 2013. We collected demographic and clinical characteristics, and calculated the frequency of children who met the severe acute respiratory illness (SARI) criteria. Nasal specimens were tested using real‐time reverse transcriptase polymerase chain reaction to detect influenza A, B, or C. Further subtyping for influenza A‐positive isolates was conducted.

Results

Of the 3168 children enrolled in our study, 119 (4%) were influenza‐positive. Influenza types and subtypes varied by season but were predominantly detected between December and February. Codetection of multiple respiratory pathogens was identified in 58% of children with the majority occurring among those <6 months. Bronchopneumonia and rule‐out sepsis were the most common admission diagnoses, with influenza A accounting for over 2/3 of children with a rule‐out sepsis admission status. One‐third of children under 6 months compared to 3/4 of children 6‐23 months met the SARI criteria.

Conclusions

Influenza was an important cause of acute respiratory illness in children under 2 years. Children <6 months had the highest burden of influenza‐associated hospitalizations and were less likely to meet the SARI global surveillance case definition. Additional surveillance is needed in the Middle East to determine the true influenza burden on a global scale.

Early detection of influenza outbreak using time derivative of incidence

For mitigation strategies of an influenza outbreak, it can be helpful to understand the characteristics of regional and age-group-specific spread. In South Korea, however, there has been no official statistic related to it. In this study, we extract the time series of influenza incidence from National Health Insurance Service claims database, which consists of all medical and prescription drug-claim records for all South Korean population. The extracted time series contains the number of new patients by region (250 city-county-districts) and age-group (0-4, 5-19, 20-64, 65+) within a week. The number of cases of influenza (2009-2017) is 12,282,356. For computing an onset of influenza outbreak by region and age-group, we propose a novel method for early outbreak detection, in which the onset of outbreak is detected as a sudden change in the time derivative of incidence. The advantage of it over the cumulative sum and the exponentially weighted moving average control charts, which have been widely used for the early outbreak detection of infectious diseases, is that information on the previous non-epidemic periods are not necessary. Then, we show that the metro area and 5-19 age-group are earlier than the rural area and other age-groups for the start of the influenza outbreak. Also, the metro area and 5-19 age-group peak earlier than the rural area and other age-groups. These results would be helpful to design a surveillance system for timely early warning of an influenza outbreak in South Korea.

Clinical, molecular, and epidemiological characterization of the SARS-CoV-2 virus and the Coronavirus Disease 2019 (COVID-19), a comprehensive literature review

Coronaviruses are an extensive family of viruses that can cause disease in both animals and humans. The current classification of coronaviruses recognizes 39 species in 27 subgenera that belong to the family Coronaviridae. From those, at least 7 coronaviruses are known to cause respiratory infections in humans. Four of these viruses can cause common cold-like symptoms. Those that infect animals can evolve and become infectious to humans. Three recent examples of these viral jumps include SARS CoV, MERS-CoV and SARS CoV-2 virus. They are responsible for causing severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS) and the most recently discovered coronavirus disease during 2019 (COVID-19). COVID-19, a respiratory disease caused by the SARS-CoV-2 virus, was declared a pandemic by the World Health Organization (WHO) on 11 March 2020. The rapid spread of the disease has taken the scientific and medical community by surprise. Latest figures from 20 May 2020 show more than 5 million people had been infected with the virus, causing more than 330,000 deaths in over 210 countries worldwide. The large amount of information received daily relating to COVID-19 is so abundant and dynamic that medical staff, health authorities, academics and the media are not able to keep up with this new pandemic. In order to offer a clear insight of the extensive literature available, we have conducted a comprehensive literature review of the SARS CoV-2 Virus and the Coronavirus Diseases 2019 (COVID-19).

Spatiotemporal transmission dynamics of the COVID-19 pandemic and its impact on critical healthcare capacity

The role of geospatial disparities in the dynamics of the COVID-19 pandemic is poorly understood. We developed a spatially-explicit mathematical model to simulate transmission dynamics of COVID-19 disease infection in relation with the uneven distribution of the healthcare capacity in Ohio, U.S. The results showed substantial spatial variation in the spread of the disease, with localized areas showing marked differences in disease attack rates. Higher COVID-19 attack rates experienced in some highly connected and urbanized areas (274 cases per 100,000 people) could substantially impact the critical health care response of these areas regardless of their potentially high healthcare capacity compared to more rural and less connected counterparts (85 cases per 100,000). Accounting for the spatially uneven disease diffusion linked to the geographical distribution of the critical care resources is essential in designing effective prevention and control programmes aimed at reducing the impact of COVID-19 pandemic.

