Month-to-month all-cause mortality forecasting: a method allowing for changes in seasonal patterns

Forecasting of seasonal mortality patterns can provide useful information for planning health-care demand and capacity. Timely mortality forecasts are needed during severe winter spikes and/or pandemic waves to guide policy-making and public health decisions. In this article, we propose a flexible method for forecasting all-cause mortality in real time considering short-term changes in seasonal patterns within an epidemiologic year. All-cause mortality data have the advantage of being available with less delay than cause-specific mortality data. In this study, we use all-cause monthly death counts obtained from the national statistical offices of Denmark, France, Spain, and Sweden from epidemic seasons 2012-2013 through 2021-2022 to demonstrate the performance of the proposed approach. The method forecasts deaths 1 month ahead, based on their expected ratio to the next month. Prediction intervals are obtained via bootstrapping. The forecasts accurately predict the winter mortality peaks before the COVID-19 pandemic. Although the method predicts mortality less accurately during the first wave of the COVID-19 pandemic, it captures the aspects of later waves better than other traditional methods. The method is attractive for health researchers and governmental offices for aiding public health responses because it uses minimal input data, makes simple and intuitive assumptions, and provides accurate forecasts both during seasonal influenza epidemics and during novel virus pandemics.

Influenza: cause or excuse? An analysis of flu's influence on worsening mortality trends in England and Wales, 2010-19

BACKGROUND

England and Wales experienced a stagnation of previously improving life expectancy during the 2010s. Public bodies cited influenza as an important cause.

SOURCES OF DATA

We used data from the Office for National Statistics to examine mortality attributed directly to influenza and to all influenza-like diseases for the total population of England and Wales 2010-19. Several combinations of ICD-10 codes were used to address the possibility of under-counting influenza deaths.

AREAS OF AGREEMENT

Deaths from influenza and influenza-like diseases declined between 2010 and 2019, while earlier improvements in mortality from all causes of death were stalling and, with some causes, worsening. Our findings support existing research showing that influenza is not an important cause of the stalling of mortality rates 2010-19.

AREAS OF CONTROVERSY

Influenza was accepted by many as an important cause of stalling life expectancy for much of the 2010s, while few in public office have accepted austerity as a key factor in the changes seen during that time.

GROWING POINTS

This adds to the mounting evidence that austerity damaged health prior to COVID-19 and left the population more vulnerable when it arrived.

AREAS FOR DEVELOPING TIMELY RESEARCH

Future research should explore why so many in public office were quick to attribute the change in trends in overall mortality in the UK in this period to influenza, and why many continue to do so through to 2023 and to deny the key role of austerity in harming population health.

When experts disagree: interviews with public health experts on health outcomes in the UK 2010-2020

OBJECTIVES

To ascertain the views of public health experts on adverse trends in life expectancy across England and Wales over the past decade, causal factors, possible solutions, and their opinions about how the prepandemic situation influenced the UK's COVID-19 response.

STUDY DESIGN

Semistructured, in-depth interviews.

METHODS

Nineteen public health experts were identified by purposeful sampling and invited to take part via e-mail. Sixty-three percent responded and participated (n = 12), six females and six males. Interviews took place via Microsoft Teams between November 2021 and January 2022. Interviews were transcribed and analysed using thematic content analysis.

RESULTS

There was no consensus on the significance of the stalling and, at some ages, reversal of previous improvements in life expectancy between 2010 and 2020. Explanations offered included data misinterpretation, widening health inequalities, and disinvestment in public services, as well as some disease-specific causes. Those accepting that the decline was concerning linked it to social factors and suggested solutions based on increased investment and implementing existing evidence on how to reduce health inequalities. These interviewees also pointed to the same factors playing a role in the UK's poor COVID-19 response, highlighting the need to understand and address these underlying issues as part of pandemic preparedness.

CONCLUSIONS

There was no consensus among a group of influential public health experts in the UK on the scale, nature, and explanations of recent trends in life expectancy. A majority called for implementation of existing evidence on reducing inequalities, especially in the wake of COVID-19. However, without agreement on what the problem is, action is likely to remain elusive.

The long-term effect of the Great Recession on European mortality

Some European countries, such as Greece and Spain, were severely hit by the 2008 economic crisis whereas others, such as Germany, were practically spared by it. This divergence allowed us to implement a difference in differences research design which offered the possibility to observe the long-lasting effects produced by the crisis on European life expectancy. Our analysis—based on Eurostat data from 2001 to 2019—shows that life expectancy increased faster, after the onset of the crisis, in those countries where the rise in unemployment was more intense. Furthermore, our results show that this gain in life expectancy persisted, and sometimes further increased, until 2019 when most macro-economic variables had returned to their pre-crisis values. Previous research has identified that mortality behaves procyclically in developed countries: when the economy slows down mortality decreases and vice versa. Our findings show, by contrast, that life expectancy behaves asymmetrically: it responded to an increase but not to a decrease in unemployment. This calls for a reconsideration of the causal mechanisms linking together the economic cycle and mortality in developed countries.

Underestimation in Reporting Excess COVID-19 Death Data in Poland during the First Three Pandemic Waves

The issue whether official Polish COVID-19 death statistics correctly reflect the actual number of deaths is a contentious issue in public discourse and an important policy-wise question in Poland although it has not been the subject of thorough research so far. There had been clearly elevated excess mortality—5100 (death rate of 2.3 per 10,000) during the first wave, 77,500 (21.0 per 10,000) during the second one, and 48,900 (13.5 per 10,000) in the third. This study finds that during the second and the third pandemic wave, our data on excess mortality will match very well the somewhat belatedly officially reported COVID-19 deaths if we assume that only 60% of cases were officially detected. Based on principal component analysis of death timing, except for the age bracket below 40, where COVID-19 deaths calculated on the basis of our model explain 55% of excess mortality, for the remaining age groups, combined COVID-19 deaths explain 95% of excess mortality. Based on the share of excess mortality attributable to COVID-19 during the second wave, this infection in Poland caused the death of 73,300 people and not of 37,600 as officially reported. The third wave caused 46,200 deaths instead of the reported 34,700. The first wave was, indeed, as officially reported, very mild, and the number of excess deaths was too low to be used to calculate COVID-19 deaths directly. However, assuming that the detection rate remained comparable to the average in subsequent waves, we can set the number of deaths at 3500 instead of the reported 2100.

Decomposition of basic mortality indicators in Serbia 1990-2021

The research of thirty-year changes in the mortality of the population of Serbia (1990-2021) is given through two basic indicators of mortality. Using the decompose method to calculated the effect of population aging on the difference between crude mortality rates, as well as the contributions of specific mortality rates and leading causes of death in the changes in life expectancy. The crude death rate shows that the intensity of dying in Serbia is very high. The pandemic contributed to record values in the last two years. Overall, in the period 1990-2019, the negative contribution of the age structure is twice as intense as the positive effect of age-specific mortality rates. Aging is more intense in the female population, which explains the greater increase in the crude death rate in women. The data show that the importance of demographic aging has always been more pronounced. The main characteristic in the observed time interval is that mortality decreases at all ages and that all age groups had a positive effect on life expectancy, as well as that men and women in Serbia have a different pattern of decreasing mortality by age. The most significant effect on life expectancy was the reduction of infant mortality (a fifth of the total contribution), a common feature of the male and female populations. In other age groups, men have more pronounced contributions up to the age of 50, and women in older cohorts. Due to higher mortality rates, the space for improving mortality is greater in young and middle-aged men than in women, so the positive effects are more pronounced at these ages. The largest number of leading causes of death burdens the population of Serbia less now than three decades earlier. Cardiovascular diseases, as the leading cause of death, contributed the most to positive changes in mortality. The biggest effect of life expectancy is the reduction of mortality rates due to diseases of the circulatory system in the 65-79 year old population. Observed by gender, the effect is greater in the female population, where cardiovascular diseases contribute to the extension of life expectancy by as much as 67% or by 2.4 years, while in the male population the importance of cardiovascular diseases in the extension of life expectancy is lower and amounts to 42% or by 1.9 years. Tumors, as the second most common cause of death in Serbia, contribute negatively to those aged 50 and over and positively to younger age groups. The overall effect on life expectancy is positive, and mortality rates in men decline until the age of 60. In women, rates increase from age 50 or older, and of all causes of death, only tumors have an overall negative effect on life expectancy growth. Among the other causes, the importance of violent deaths and their positive effect should be singled out, due to the reduction of mortality rates at all ages, especially among the younger population. Positive changes in the age of 15-49 years in the male population contribute to an increase in life expectancy of even 1 year. In the female population, a positive contribution is also present at all ages, but the effect is significantly lower. The COVID-19 pandemic brought the highest increase in mortality in Serbia in the last 70 years. Mortality increased by 14% in the first year of the pandemic, and by 34% in the second, compared to the 2017-2019 average. The crude death rate has increased tremendously and for men in 2020 it is 18.0‰, and in 2021 it will show a maximum value of 21 deaths per 1,000 persons. For women, this mortality rate is 15.9‰ and 19.0‰ (in 2020 and 2021, respectively). Changes compared to the values from 2019, for both sexes, are solely the result of the increase in mortality by age, while changes in the distribution of the population by age had a negligible effect in this period. The last analyzed year (2021) brings a drop in life expectancy for men of as much as 3.4 years compared to the period before the pandemic. Women in Serbia have a slightly smaller decline in life expectancy in this period of 2.9 years.

Risk Factors Associated with 30-Day Mortality in Older Patients with Influenza

Background: Influenza is a common viral condition, but factors related to short-term mortality have not been fully studied in older adults. Our objective was to determine whether there is an association between geriatric factors and 30-day mortality. Methods: This was a retrospective cohort design. All patients aged 75 years and over, with a diagnosis of influenza confirmed by a positive RT-PCR, were included. The primary endpoint was death within the 30 days after diagnosis. Results: 114 patients were included; 14 (12.3%) patients died within 30 days. In multivariate analysis these patients were older (OR: 1.37 95% CI (1.05, 1.79), p = 0.021), and had a lower ADL score (OR: 0.36 95% CI (0, 17; 0.75), p = 0.006), and a higher SOFA score (OR: 2.30 95% CI (1.07, 4.94), p = 0.03). Oseltamivir treatment, initiated within the first 48 h, was independently associated with survival (OR: 0.04 95% CI (0.002, 0.78), p = 0.034). Conclusions: Identification of mortality risk factors makes it possible to consider specific secondary prevention measures such as the rapid introduction of antiviral treatment. Combined with primary prevention, these measures could help to limit the mortality associated with influenza in older patients.

Modelling of Temperature-Attributable Mortality among the Elderly in Lisbon Metropolitan Area, Portugal: A Contribution to Local Strategy for Effective Prevention Plans

Epidemiological studies on the impact of determining environmental factors on human health have proved that temperature extremes and variability constitute mortality risk factors. However, few studies focus specifically on susceptible individuals living in Portuguese urban areas. This study aimed to estimate and assess the health burden of temperature-attributable mortality among age groups (0-64 years; 65-74 years; 75-84 years; and 85+ years) in Lisbon Metropolitan Area, from 1986-2015. Non-linear and delayed exposure-lag-response relationships between temperature and mortality were fitted with a distributed lag non-linear model (DLNM). In general, the adverse effects of cold and hot temperatures on mortality were greater in the older age groups, presenting a higher risk during the winter season. We found that, for all ages, 10.7% (95% CI: 9.3-12.1%) deaths were attributed to cold temperatures in the winter, and mostly due to moderately cold temperatures, 7.0% (95% CI: 6.2-7.8%), against extremely cold temperatures, 1.4% (95% CI: 0.9-1.8%). When stratified by age, people aged 85+ years were more burdened by cold temperatures (13.8%, 95% CI: 11.5-16.0%). However, for all ages, 5.6% of deaths (95% CI: 2.7-8.4%) can be attributed to hot temperatures. It was observed that the proportion of deaths attributed to exposure to extreme heat is higher than moderate heat. As with cold temperatures, people aged 85+ years are the most vulnerable age group to heat, 8.4% (95% CI: 3.9%, 2.7%), and mostly due to extreme heat, 1.3% (95% CI: 0.8-1.8%). These results provide new evidence on the health burdens associated with alert thresholds, and they can be used in early warning systems and adaptation plans.

Seasonal Influenza Vaccine: Uptake, Attitude, and Knowledge Among Patients Receiving Immunoglobulin Replacement Therapy

Influenza is a potential cause of severe disease in the immunocompromised. Patients with hypogammaglobulinemia, in spite of adequate replacement therapy, are at risk of significant morbidity and adverse outcomes. A seasonal vaccine is the primary prophylactic countermeasure to limit disease. The aim of this study was to evaluate the attitude, knowledge, and influenza vaccine uptake among Irish patients receiving immunoglobulin replacement therapy (IgRT), as well as uptake in co-habitants. Fifty-seven percent of patients receiving IgRT at a regional immunology referral center completed a questionnaire evaluation. Seventy-six percent of IgRT patients received the influenza vaccine for the 2019 season. Ninety-eight percent recognized that influenza could be prevented with vaccination, and 81% deemed it a safe treatment. Ninety-three percent correctly identified that having a chronic medical condition, independent of age, was an indication for vaccination. Despite excellent compliance and knowledge, many were not aware that vaccination was recommended for co-habitants, and only 24% had full vaccine coverage at home. Those who received advice regarding vaccination of household members had higher rates of uptake at home. This study demonstrates awareness and adherence to seasonal influenza vaccine recommendations among patients receiving IgRT. Over three quarters felt adequately informed, the majority stating physicians as their information source. We identified an easily modifiable knowledge gap regarding vaccination of household members. This data reveals a need to emphasize the importance of vaccination for close contacts of at-risk patients, to maintain optimal immunity and health outcome.

Excess Deaths during Influenza and Coronavirus Disease and Infection-Fatality Rate for Severe Acute Respiratory Syndrome Coronavirus 2, the Netherlands

Since the 2009 influenza pandemic, the Netherlands has used a weekly death monitoring system to estimate deaths in excess of expectations. We present estimates of excess deaths during the ongoing coronavirus disease (COVID-19) epidemic and 10 previous influenza epidemics. Excess deaths per influenza epidemic averaged 4,000. The estimated 9,554 excess deaths (41% in excess) during the COVID-19 epidemic weeks 12–19 of 2020 appeared comparable to the 9,373 excess deaths (18%) during the severe influenza epidemic of 2017–18. However, these deaths occurred in a shorter time, had a higher peak, and were mitigated by nonpharmaceutical control measures. Excess deaths were 1.8-fold higher than reported laboratory-confirmed COVID-19 deaths (5,449). Based on excess deaths and preliminary results from seroepidemiologic studies, we estimated the infection-fatality rate to be 1%. Monitoring of excess deaths is crucial for timely estimates of disease burden for influenza and COVID-19. Our data complement laboratory-confirmed COVID-19 death reports and enable comparisons between epidemics.