Epidemiological and evolutionary dynamics of influenza B virus in coastal Kenya as revealed by genomic analysis of strains sampled over a single season

The genomic epidemiology of influenza B virus (IBV) remains understudied in Africa despite significance to design of effective local and global control strategies. We undertook surveillance throughout 2016 in coastal Kenya, recruiting individuals presenting with acute respiratory illness at nine outpatient health facilities (any age) or admitted to the Kilifi County Hospital (<5 years old). Whole genomes were sequenced for a selected 111 positives; 94 (84.7%) of B/Victoria lineage and 17 (15.3%) of B/Yamagata lineage. Inter-lineage reassortment was detected in ten viruses; nine with B/Yamagata backbone but B/Victoria NA and NP segments and one with a B/Victoria backbone but B/Yamagata PB2, PB1, PA, and MP segments. Five phylogenomic clusters were identified among the sequenced viruses; (i), pure B/Victoria clade 1A (n = 93, 83.8%), (ii), reassortant B/Victoria clade 1A (n = 1, 0.9%), (iii), pure B/Yamagata clade 2 (n = 2, 1.8%), (iv), pure B/Yamagata clade 3 (n = 6, 5.4%), and (v), reassortant B/Yamagata clade 3 (n = 9, 8.1%). Using divergence dates and clustering patterns in the presence of global background sequences, we counted up to twenty-nine independent IBV strain introductions into the study area (∼900 km2) in 2016. Local viruses, including the reassortant B/Yamagata strains, clustered closely with viruses from neighbouring Tanzania and Uganda. Our study demonstrated that genomic analysis provides a clearer picture of locally circulating IBV diversity. The high number of IBV introductions highlights the challenge in controlling local influenza epidemics by targeted approaches, for example, sub-population vaccination or patient quarantine. The finding of divergent IBV strains co-circulating within a single season emphasises why broad immunity vaccines are the most ideal for influenza control in Kenya.

Temperature, Humidity, and Latitude Analysis to Estimate Potential Spread and Seasonality of Coronavirus Disease 2019 (COVID-19)

IMPORTANCE

Coronavirus disease 2019 (COVID-19) infection has resulted in a global crisis. Investigating the potential association of climate and seasonality with the spread of this infection could aid in preventive and surveillance strategies.

OBJECTIVE

To examine the association of climate with the spread of COVID-19 infection.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study examined climate data from 50 cities worldwide with and without substantial community spread of COVID-19. Eight cities with substantial spread of COVID-19 (Wuhan, China; Tokyo, Japan; Daegu, South Korea; Qom, Iran; Milan, Italy; Paris, France; Seattle, US; and Madrid, Spain) were compared with 42 cities that have not been affected or did not have substantial community spread. Data were collected from January to March 10, 2020.

MAIN OUTCOMES AND MEASURES

Substantial community transmission was defined as at least 10 reported deaths in a country as of March 10, 2020. Climate data (latitude, mean 2-m temperature, mean specific humidity, and mean relative humidity) were obtained from ERA-5 reanalysis.

RESULTS

The 8 cities with substantial community spread as of March 10, 2020, were located on a narrow band, roughly on the 30° N to 50° N corridor. They had consistently similar weather patterns, consisting of mean temperatures of between 5 and 11 °C, combined with low specific humidity (3-6 g/kg) and low absolute humidity (4-7 g/m3). There was a lack of substantial community establishment in expected locations based on proximity. For example, while Wuhan, China (30.8° N) had 3136 deaths and 80 757 cases, Moscow, Russia (56.0° N), had 0 deaths and 10 cases and Hanoi, Vietnam (21.2° N), had 0 deaths and 31 cases.

CONCLUSIONS AND RELEVANCE

In this study, the distribution of substantial community outbreaks of COVID-19 along restricted latitude, temperature, and humidity measurements was consistent with the behavior of a seasonal respiratory virus. Using weather modeling, it may be possible to estimate the regions most likely to be at a higher risk of substantial community spread of COVID-19 in the upcoming weeks, allowing for concentration of public health efforts on surveillance and containment.

The burden of laboratory-confirmed influenza infection in Lebanon between 2008 and 2016: a single tertiary care center experience

BACKGROUND

Influenza is a major cause of morbidity and mortality worldwide. Following the 2009 pandemic, there was widened interest in studying influenza burden in all regions. However, since data from the World Health Organization (WHO) Middle East and North Africa (MENA) region remain limited, we aimed to contribute to the understanding of influenza burden in Lebanon.

METHODS

A retrospective chart review extending over a period of 8 seasons from Jan 1st, 2008 till June 30th, 2016 at a tertiary care center in Beirut was performed. All cases confirmed to have influenza based on rapid antigen detection or/and polymerase chain reaction on a respiratory sample were included for analysis. Data on epidemiology, clinical presentation, complications, antiviral use and mortality were collected for analysis.

RESULTS

A total of 1829 cases of laboratory-confirmed influenza were identified. Average annual positivity rate was 14% (positive tests over total requested). Both influenza A and B co-circulated in each season with predominance of influenza A. Influenza virus started circulating in December and peaked in January and February. The age group of 19-50 years accounted for the largest proportion of cases (22.5%) followed by the age group of 5-19 years (18%). Pneumonia was the most common complication reported in 33% of cases. Mortality reached 3.8%. The two extremes of age (< 2 years and ≥ 65 years) were associated with a more severe course of disease, hospitalization, intensive care unit (ICU) admission, complications, and mortality rate. Of all the identified cases, 26% were hospitalized. Moderate-to-severe disease was more likely in influenza B cases but no difference in mortality was reported between the two types. Antivirals were prescribed in 68.8% and antibiotics in 41% of cases. There seemed to be an increasing trend in the number of diagnosed and hospitalized cases over the years of the study.

CONCLUSION

Patients with laboratory-confirmed influenza at our center had a high rate of hospitalization and mortality. A population based prospective surveillance study is needed to better estimate the burden of Influenza in Lebanon that would help formulate a policy on influenza control.

Applying the moving epidemic method to determine influenza epidemic and intensity thresholds using influenza-like illness surveillance data 2009-2018 in Tunisia

Background

Defining the start and assessing the intensity of influenza seasons are essential to ensure timely preventive and control measures and to contribute to the pandemic preparedness. The present study aimed to determine the epidemic and intensity thresholds of influenza season in Tunisia using the moving epidemic method.

Methods

We applied the moving epidemic method (MEM) using the R Language implementation (package “mem”). We have calculated the epidemic and the different intensity thresholds from historical data of the past nine influenza seasons (2009‐2010 to 2017‐2018) and assessed the impact of the 2009‐2010 pandemic year. Data used were the weekly influenza‐like illness (ILI) proportions compared with all outpatient acute consultations. The goodness of the model was assessed using a cross validation procedure.

Results

The average duration of influenza epidemic during a typical season was 20 weeks and ranged from 11 weeks (2009‐2010 season) to 23 weeks (2015‐2016 season). The epidemic threshold with the exclusion of the pandemic season was 6.25%. It had a very high sensitivity of 85% and a high specificity of 69%. The different levels of intensity were established as follows: low, if ILI proportion is below 9.74%, medium below 12.05%; high below 13.27%; and very high above this last rate.

Conclusions

This is the first mathematically based study of seasonal threshold of influenza in Tunisia. As in other studies in different countries, the model has shown both good specificity and sensitivity, which allows timely and accurate detection of the start of influenza seasons. The findings will contribute to the development of more efficient measures for influenza prevention and control.

Molecular epidemiology of influenza, RSV, and other respiratory infections among children in Qatar: A six years report (2012-2017)

•

Throughout a five years period, HRV, RSV, and influenza viruses were responsible for two-thirds of acute respiratory infections among children in Qatar.

•

RSV, influenza, and HMPV circulated in winter, whereas HRV was highly active during other seasons.

•

RSV is more prevalent among infants, while influenza circulates more among children above five years of age.