Illness Severity in Hospitalized Influenza Patients by Virus Type and Subtype, Spain, 2010-2017

Influenza A(H1N1)pdm09 caused more hospitalizations, intensive care unit admissions, and deaths than influenza A(H3N2) or B.

We conducted a retrospective cohort study to assess the effect of influenza virus type and subtype on disease severity among hospitalized influenza patients in Spain. We analyzed the cases of 8,985 laboratory-confirmed case-patients hospitalized for severe influenza by using data from a national surveillance system for the period 2010–2017. Hospitalized patients with influenza A(H1N1)pdm09 virus were significantly younger, more frequently had class III obesity, and had a higher risk for pneumonia or acute respiratory distress syndrome than patients infected with influenza A(H3N2) or B (p<0.05). Hospitalized patients with influenza A(H1N1)pdm09 also had a higher risk for intensive care unit admission, death, or both than patients with influenza A(H3N2) or B, independent of other factors. Determining the patterns of influenza-associated severity and how they might differ by virus type and subtype can help guide planning and implementation of adequate control and preventive measures during influenza epidemics.

How have changes in death by cause and age group contributed to the recent stalling of life expectancy gains in Scotland? Comparative decomposition analysis of mortality data, 2000-2002 to 2015-2017

OBJECTIVE

Annual gains in life expectancy in Scotland were slower in recent years than in the previous two decades. This analysis investigates how deaths in different age groups and from different causes have contributed to annual average change in life expectancy across two time periods: 2000-2002 to 2012-2014 and 2012-2014 to 2015-2017.

SETTING

Scotland.

METHODS

Life expectancy at birth was calculated from death and population counts, disaggregated by 5 year age group and by underlying cause of death. Arriaga's method of life expectancy decomposition was applied to produce estimates of the contribution of different age groups and underlying causes to changes in life expectancy at birth for the two periods.

RESULTS

Annualised gains in life expectancy between 2012-2014 and 2015-2017 were markedly smaller than in the earlier period. Almost all age groups saw worsening mortality trends, which deteriorated for most cause of death groups between 2012-2014 and 2015-2017. In particular, the previously observed substantial life expectancy gains due to reductions in mortality from circulatory causes, which most benefited those aged 55-84 years, more than halved. Mortality rates for those aged 30-54 years and 90+ years worsened, due in large part to increases in drug-related deaths, and dementia and Alzheimer's disease, respectively.

CONCLUSION

Future research should seek to explain the changes in mortality trends for all age groups and causes. More investigation is required to establish to what extent shortcomings in the social security system and public services may be contributing to the adverse trends and preventing mitigation of the impact of other contributing factors, such as influenza outbreaks.

Evaluation of the French reactive mortality surveillance system supporting decision making

BACKGROUND

In France, a mortality syndromic surveillance system was set up with objectives of early detection and reactive evaluation of the impact of expected and unexpected events to support decision makers. This study aims to describe the characteristics of the system and its usefulness for decision makers.

METHODS

Anonymized data from the administrative part of death certificates were daily collected from 3062 computerized city halls and were transmitted to Santé publique France in routine. Coverage of the system was measured as the proportion of deaths registered by the system among the complete number of deaths and analyzed by age, month and region. Deaths were described by gender, age and geographical level using proportion. The excess periods of deaths were described based on the comparison of the weekly observed and expected numbers of deaths between 2012 and 2016.

RESULTS

The system recorded 77.5% of the national mortality covering the whole territory. About 81% of deaths were aged 65 years old and more. The surveillance system identified mortality variations mainly during winter and summer, for some concomitant with influenza epidemic or heatwave period, and thus provided information for decision makers.

CONCLUSION

The ability of the system to detect and follow mortality outbreaks in routine in the whole territory has been demonstrated. It is a useful tool to provide early evaluation of the impact of threats on mortality and alert decision makers to adapt control measures. However, the absence of information on medical causes of death may limit the ability to target recommendations.

Vaccination Coverage of the Elderly in Greece: A Cross-Sectional Nationwide Study

Vaccines are important for older adults, and the morbidity and mortality of vaccine-preventable diseases among older adults are high. There are limited data on vaccination coverage among elderly people in Greece. The aim of this observational study was to record the vaccination coverage for vaccines recommended by the National Vaccination Program in Greece for the elderly people ≥60 years old. Two hundred general practitioners (GPs) around the country from the primary healthcare system were invited to “participate,” and one hundred fifty from them participated in the present study. The GPs were selected using geographically stratified random sampling methodology. Two thousand and seventy-two participants participated in the present study: of which, 1043 were males and 1029 were females. The mean age of the participants was 73.3 years, and 83% vaccination coverage for flu vaccine, 49.5% for conjugate pneumococcal vaccine, and 23.5% for polysaccharide pneumococcal vaccine were recorded. In addition, the vaccination coverage for herpes zoster vaccine was 20%, while very low percentages were recorded for diphtheria, tetanus, pertussis, and polio vaccine for adults. We found significant gaps in vaccination coverage, especially with regard to pneumococcal, herpes zoster, and tetanus. On the contrary, influenza vaccination coverage was satisfactory.

Real-time estimation of the influenza-associated excess mortality in Hong Kong

Statistical models are commonly employed in the estimation of influenza-associated excess mortality that, due to various reasons, is often underestimated by laboratory-confirmed influenza deaths reported by healthcare facilities. However, methodology for timely and reliable estimation of that impact remains limited because of the delay in mortality data reporting. We explored real-time estimation of influenza-associated excess mortality by types/subtypes in each year between 2012 and 2018 in Hong Kong using linear regression models fitted to historical mortality and influenza surveillance data. We could predict that during the winter of 2017/2018, there were ~634 (95% confidence interval (CI): (190, 1033)) influenza-associated excess all-cause deaths in Hong Kong in population ⩾18 years, compared to 259 reported laboratory-confirmed deaths. We estimated that influenza was associated with substantial excess deaths in older adults, suggesting the implementation of control measures, such as administration of antivirals and vaccination, in that age group. The approach that we developed appears to provide robust real-time estimates of the impact of influenza circulation and complement surveillance data on laboratory-confirmed deaths. These results improve our understanding of the impact of influenza epidemics and provide a practical approach for a timely estimation of the mortality burden of influenza circulation during an ongoing epidemic.

Characteristics of hospitalizations with an influenza diagnosis, France, 2012-2013 to 2016-2017 influenza seasons

Background

Estimating the global burden of influenza hospitalizations is required to allocate resources and assess interventions that aim to prevent severe influenza. In France, the current routine influenza surveillance system does not fully measure the burden of severe influenza cases. The objective was to describe the characteristics and severity of influenza hospitalizations by age‐group and by season between 2012 and 2017.

Methods

All hospitalizations with a diagnosis of influenza in metropolitan France between July 2012 and June 2017 were extracted from the French national hospital discharge database (PMSI). For each season, the total number of influenza hospitalizations, admissions to intensive care units (ICU), proportion of deaths, lengths of stay, and distribution in diagnosis‐related groups were described by age‐group.