•

Influenza–RSV co-infections are significantly associated with age.

•

Gender-dependent differences affect infection rates.

Background

Studies on the etiology of respiratory infections among children in Qatar and surrounding countries are limited.

Objectives

To describe the prevalence and seasonality of RSV, influenza, and other respiratory pathogens among children in Qatar.

Methods

We retrospectively collected and analyzed data of 33,404 children (<15 years) presented with influenza-like illness from 2012 to 2017.

Results

At least one respiratory pathogen was detected in 26,138 (78%) of patients. Together, human rhinoviruses (HRV), respiratory syncytial virus (RSV), and influenza viruses comprised nearly two-thirds of all cases, affecting 24%, 19.7%, and 18.5%, respectively. A prevalence of 5-10% was recorded for adenovirus, parainfluenza viruses (PIVs), human bocavirus (HboV), and human coronaviruses (HCoVs). Human metapneumovirus (HMPV), enteroviruses, M. pneumonia, and parechovirus had prevalences below 5%. While RSV, influenza, and HMPV exhibited strong seasonal activity in the winter, HRV was active during low RSV and influenza circulation. The burden of RSV exceeds that of influenza among young age groups, whereas influenza correlated positively with age. Further, HRV, adenovirus, influenza, and RSV infection rates varied significantly between male and females.

Conclusion

This comprehensive multi-year study provides insights into the etiology of ILI among children in Qatar, which represents the Gulf region. Our results reinforce the significance of active surveillance of respiratory pathogens to improve infection prevention and control strategies, particularly among children.

Temperature, humidity, and latitude analysis to predict potential spread and seasonality for COVID-19

Background

A significant number of infectious diseases display seasonal patterns in their incidence, including human coronaviruses. Betacoronaviruses such as MERS-CoV and SARS-CoV are not thought to be seasonal.

Methods

We examined climate data from cities with significant community spread of COVID-19 using ERA-5 reanalysis, and compared to areas that are either not affected, or do not have significant community spread.

Results

To date, Coronavirus Disease 2019 (COVID-19), caused by SARS-CoV-2, has established significant community spread in cities and regions along a narrow east west distribution roughly along the 30-50° N' corridor at consistently similar weather patterns consisting of average temperatures of 5-11°C, combined with low specific (3-6 g/kg) and absolute humidity (4-7 g/m3). There has been a lack of significant community establishment in expected locations that are based only on population proximity and extensive population interaction through travel.

Conclusions and Relevance

The distribution of significant community outbreaks along restricted latitude, temperature, and humidity are consistent with the behavior of a seasonal respiratory virus. Additionally, we have proposed a simplified model that shows a zone at increased risk for COVID-19 spread. Using weather modeling, it may be possible to predict the regions most likely to be at higher risk of significant community spread of COVID-19 in the upcoming weeks, allowing for concentration of public health efforts on surveillance and containment.

Temperature, Humidity and Latitude Analysis to Predict Potential Spread and Seasonality for COVID-19

BACKGROUND

A significant number of infectious diseases display seasonal patterns in their incidence, including human coronaviruses. Betacoronaviruses such as MERS-CoV and SARS-CoV are not thought to be seasonal.

METHODS

We examined climate data from cities with significant community spread of COVID-19 using ERA-5 reanalysis, and compared to areas that are either not affected, or do not have significant community spread.

FINDINGS

To date, Coronavirus Disease 2019 (COVID-19), caused by SARS-CoV-2, has established significant community spread in cities and regions along a narrow east west distribution roughly along the 30-50o N' corridor at consistently similar weather patterns consisting of average temperatures of 5-11oC, combined with low specific (3-6 g/kg) and absolute humidity (4-7 g/m3). There has been a lack of significant community establishment in expected locations that are based only on population proximity and extensive population interaction through travel.

INTERPRETATION

The distribution of significant community outbreaks along restricted latitude, temperature, and humidity are consistent with the behavior of a seasonal respiratory virus. Additionally, we have proposed a simplified model that shows a zone at increased risk for COVID-19 spread. Using weather modeling, it may be possible to predict the regions most likely to be at higher risk of significant community spread of COVID-19 in the upcoming weeks, allowing for concentration of public health efforts on surveillance and containment.