Results

Over the five seasons, 91 255 hospitalizations with a diagnosis of influenza were identified. The average influenza hospitalization rate varied from 13/100 000 in 2013‐2014 to 46/100 000 in 2016‐2017. A high rate was observed in elderlies during the 2014‐2015 and 2016‐2017 seasons, dominated by A(H3N2) virus. The youngest were impacted in 2015‐2016, dominated by B/Victoria virus. The proportion of influenza hospitalizations with ICU admission was 10%, and was higher in age‐group 40‐79 years. The proportion of deaths and length of stay increased with age.

Conclusions

The description of influenza hospitalizations recorded in the PMSI give key information on the burden of severe influenza in France. Analyses of these data annually is valuable in order to document the severity of influenza hospitalizations by age‐group and according to the circulating influenza viruses.

Recent adverse mortality trends in Scotland: comparison with other high-income countries

OBJECTIVE

Gains in life expectancy have faltered in several high-income countries in recent years. Scotland has consistently had a lower life expectancy than many other high-income countries over the past 70 years. We aim to compare life expectancy trends in Scotland to those seen internationally and to assess the timing and importance of any recent changes in mortality trends for Scotland.

SETTING

Austria, Croatia, Czech Republic, Denmark, England and Wales, Estonia, France, Germany, Hungary, Iceland, Israel, Japan, Korea, Latvia, Lithuania, Netherlands, Northern Ireland, Poland, Scotland, Slovakia, Spain, Sweden, Switzerland and USA.

METHODS

We used life expectancy data from the Human Mortality Database (HMD) to calculate the mean annual life expectancy change for 24 high-income countries over 5-year periods from 1992 to 2016. Linear regression was used to assess the association between life expectancy in 2011 and mean life expectancy change over the subsequent 5 years. One-break and two-break segmented regression models were used to test the timing of mortality rate changes in Scotland between 1990 and 2018.

RESULTS

Mean improvements in life expectancy in 2012-2016 were smallest among women (<2 weeks/year) in Northern Ireland, Iceland, England and Wales, and the USA and among men (<5 weeks/year) in Iceland, USA, England and Wales, and Scotland. Japan, Korea and countries of Eastern Europe had substantial gains in life expectancy over the same period. The best estimate of when mortality rates changed to a slower rate of improvement in Scotland was the year to 2012 quarter 4 for men and the year to 2014 quarter 2 for women.

CONCLUSIONS

Life expectancy improvement has stalled across many, but not all, high-income countries. The recent change in the mortality trend in Scotland occurred within the period 2012-2014. Further research is required to understand these trends, but governments must also take timely action on plausible contributors.

Cardiovascular mortality and risk behaviours by degree of urbanization before, during and after the economic crisis in Spain

BACKGROUND

To estimate the relationship of the degree of urbanization to cardiovascular mortality and to risk behaviours before, during and after the 2008 economic crisis in Spain.

METHODS

In three areas of residence - large urban areas, small urban areas and rural areas - we calculated the rate of premature mortality (0-74 years) from cardiovascular diseases before the crisis (2005-2007), during the crisis (2008-2010 and 2011-2013) and after the crisis (2014-2016), and the prevalence of risk behaviours in 2006, 2011 and 2016. In each period we estimated the mortality rate ratio (MRR) and the prevalence ratio, taking large urban areas as the reference.

RESULTS

In men, no significant differences were observed in mortality between the two urban areas, while the MRR in rural areas went from 0.92 [95% confidence interval, 0.90-0.94) in 2005-2007 to 0.94 (0.92-0.96) in 2014-2016. In women, no significant differences were observed in mortality between the rural and large urban areas, whereas the MRR in small urban areas decreased from 1.11 (1.08-1.14) in 2005-2007 to 1.06 (1.02-1.09) in 2014-2016. The rural areas had the lowest prevalence of smoking, obesity and physical inactivity in men, and of obesity in women. No significant differences were observed in smoking or physical inactivity by area of residence in women.

CONCLUSION

The pattern of cardiovascular mortality by degree of urbanization was similar before and after the crisis, although in women the excess mortality in small urban areas with respect to large urban areas was smaller after the crisis. The different pattern of risk behaviours in men and women, according to area of residence, could explain these findings.

Life Expectancy: Frequently Used, but Hardly Understood

Period life expectancy is one of the most used summary indicators for the overall health of a population. Its levels and trends direct health policies, and researchers try to identify the determining risk factors to assess and forecast future developments. The use of period life expectancy is often based on the assumption that it directly reflects the mortality conditions of a certain year. Accordingly, the explanation for changes in life expectancy are typically sought in factors that have an immediate impact on current mortality conditions. It is frequently overlooked, however, that this indicator can also be affected by at least three kinds of effects, in particular in the situation of short-term fluctuations: cohort effects, heterogeneity effects, and tempo effects. We demonstrate their possible impact with the example of the almost Europe-wide decrease in life expectancy in 2015, which caused a series of reports about an upsurge of a health crisis, and we show that the consideration of these effects can lead to different conclusions. Therefore, we want to raise an awareness concerning the sensitivity of life expectancy to sudden changes and the menaces a misled interpretation of this indicator can cause.

Mortality in Spain in the Context of the Economic Crisis and Austerity Policies

Objectives. To analyze the mortality trend in Spain before, during, and after the economic crisis and austerity policies. Methods. We calculated age-standardized annual mortality rates in 2001 through 2016 and estimated linear trends in mortality rates during 4 periods (2001-2007, 2008-2010, 2011-2013, and 2014-2016) using the annual percentage change (APC). Results. All-cause mortality rate decreased during the period 2001 to 2016, although we found increases over the previous year. After adjusting for increased influenza activity (P = .743) and heat waves (P = .473), we found the greatest declines during the economic crisis (2008-2010) and the smallest in the period 2014 to 2016, in which the APC in mortality rates was -2.9 and -0.6, respectively. The APC before the crisis (2001-2007) and during austerity (2011-2013) was -2.0 and -2.2, respectively. We observed similar results in mortality from cardiovascular, respiratory, and digestive diseases and motor vehicle accidents. Mortality from cancer showed the smallest decline during the crisis and the austerity period, whereas suicide increased in the period 2011 to 2013. Conclusions. Lifestyle changes could explain the decline in mortality during the economic crisis. Increased influenza activity and the 2015 heat wave may prevent identifying a possible delayed effect of austerity policies in the slowing down of mortality decline in the period 2014 to 2016.

Mortality in working-age population during the Great Recession and austerity in Spain

OBJECTIVE

To analyze the mortality trend in Spain before, during and after the economic crisis and austerity policies in the working-age population.

METHODS

From 2005 to 2016 we calculated the annual all-cause mortality rate and the annual mortality rate from the main causes of death in the population aged 15 to 64. We also estimated the linear trends in mortality rates during four time intervals-2005-2007 (before crisis), 2008-2010 (first part of the crisis), 2011-2013 (second part of the crisis and implementation of austerity policies) and 2014-2016 (after the crisis)- by the annual percentage change (APC).

RESULTS

The all-cause mortality rate in men and women showed the greatest decline in 2008-2010 and the smallest decline in 2014-2016. The decline in 2011-2013 was higher than in 2014-2016. The APCs in 2005-2007, 2008-2010, 2011-2013 and 2014-2016 were -2.8, -4.1, -3.0 and -1.5 in men and -1.0. -2.1, -1.1 and -0.6 in women, respectively, although the APC in 2014-2016 in women was not significant. In 2014-2016, cancer mortality showed the largest decrease, mortality from cardiovascular diseases (men), respiratory diseases and traffic accidents reversed and showed an upward trend, and the downward trend in mortality from infectious diseases and digestive diseases was equal to or greater than that observed before the crisis.

CONCLUSION

The decline in all-cause mortality in the working-age population during the economic crisis and the introduction of austerity measures was greater than that observed before and after the economic crisis. The slowing of the decline after the crisis was due to the reversal of the trend in mortality from cardiovascular and respiratory diseases.

Immunosenescence: A systems-level overview of immune cell biology and strategies for improving vaccine responses

Immunosenescence contributes to a decreased capacity of the immune system to respond effectively to infections or vaccines in the elderly. The full extent of the biological changes that lead to immunosenescence are unknown, but numerous cell types involved in innate and adaptive immunity exhibit altered phenotypes and function as a result of aging. These manifestations of immunosenescence at the cellular level are mediated by dysregulation at the genetic level, and changes throughout the immune system are, in turn, propagated by numerous cellular interactions. Environmental factors, such as nutrition, also exert significant influence on the immune system during aging. While the mechanisms that govern the onset of immunosenescence are complex, systems biology approaches allow for the identification of individual contributions from each component within the system as a whole. Although there is still much to learn regarding immunosenescence, systems-level studies of vaccine responses have been highly informative and will guide the development of new vaccine candidates, novel adjuvant formulations, and immunotherapeutic drugs to improve vaccine responses among the aging population.

The increase of sepsis-related mortality in Italy: a nationwide study, 2003-2015

The true burden of sepsis is largely unknown. Conventional underlying cause of death (UCoD) statistics largely underestimates sepsis-related mortality. This study aims to analyze all the conditions mentioned in the death certificates (multiple causes of death-MCoD) to estimate the nationwide burden of sepsis-related mortality in Italy, to investigate time trends and main comorbidities in sepsis-related deaths. All death certificates mentioning sepsis from 2003 to 2015 were analyzed. Age-standardized mortality rates were calculated for sepsis as both UCoD and MCoD, by gender and broad age groups. The ratio of the age-standardized proportions of any mention of sepsis in the presence/absence of associated chronic diseases (ASPR) was computed. The number of certificates reporting sepsis increased from 18,939 in 2003 to 49,010 in 2015 (from 3 to 8% of all deaths). The increase in sepsis mortality rates was larger for UCoD (males, + 200%; females, + 175%) than for MCoD-based figures (+ 100%; + 90%); MCoD rates remained noticeably higher than UCoD rates (2015, 87.3 per 100,000 vs. 16.3 for males; 54.9 vs. 11.8 for females). The largest increase was observed among the very elderly. The association between sepsis and chronic diseases was stronger for subjects aged less than 75 years. The increased awareness within the medical community in addition to the growing susceptible elderly population and the spread of antimicrobial resistance could have contributed to the sepsis-related mortality increase. MCoD statistics could help in recognizing sepsis not only as a clinical challenge, but also as a major public health issue.

Seasonal influenza: Knowledge, attitude and vaccine uptake among adults with chronic conditions in Italy

This cross-sectional study aimed at evaluating the knowledge and attitudes concerning influenza vaccination in Southern Italy, and investigating the potential determinants of vaccine uptake. The sample consisted of 700 adults (mean age 58.7y) with chronic diseases attending four public specialty clinics in Italy. Overall, 64.7% of the participants were aware that influenza can be prevented with vaccines and that patients with chronic diseases are at higher risk of developing severe complications. Less than half of the sample (42.1%) received influenza vaccine in the last season, and 46.9% declared the will to receive influenza vaccination in the next season. The level of awareness was significantly lower among the elderly (> = 65y) and those with a higher self-reported health. A significantly higher likelihood of vaccination was observed among the elderly, the subjects with a higher knowledge about vaccine utility and safety, the participants with chronic respiratory diseases, and those who had taken more drugs. Future education programs and communication strategies are strongly needed in adults with chronic diseases to improve influenza vaccination knowledge and uptake.

Socioeconomic disparities in life expectancy gains among retired German men, 1997-2016

Background

Although estimates of socioeconomic mortality disparities in Germany exist, the trends in these disparities since the 1990s are still unknown. This study examines mortality trends across socioeconomic groups since the late 1990s among retired German men aged 65 and above.

Methods

Large administrative data sets were used to estimate mortality among retired German men, grouped according to their working-life biographies. The data covered the years 1997–2016 and included more than 84.1 million person-years and 4.3 million deaths. Individual pension entitlements served as a measure of lifetime income. Changes in total life expectancy at age 65 over time were decomposed into effects of group-specific mortality improvements and effects of compositional change.

Results

Over the two decades studied, male mortality declined in all income groups in both German regions. As mortality improved more rapidly among higher status groups, the social gradient in mortality widened. Since 1997, the distribution of pension entitlements of retired East German men has shifted substantially downwards. As a result, the impact of the most disadvantaged group on total mortality has increased and has partly attenuated the overall improvement.

Conclusion

Our results demonstrate that socioeconomic deprivation has substantial effects on levels of mortality in postreunification Germany. While East German retirees initially profited from the transition to the West German pension system, subsequent cohorts had to face challenges associated with the transition to the market economy. The results suggest that postreunification unemployment and status decline had delayed effects on old-age mortality in East Germany.

Active surveillance for safety monitoring of seasonal influenza vaccines in Italy, 2015/2016 season

BACKGROUND

Surveillance for adverse events following immunization is an important component of any national immunization programme because it is critical to assessing the safety of vaccines and to detecting potentially rare and severe adverse events and responding in a timely manner. We conducted an enhanced active surveillance aimed at assessing the safety of flu vaccines in the 2015-2016 season in Italy. The study was targeted to the population groups for which the seasonal vaccine is recommended in Italy.

METHODS

During the study period, a total of 3213 individuals receiving seasonal influenza vaccination were registered on the web-based platform. Any adverse events experienced after 7 days from vaccination by individuals aged six months or more were collected through a telephone interview or by a web-based self-administered questionnaire. All individuals experiencing at least one event during the 7 days of follow-up were contacted for follow-up to 60 days.

RESULTS

Overall, 854 events were reported: 845 events (26%) after administration of the first dose and 9 (12%) after the second dose. The majority of adverse events reported after 7 days from the first dose were of little clinical importance, and most involved local symptoms.

CONCLUSION

Our data, even though the number of vaccinated individuals was smaller than expected, is consistent with the safety of influenza vaccines in Italy during the 2015-2016 season regarding the most common adverse events. Further efforts are needed to obtain sufficient power to study rarer adverse events. Active monitoring and systematic studies to test generated signals and hypotheses are crucial to intensify awareness among the public and professionals with regard to the safety of vaccines.

The incidence of symptomatic infection with influenza virus in the Netherlands 2011/2012 through 2016/2017, estimated using Bayesian evidence synthesis

Due to differences in the circulation of influenza viruses, distribution and antigenic drift of A subtypes and B lineages, and susceptibility to infection in the population, the incidence of symptomatic influenza infection can vary widely between seasons and age-groups. Our goal was to estimate the symptomatic infection incidence in the Netherlands for the six seasons 2011/2012 through 2016/2017, using Bayesian evidence synthesis methodology to combine season-specific sentinel surveillance data on influenza-like illness (ILI), virus detections in sampled ILI cases and data on healthcare-seeking behaviour. Estimated age-aggregated incidence was 6.5 per 1000 persons (95% uncertainty interval (UI): 4.7–9.0) for season 2011/2012, 36.7 (95% UI: 31.2–42.8) for 2012/2013, 9.1 (95% UI: 6.3–12.9) for 2013/2014, 41.1 (95% UI: 35.0–47.7) for 2014/2015, 39.4 (95% UI: 33.4–46.1) for 2015/2016 and 27.8 (95% UI: 22.7–33.7) for season 2016/2017. Incidence varied substantially between age-groups (highest for the age-group <5 years: 23 to 47/1000, but relatively low for 65+ years: 2 to 34/1000 over the six seasons). Integration of all relevant data sources within an evidence synthesis framework has allowed the estimation – with appropriately quantified uncertainty – of the incidence of symptomatic influenza virus infection. These estimates provide valuable insight into the variation in influenza epidemics across seasons, by virus subtype and lineage, and between age-groups.