Bronchiolitis clinical practice guidelines implementation: surveillance study of hospitalized children in Jordan

INTRODUCTION

Bronchiolitis is a leading cause of hospital admissions and death in young children. Clinical practice guidelines (CPG) to diagnose and manage bronchiolitis have helped healthcare providers to avoid unnecessary investigations and interventions and to provide evidence-based treatment. Aim of this study is to determine the effect of implementing CPG for the diagnosis and management of bronchiolitis in a tertiary hospital in Jordan.

METHODS

The study compared children (age <24 months) diagnosed with bronchiolitis and who required admission to King Abdullah University Hospital in Irbid during the winter of 2017 (after CPG implementation) and age-matched children admitted in the winter of 2016. The proportion of patients receiving diagnostic tests and treatments in the two groups were compared.

RESULTS

Eighty-eight and 91 patients were diagnosed with bronchiolitis before and after CPG implementation, respectively. Respiratory syncytial virus rapid antigen detection testing decreased after CPG implementation [n=64 (72.7%) vs n=46 (50.5%), p=0.002]. However, there was no significant change in terms of other diagnostic tests. The use of nebulized salbutamol [n=44 (50%) vs n=29 (31.9%), p=0.01], hypertonic saline [n=39 (44.3%) vs n=8 (8.8%), p<0.001], and inappropriate antibiotics [n=31 (35.2%) vs n=15 (16.5%), p=0.004] decreased after CPG implementation. There was no difference in mean LOS (standard deviation; SD) between the pre- and post-CPG groups [3.5(2) vs 4 (3.4) days, p=0.19]. The mean cost of stay (SD) was 449.4 (329.1) US dollars for pre-CPG compared to 507.3 (286.1) US dollars for the post-CPG group (p=0.24).

CONCLUSION

We observed that the implementation of CPG for bronchiolitis diagnosis and management helped change physicians' behavior toward evidence-based practices. However, adherence to guidelines must be emphasized to improve practices in developing countries, focusing on the rational use of diagnostic testing, and avoiding use of unnecessary medications when managing children with a diagnosis of bronchiolitis.

Spatial, Temporal and Genetic Dynamics Characteristics of Influenza B Viruses in China, 1973-2018

Annual influenza B virus epidemics and outbreaks cause severe influenza diseases in humans and pose a threat to public health. China is an important epidemic area of influenza B viruses. However, the spatial, temporal transmission pathways and the demography history of influenza B viruses in China remain unknown. We collected the haemagglutinin gene sequences sampled of influenza B virus in China between 1973 and 2018. A Bayesian Markov chain Monte Carlo phylogeographic discrete approach was used to infer the spatial and temporal phylodynamics of influenza B virus. The Bayesian phylogeographic analysis of influenza B viruses showed that the North subtropical and South subtropical zones are the origins of the Victoria and Yamagata lineage viruses, respectively. Furthermore, the South temperate and North subtropical zones acted as transition nodes in the Victoria lineage virus dispersion network and that the North subtropical and Mid subtropical zones acted as transition nodes in the Yamagata lineage virus dispersion network. Our findings contribute to the knowledge regarding the spatial and temporal patterns of influenza B virus outbreaks in China.

Seasonality of influenza and its association with meteorological parameters in two cities of Pakistan: A time series analysis

Background

Influenza is known to have a specific pattern of seasonality the reasons for which are yet to be fully ascertained. Temperate zones show influenza epidemic during the winter months. The tropical and subtropical regions show more diverse influenza outbreak patterns. This study explores the seasonality of influenza activity and predicts influenza peak based on historical surveillance time series data in Islamabad and Multan, Pakistan.

Methods

This is a descriptive study of routinely collected monthly influenza sentinel surveillance data and meteorological data from 2012–16 in two sentinel sites of Pakistan: Islamabad (North) and Multan (Central).

Results

Mean number of cases of influenza and levels of precipitation were higher in Islamabad compared to Multan. Mean temperature and humidity levels were similar in both the cities. The number of influenza cases rose with decrease in precipitation and temperature in Islamabad during 2012–16, although the same cannot be said about humidity. The relationship between meteorological parameters and influenza incidence was not pronounced in case of Multan. The forecasted values in both the cities showed a significant peak during the month of January.

Conclusion

The influenza surveillance system gave a better understanding of the disease trend and could accurately forecast influenza activity in Pakistan.

Epidemiology of respiratory infections among adults in Qatar (2012-2017)

BACKGROUND

Limited data is available about the etiology of influenza like illnesses (ILIs) in Qatar.

OBJECTIVES

This study aimed at providing preliminary estimates of influenza and other respiratory infections circulating among adults in Qatar.

METHODS

We retrospectively collected data of about 44,000 patients who visited Hamad General Hospital clinics, sentinel sites, and all primary healthcare centers in Qatar between 2012 and 2017. All samples were tested for influenza viruses, whereas about 38,000 samples were tested for influenza and a panel of respiratory viruses using Fast Track Diagnostics (FTD) RT-PCR kit.

RESULTS

Among all ILIs cases, 20,278 (46.5%) tested positive for at least one respiratory pathogen. Influenza virus was predominating (22.6%), followed by human rhinoviruses (HRVs) (9.5%), and human coronaviruses (HCoVs) (5%). A detection rate of 2-3% was recorded for mycoplasma pneumonia, adenoviruses, human parainfluenza viruses (HPIVs), respiratory syncytial virus (RSV), and human metapneumovirus (HMPV). ILIs cases were reported throughout the year, however, influenza, RSV, and HMPV exhibited strong seasonal peaks in the winter, while HRVs circulated more during fall and spring. Elderly (>50 years) had the lowest rates of influenza A (13.9%) and B (4.2%), while presenting the highest rates of RSV (3.4%) and HMPV (3.3%). While males had higher rates of HRVs (11.9%), enteroviruses (1.1%) and MERS CoV (0.2%), females had higher proportions of influenza (26.3%), HPIVs (3.2%) and RSV (3.6%) infections.

CONCLUSION

This report provides a comprehensive insight about the epidemiology of ILIs among adults in the Qatar, as a representative of Gulf States. These results would help in improvement and optimization of diagnostic procedures, as well as control and prevention of the respiratory infections.

Knowledge, attitudes and practices related to influenza illness and vaccination in children: Role of awareness campaigns in changing parents' attitudes toward influenza vaccination in Jordan

BACKGROUND

Influenza infection is associated with a significant health burden in children, especially in developing countries. The influenza vaccine is an important preventive strategy for flu illness. Aim of this study to assess knowledge, attitudes and practices (KAP) related to influenza illness and vaccination in children in the Jordanian population and to study the effect of awareness campaigns on changing the attitudes of parents toward vaccinating their children against influenza.

METHODS

A cross-sectional study was conducted among families visiting shopping malls and parks in November 2016. A questionnaire was administered via in-person interviews. Answers to KAP questions regarding influenza illness and vaccination were summed, with a total KAP score of 30. Facts about influenza illness and vaccination were explained to parents and provided in printed pamphlets.

RESULTS

There were 1241 respondents. 10.9% of participants had vaccinated their children during the last season 2015/2016. The mean KAP score (standard deviation) was 16.21 (4.61). People living in urban areas, with high monthly income >600 JD and healthcare workers had higher KAP scores than their counterparts. Compared to other sources of information about the influenza vaccine, health resources correlated most with vaccinating children. Awareness and educational pamphlets changed attitudes positively in 29% of parents who refused the influenza vaccine for their children.

CONCLUSIONS

Awareness about influenza illness and vaccination is insufficient, and the coverage rate of influenza vaccination in children is low in the Jordanian population. Implementing public health policies is necessary to spread knowledge about influenza illness and vaccination and to promote the practice of receiving the influenza vaccine in children. Educational campaigns are helpful in changing the attitudes of parents toward vaccinating their children against the flu.

Epidemiological and genetic characterization of pH1N1 and H3N2 influenza viruses circulated in MENA region during 2009-2017

BACKGROUND

Influenza surveillance is necessary for detection of emerging variants of epidemiologic and clinical significance. This study describes the epidemiology of influenza types A and B, and molecular characteristics of surface glycoproteins (hemagglutinin [HA] and neuraminidase [NA]) of influenza A subtypes: pH1N1 and H3N2 circulated in Arabian Gulf, Levant and North Africa regions during 2009-2017.