Comparison of the Cepheid Xpert Xpress Flu/RSV Assay to in-house Flu/RSV triplex real-time RT-PCR for rapid molecular detection of Influenza A, Influenza B and Respiratory Syncytial Virus in respiratory specimens

This study compared the performance of the commercially available Xpert Xpress Flu/RSV assay to an in-house FluAB/RSV triplex real-time RT-PCR assay for the detection of influenza A/B viruses and respiratory syncitial virus (RSV) from both nasopharyngeal aspirate (NPA) and nasopharyngeal flocked swab (NPS). A total of 20 external quality assurance (EQA) samples and 172 clinical respiratory samples were tested prospectively using both the Xpert Xpress Flu/RSV assay and the in-house FluAB/RSV triplex assay. For the EQA samples, concordance rate was 100 % when tested with both assays. For clinical samples, there was 100 % agreement between the two assays for detection of influenza A and influenza B, 96.7 % agreement for detection of RSV and 99.7 % agreement for negative results. With a shortened turnaround time and good diagnostic performance, application of the Xpert Xpress Flu/RSV assay can facilitate patient triage for prompt implementation of infection control measures and management of high-risk patients during influenza epidemics.

The inter-annual variability of heat-related mortality in nine European cities (1990-2010)

BACKGROUND

The association between heat and daily mortality and its temporal variation are well known. However, few studies have analyzed the inter-annual variations in both the risk estimates and impacts of heat. The aim is to estimate inter-annual variations in the effect of heat for a fixed temperature range, on mortality in 9 European cities included in the PHASE (Public Health Adaptation Strategies to Extreme weather events) project for the period 1990-2010. The second aim is to evaluate overall summer effects and heat-attributable deaths for each year included in the study period, considering the entire air temperature range (both mild and extreme temperatures).

METHODS

A city-specific daily time-series analysis was performed, using a generalized additive Poisson regression model, restricted to the warm season (April-September). To study the temporal variation for a fixed air temperature range, a Bayesian Change Point analysis was applied to the relative risks of mortality for a 2 °C increase over the 90th percentile of the city-specific distribution. The number of heat attributable deaths in each summer were also calculated for mild (reference to 95th percentile) and extreme heat (95th percentile to maximum value).

RESULTS

A decline in the effects of heat over time was observed in Athens and Rome when considering a fixed interval, while an increase in effects was observed in Helsinki. The greatest impact of heat in terms of attributable deaths was observed in the Mediterranean cities (Athens, Barcelona and Rome) for extreme air temperatures. In the other cities the impact was mostly related to extreme years with 2003 as a record breaking year in Paris (+ 1900 deaths) and London (+ 1200 deaths).

CONCLUSIONS

Monitoring the impact of heat over time is important to identify changes in population vulnerability and evaluate adaptation measures.

Trends and inequalities in the burden of mortality in Scotland 2000-2015

BACKGROUND

Cause-specific mortality trends are routinely reported for Scotland. However, ill-defined deaths are not routinely redistributed to more precise and internationally comparable categories nor is the mortality reported in terms of years of life lost to facilitate the calculation of the burden of disease. This study describes trends in Years of Life Lost (YLL) for specific causes of death in Scotland from 2000 to 2015.

METHODS

We obtained records of all deaths in Scotland by age, sex, area and underlying cause of death between 2000 and 2015. We redistributed Ill-Defined Deaths (IDDs) to more exact and meaningful causes using internationally accepted methods. Years of Life Lost (YLL) using remaining life expectancy by sex and single year of age from the 2013 Scottish life table were calculated for each death. These data were then used to calculate the crude and age-standardised trends in YLL by age, sex, cause, health board area, and area deprivation decile.

RESULTS

Between 2000 and 2015, the annual percentage of deaths that were ill-defined varied between 10% and 12%. The proportion of deaths that were IDDs increased over time and were more common: in women; amongst those aged 1-4 years, 25-34 years and >80 years; in more deprived areas; and in the island health boards. The total YLL fell from around 17,800 years per 100,000 population in 2000 to around 13,500 years by 2015. The largest individual contributors to YLL were Ischaemic Heart Disease (IHD), respiratory cancers, Chronic Obstructive Pulmonary Disease (COPD), cerebrovascular disease and Alzheimer's/dementia. The proportion of total YLL due to IHD and stroke declined over time, but increased for Alzheimer's/dementia and drug use disorders. There were marked absolute inequalities in YLL by area deprivation, with a mean Slope Index of Inequality (SII) for all causes of 15,344 YLL between 2001 and 2015, with IHD and COPD the greatest contributors. The Relative Index of Inequality (RII) for YLL was highest for self-harm and lower respiratory infections.

CONCLUSION

The total YLL per 100,000 population in Scotland has declined over time. The YLL in Scotland is predominantly due to a wide range of chronic diseases, substance misuse, self-harm and increasingly Alzheimer's disease and dementia. Inequalities in YLL, in both relative and absolute terms, are stark.

Significant spike in excess mortality in England in winter 2014/15 - influenza the likely culprit

Significant increases in excess all-cause mortality, particularly in the elderly, were observed during the winter of 2014/15 in England. With influenza A(H3N2) the dominant circulating influenza A subtype, this paper determines the contribution of influenza to this excess controlling for weather. A standardised multivariable Poisson regression model was employed with weekly all-cause deaths the dependent variable for the period 2008-2015. Adjusting for extreme temperature, a total of 26 542 (95% CI 25 301-27 804) deaths in 65+ and 1942 (95% CI 1834-2052) in 15-64-year-olds were associated with influenza from week 40, 2014 to week 20, 2015. This is compatible with the circulation of influenza A(H3N2). It is the largest estimated number of influenza-related deaths in England since prior to 2008/09. The findings highlight the potential health impact of influenza and the important role of the annual influenza vaccination programme that is required to protect the population including the elderly, who are vulnerable to a severe outcome.

Influenza-associated mortality determined from all-cause mortality, Denmark 2010/11-2016/17: The FluMOMO model

Background

In temperate zones, all‐cause mortality exhibits a marked seasonality, and influenza represents a major cause of winter excess mortality. We present a statistical model, FluMOMO, which estimate influenza‐associated mortality from all‐cause mortality data and apply it to Danish data from 2010/11 to 2016/17.

Methods

We applied a multivariable time series model with all‐cause mortality as outcome, influenza activity and extreme temperatures as explanatory variables while adjusting for time trend and seasonality. Three indicators of weekly influenza activity (IA) were explored: percentage of consultations for influenza‐like illness (ILI) at primary health care, national percentage of influenza‐positive samples, and the product of ILI percentage and percentage of influenza‐positive specimens in a given week, that is, the Goldstein index.