METHODS

Analysis of phylogenetics and evolution of HA and NA genes was done using full HA and NA sequences (n = 1229) downloaded from Influenza Research Database (IRD).

RESULTS

In total, 130,354 influenza positive cases were reported to WHO during study period. Of these, 50.8% were pH1N1 positive, 15.9% were H3N2 positives and 17.2% were influenza B positive. With few exceptions, all three regions were showing the typical seasonal influenza peak similar to that reported in Northern hemisphere (December-March). However, influenza activity started earlier (October) in both Gulf and North Africa while commenced later during November in Levant countries. The molecular analysis of the HA genes (influenza A subtypes) revealed similar mutations to those reported worldwide. Generally, amino acid substitutions were most frequently found in head domain in H1N1 pandemic viruses, while localized mainly in the stem region in H3N2 viruses. Expectedly, seasons with high pH1N1 influenza activity was associated with a relatively higher number of substitutions in the head domain of the HA in pH1N1 subtype. Furthermore, nucleotide variations were lower at the antigenic sites of pH1N1 viruses compared to H3N2 viruses, which experienced higher variability at the antigenic sites, reflecting the increased immunological pressure because of longer circulation and continuous vaccine changes. Analysis of NA gene of pH1N1 viruses revealed sporadic detections of oseltamivir-resistance mutation, H275Y, in 4% of reported sequences, however, none of NAI resistance mutations were found in the NA of H3N2 viruses.

CONCLUSIONS

Molecular characterization of H1N1 and H3N2 viruses over 9 years revealed significant differences with regard to position and function of characterized substitutions. While pH1N1 virus substitutions were mainly found in HA head domain, H3N2 virus substitutions were mostly found in HA stem domain. Additionally, more fixed substitutions were encountered in H3N2 virus compared to larger number of non-fixed substitutions in pH1N1.

Epidemiology and timing of seasonal influenza epidemics in the Asia-Pacific region, 2010-2017: implications for influenza vaccination programs

Background

Description of the epidemiology of influenza is needed to inform influenza vaccination policy. Here we examined influenza virus circulation in countries in the Asia-Pacific region and compared the timing of seasonal epidemics with the timing of influenza vaccination.

Methods

Data were obtained from the World Health Organization (WHO) FluNet database for 2010–2017 for countries in the WHO Asia-Pacific region. Data from countries covering ≥5 consecutive seasons and ≥ 100 influenza positive cases per year were included. Median proportions of cases for each influenza virus type were calculated by country and season. The timing and amplitude of the epidemic peaks were determined by Fourier decomposition. Vaccination timing was considered appropriate for each country if it was recommended ≤4 months before the primary peak of influenza circulation.

Results

Seven hundred eleven thousand seven hundred thirty-four influenza cases were included from 19 countries. Peak circulation coincided with the winter seasons in most countries, although patterns were less clear in some countries in the inter-tropical area due to substantial secondary peaks. Influenza A/H3N2 dominated overall, but proportions of A and B strains varied by year and by country. Influenza B represented 31.4% of all cases. The WHO-recommended timing for influenza vaccination was appropriate in 12 countries. Vaccination timing recommendations were considered inappropriate in Laos, Cambodia, and Thailand, and were inconclusive for India, Sri Lanka, Singapore, and Vietnam due to unclear seasonality of influenza virus circulation.

Conclusions

Influenza virus circulation varied considerably across the Asia-Pacific region with an unusually high burden of influenza B. The recommended timing for vaccination was appropriate in most countries, except for several countries with unclear seasonality, mainly located in the inter-tropical area.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6647-y) contains supplementary material, which is available to authorized users.

Molecular epidemiology survey and characterization of human influenza A viruses circulating among Palestinians in East Jerusalem and the West Bank in 2015

Frequent typing and molecular characterization of influenza A (IAV) strains are crucial for the identification of circulating subtypes and for the selection of the subtypes’ lineages to be included in the annually prepared vaccine cocktail. We investigated IAV sampled from an underrepresented population from Palestine. 200 nasopharyngeal aspirates (NPA) were collected between February and May of 2015 from Palestinians in East Jerusalem and the West Bank suffering from mild to severe symptoms of upper respiratory infections. NPA were screened for the presence of IAV using RT-PCR. Epidemiological data, hemagglutinin (HA) and neuraminidase (NA) gene sequences were analyzed in IAV positive samples. 50 samples tested positive for IAV; 48% of which were identified as A(H1N1)pdm09 and 52% as A(H3N2), respectively. Infection with A(H1N1)pdm09 occurred mainly in April, while A(H3N2) infections were mainly detected in March. Most IAV infections in 6-year-olds and below were attributed to subtype A(H3N2), while A(H1N1)pdm09 was responsible for most infections in adults above 18-year-olds. Analyses of HA and NA amino acid sequences revealed numerous substitutions. Thereafter, and based on the HA analysis, the Palestinian A(H1N1)pdm09 isolates fell into clade 6B, while the A(H3N2) isolates fell into clades 3C.2 and 3C.3, respectively. This study is significant in providing the first insight into the epidemiology and genetic properties of IAV circulating in Palestine. In contrast to international reports for the same season, A(H3N2) was not the dominant subtype as in northern hemisphere, nor was A(H1N1)pdm09 as in WHO reports for the Middle East, however genetic properties of Palestinian A(H3N2) and A(H1N1)pdm09 were in line with global isolates.

Influenza vaccination situation in Middle-East and North Africa countries: Report of the 7th MENA Influenza Stakeholders Network (MENA-ISN)

Background

The Middle East and North Africa (MENA) region faces a dual challenge with regard to influenza infection due to severe zoonotic influenza outbreaks episodes and the circulation of Northern Hemisphere human influenza viruses among pilgrims.

Methods

The MENA Influenza Stakeholder Network (MENA-ISN) was set-up with the aim of increasing seasonal influenza vaccination coverage by (i) enhancing evidence-based exchanges, and (ii) increasing awareness on the safety and benefits of seasonal vaccination. During the 7th MENA-ISN meeting, representatives from 8 countries presented their influenza surveillance, vaccination coverage and actions achieved and provided a list of country objectives for the upcoming 3 years.

Results

MENA-ISN countries share the goal to reduce influenza related morbidity and mortality. Participants admitted that lack of knowledge about influenza, its consequences in terms of morbidity, mortality and economy are the major barrier to attaining higher influenza vaccination coverage in their countries. The cost of the vaccine is another key barrier that could contribute to low vaccination coverage. Participants drew a list of strategic interventions to bridge gaps in the knowledge of influenza burden in this region.

Conclusions

Participating countries concluded that despite an increase in vaccine uptake observed during the last few years, influenza vaccination coverage remains relatively low. Priority areas should be identified and action plans tailored to each country situation set-up to investigate the best way to move forward.

Epidemiology of seasonal influenza in the Middle East and North Africa regions, 2010-2016: Circulating influenza A and B viruses and spatial timing of epidemics

BACKGROUND

There is a limited knowledge regarding the epidemiology of influenza in Middle East and North Africa.

OBJECTIVES

We described the patterns of influenza circulation and the timing of seasonal epidemics in countries of Middle East and North Africa.

METHODS

We used virological surveillance data for 2010-2016 from the WHO FluNet database. In each country, we calculated the median proportion of cases that were caused by each virus type and subtype; determined the timing and amplitude of the primary and secondary peaks; and used linear regression models to test for spatial trends in the timing of epidemics.

RESULTS

We included 70 532 influenza cases from seventeen countries. Influenza A and B accounted for a median 76.5% and 23.5% of cases in a season and were the dominant type in 86.8% and 13.2% of seasons. The proportion of influenza A cases that were subtyped was 85.9%, while only 4.4% of influenza B cases were characterized. For most countries, influenza seasonality was similar to the Northern Hemisphere, with a single large peak between January and March; exceptions were the countries in the Arabian Peninsula and Jordan, all of which showed clear secondary peaks, and some countries had an earlier primary peak (in November-December in Bahrain and Qatar). The direction of the timing of influenza activity was east to west and south to north in 2012-2013 and 2015-2016, and west to east in 2014-2015.

CONCLUSIONS

The epidemiology of influenza is generally uniform in countries of Middle East and North Africa, with influenza B playing an important role in the seasonal disease burden.