Results

Independent of the choice of parameter to represent influenza activity, the estimated influenza‐associated mortality showed similar patterns with the Goldstein index being the most conservative. Over the 7 winter seasons, the median influenza‐associated mortality per 100 000 population was 17.6 (range: 0.0‐36.8), 14.1 (0.3‐31.6) and 8.3 (0.0‐25.0) for the 3 indicators, respectively, for all ages.

Conclusion

The FluMOMO model fitted the Danish data well and has the potential to estimate all‐cause influenza‐associated mortality in near real time and could be used as a standardised method in other countries. We recommend using the Goldstein index as the influenza activity indicator in the FluMOMO model. Further work is needed to improve the interpretation of the estimated effects.

Clinicians' attitude towards a placebo-controlled randomised clinical trial investigating the effect of neuraminidase inhibitors in adults hospitalised with influenza

Background

The value of neuraminidase inhibitors (NAIs) in reducing severe clinical outcomes from influenza is debated. A clinical trial to generate better evidence is desirable. However, it is unknown whether UK clinicians would support a placebo-controlled trial. A survey was conducted to determine the attitude of clinicians towards a clinical trial and their current practice in managing adults admitted to hospital with suspected influenza.

Methods

Senior clinicians (n = 50) across the UK actively involved in the care of patients hospitalised with severe respiratory infections and/or respiratory infection research were invited to participate in an on-line survey. Participants were asked their opinion on the evidence for benefit of NAIs in influenza, their current practice in relation to: a) testing for influenza; b) treating empirically with NAIs; and c) when influenza infection is virolologically confirmed, prescribing NAIs.

Results

Thirty-five (70%) of 50 clinicians completed the survey. Respondents were drawn mainly from infectious diseases, intensive care and respiratory medicine. Only 11 (31%) of 35 respondents agreed that NAIs are effective at reducing influenza mortality; 14 (40%) disagreed, 10 (28.6%) neither agreed nor disagreed. When managing adults admitted to non-ICU wards with a respiratory infection during an influenza season, 15 (51.7%) clinicians indicated they would usually perform a test for influenza in greater than 60% of patients but only 9 (31%) would treat empirically with NAIs in greater than 60% of patients. Few clinicians would either test or empirically treat patients presenting with other (non-respiratory infection related) diagnoses. If influenza infection is confirmed, 17 (64.5%) clinicians would prescribe NAIs in greater than 80% of patients with a respiratory infection treated on non-ICU wards Thirty-one (89%) clinicians agreed that a placebo-controlled clinical trial should be conducted and 29 (85%) would participate in such a trial.

Conclusions

There is strong support from UK clinicians for a placebo-controlled trial of NAI treatment in adults hospitalised with suspected influenza. Current variation in medical opinion and clinical practice demonstrates collective equipoise, supporting ethical justification for a trial. Low use of NAIs in the UK suggests randomisation of treatment would not substantially divert patients towards placebo.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3122-x) contains supplementary material, which is available to authorized users.

Seasonal Influenza Vaccination in Health Care Workers. A Pre-Post Intervention Study in an Italian Paediatric Hospital

Despite relevant recommendations and evidences on the efficacy of influenza vaccination in health care workers (HCWs), vaccination coverage rates in Europe and Italy currently do not exceed 25%. Aim of the study is to measure the variations in vaccination coverage rates in an Italian pediatric hospital after a promotion campaign performed in the period October⁻December 2017. The design is a pre-post intervention study. The intervention is based on a wide communication campaign and an expanded offer of easy vaccination on site. The study was carried out at Bambino Gesù Children’s hospital in Rome, Italy, on the whole population of HCWs. Univariate and multivariate statistical analyses were performed. Vaccination coverage rate increased in 2017/18 campaign compared with the 2016/17 one (+95 HCWs vaccinated; +4.4%). The highest increases were detected in males (+45.7%), youngest employees (+142.9%), mean age of employment (+175%), other HCWs (+209.1%), Emergency Area (+151.6%) and Imaging Diagnostic Department (+200.0%). At multivariate logistic regression, working in some departments and being nurses represents a higher risk of being unvaccinated. Although the vaccination coverage rate remained low, a continuous increase of the coverage rate and development of a different consciousness in HCWs was highlighted. The study significantly identified the target for future campaigns.

Trends of influenza B during the 2010-2016 seasons in 2 regions of north and south Italy: The impact of the vaccine mismatch on influenza immunisation strategy

Influenza A and B viruses are responsible for respiratory infections, representing globally seasonal threats to human health. The 2 viral types often co-circulate and influenza B plays an important role in the spread of infection. A 6-year retrospective surveillance study was conducted between 2010 and 2016 in 2 large administrative regions of Italy, located in the north (Liguria) and in the south (Sicily) of the country, to describe the burden and epidemiology of both B/Victoria and B/Yamagata lineages in different healthcare settings. Influenza B viruses were detected in 5 of 6 seasonal outbreaks, exceeding influenza A during the season 2012-2013. Most of influenza B infections were found in children aged ≤ 14 y and significant differences were observed in the age-groups infected by the different lineages. B/Victoria strains prevailed in younger population than B/Yamagata, but also were more frequently found in the community setting. Conversely, B/Yamagata viruses were prevalent among hospitalized cases suggesting their potential role in the development of more severe disease. The relative proportions of viral lineages varied from year to year, resulting in different lineage-level mismatch for the B component of trivalent influenza vaccine. Our findings confirmed the need for continuous virological surveillance of seasonal epidemics and bring attention to the adoption of universal influenza immunization program in the childhood. The use of tetravalent vaccine formulations may be useful to improve the prevention and control of the influenza burden in general population.

Impact of a multicomponent hand hygiene-related intervention on the infectious risk in nursing homes: A cluster randomized trial

BACKGROUND

The aim of this study was to assess the impact of a multifaceted hand hygiene (HH) program on the infectious risk in nursing homes (NHs).

METHODS

This was a 2-arm cluster randomized trial; French NHs were allocated randomly to the intervention (13 NHs) or control (13 NHs) groups. The intervention consisted of implementing a bundle of HH-related measures over 1 year, including increased availability of alcohol-based handrub, HH promotion, staff education, and local work groups. The primary end point was the incidence rate of acute respiratory infections and gastroenteritis reported in the context of clustered cases episodes. Secondary end points were mortality, hospitalization, and antibiotic prescription rates.

RESULTS

Baseline characteristics did not differ between groups. The overall handrub consumption was higher in the intervention group over the 1-year intervention period. Because of underreporting, data on the primary end points were of insufficient quality for analysis. Hospitalizations did not differ between the 2 groups. However, the intervention group showed significantly lower mortality (2.10 vs 2.65 per 100 residents per month, respectively; P = .003) and antibiotic prescriptions (5.0 vs 5.8 defined daily doses per 100 resident days, respectively; P < .001). These results were confirmed by the longitudinal multivariate analysis adjusted for NH and resident characteristics and for seasonality (mortality rate ratio, 0.76).

CONCLUSIONS

A multifaceted HH intervention may have a short-term impact on mortality in NHs. Nevertheless, other strategies may remain necessary to reduce morbidity.

Strategies in recommending influenza vaccination in Europe and US

There is potential for influenza vaccine programmes to make a substantial impact on the disease burden. The World Health Organization (WHO) has identified young children, pregnant women, persons with chronic medical conditions, and the elderly as being at risk for severe influenza disease and therefore important groups to be considered for influenza vaccination. Applying the methodology of scoping review of grey and scientific literature we described the European and the US approach to influenza vaccine prevention. Although vaccination remains the most effective means of reducing the incidence and severity of influenza, vaccine uptake in many European countries remains suboptimal (i.e. 45.5% in the elderly, 24% in health care workers, from 49.8% in patients with chronic medical conditions, median 23.6% in pregnant women) and vaccine strategies are not harmonized in particular with regard to vaccinating healthy children. Whereas in the US the vaccine strategies are more standardized across states and vaccine coverage are higher than those reported in EU on average. The integration of different strategies is crucial in order to increase influenza vaccine coverage: public health authorities should encourage healthcare workers to vaccinate themselves, as target category, and to recommend seasonal influenza vaccination to people in the target groups; there should also be structured communication campaigns on influenza and influenza vaccines, directed specifically at these target groups, and an adequate and sustainable funding is also an important factor to achieve higher vaccination coverage rates.

How close are countries of the WHO European Region to achieving the goal of vaccinating 75% of key risk groups against influenza? Results from national surveys on seasonal influenza vaccination programmes, 2008/2009 to 2014/2015

Background

Influenza vaccination is recommended especially for persons at risk of complications. In 2003, the World Health Assembly urged Member States (MS) to increase vaccination coverage to 75% among older persons by 2010.

Objective

To assess progress towards the 2010 vaccination goal and describe seasonal influenza vaccination recommendations in the World Health Organization (WHO) European Region.

Methods

Data on seasonal influenza vaccine recommendations, dose distribution, and target group coverage were obtained from two sources: European Union and European Economic Area MS data were extracted from influenza vaccination surveys covering seven seasons (2008/2009–2014/2015) published by the Vaccine European New Integrated Collaboration Effort and European Centre for Disease Prevention and Control. For the remaining WHO European MS, a separate survey on policies and uptake for all seasons (2008/2009–2014/2015) was distributed to national immunization programmes in 2015.

Results

Data was available from 49 of 53 MS. All but two had a national influenza vaccination policy. High-income countries distributed considerably higher number of vaccines per capita (median; 139.2 per 1000 population) compared to lower-middle-income countries (median; 6.1 per 1000 population). Most countries recommended vaccination for older persons, individuals with chronic disease, healthcare workers, and pregnant women. Children were included in < 50% of national policies. Only one country reached 75% coverage in older persons (2014/2015), while a number of countries reported declining vaccination uptake. Coverage of target groups was overall low, but with large variations between countries. Vaccination coverage was not monitored for several groups.

Conclusions

Despite policy recommendations, influenza vaccination uptake remains suboptimal. Low levels of vaccination is not only a missed opportunity for preventing influenza in vulnerable groups, but could negatively affect pandemic preparedness. Improved understanding of barriers to influenza vaccination is needed to increase uptake and reverse negative trends. Furthermore, implementation of vaccination coverage monitoring is critical for assessing performance and impact of the programmes.

Epidemiology of Respiratory Pathogens among Elderly Nursing Home Residents with Acute Respiratory Infections in Corsica, France, 2013-2017

Background

The current study aims to describe the demographical and clinical characteristics of elderly nursing home (NH) residents with acute respiratory infections (ARIs) during four winter seasons (2013/2014–2016/2017), as well as the microbiological etiology of these infections.

Methods

Seventeen NHs with at least one ARI resident in Corsica, France, were included. An ARI resident was defined as a resident developing a sudden onset of any constitutional symptoms in addition to any respiratory signs. Nasopharyngeal swabs from ARI residents were screened for the presence of 21 respiratory agents, including seasonal influenza viruses.

Results

Of the 107 ARI residents enrolled from NHs, 61 (57%) were positive for at least one of the 21 respiratory pathogens. Forty-one (38.3%) of the 107 ARI residents had influenza: 38 (92%) were positive for influenza A (100% A(H3N2)) and three (8%) for influenza B/Victoria. Axillary fever (≥38°C) was significantly more common among patients infected with influenza A(H3N2).

Conclusion

The circulation of seasonal respiratory viruses other than influenza A(H3N2) seems to be sporadic among elderly NH residents. Investigating the circulation of respiratory viruses in nonwinter seasons seems to be important in order to understand better the dynamic of their year-round circulation in NHs.

Excess mortality in 2015: a time series and cause-of-death analysis in Northern Italy

AIMS

To investigate the excess mortality registered in the Veneto Region (Northern Italy) in 2015.

METHODS

A Seasonal Autoregressive Integrated Moving Average Model was applied to predict overall mortality expected in 2014-2015 based on that observed in 2000-2013. The annual percent change in age-standardized rates (APC) was estimated for specific causes of death in 2007-2015.

RESULTS

Compared to 2014, the number of deaths and the overall age-standardized mortality increased in 2015 by 7.8 and 4.5%, respectively. When accounting for time trends, the observed mortality was lower than expected in 2014 (-4.5%) and slightly higher in 2015 (+1.1%). In 2015, mortality increased especially for causes with an already rising trend: neurologic/psychiatric (APC = 1.2; 95% Confidence Interval 0.3-2.0%) and infectious diseases (APC = 5.9; 3.6-8.2%).

CONCLUSIONS

Short-term changes and long-term trends in mortality must be interpreted within the frame of a rapid growth in the population of elderly subjects affected by multiple comorbidities.

Excess mortality in Italy: Should we care about low influenza vaccine uptake?

AIMS

The aims of this study were to explore 2015 mortality data further and to assess excess deaths' determinants.

METHODS

We analysed data from a large metropolitan area in the north of Italy, the city of Bologna. We took advantage of a comprehensive local-level database and merged three different data sources to analitically explore reported 2014-2015 excess mortality and its determinants. Effect estimates were derived from multivariable Poisson regression analysis, according to vaccination status and frailty index.

RESULTS

We report 9.8% excess mortality in 2015 compared to 2014, with seasonal and age distribution patterns in line with national figures. All-cause mortality in the elderly population is 36% higher (risk ratio [RR]=1.36, 95% confidence interval [CI] 1.27-1.45) in subjects not vaccinated against seasonal flu compared to vaccinated subjects, with risk of death for influenza or pneumonia being 43% higher (RR=1.43, 95% CI 1.02-2.00) in unvaccinated subjects.

CONCLUSIONS

Reported excess mortality's determinants in Italy should be further explored. Elderly subjects not vaccinated against the flu appear to have increased risk of all-cause and cause-specific mortality compared to vaccinated subjects after accounting for possible confounders. Our findings raise awareness of the need to promote immunisation against the flu among elder populations and offer insights to plan and implement effective public-health interventions.

Excess all-cause and influenza-attributable mortality in Europe, December 2016 to February 2017

Since December 2016, excess all-cause mortality was observed in many European countries, especially among people aged ≥ 65 years. We estimated all-cause and influenza-attributable mortality in 19 European countries/regions. Excess mortality was primarily explained by circulation of influenza virus A(H3N2). Cold weather snaps contributed in some countries. The pattern was similar to the last major influenza A(H3N2) season in 2014/15 in Europe, although starting earlier in line with the early influenza season start.

Implementation of Alere i Influenza A & B point of care test for the diagnosis of influenza in an ED

STUDY OBJECTIVE

This study aimed to evaluate the impact of implementing rapid point-of-care testing (POCT) with the Alere i Influenza A & B in an emergency department (ED) during an influenza epidemic.

METHODS

Direct nasal swabs were prospectively collected following the physical examination of patients aged >18years who presented to the ED of a tertiary hospital in France with influenza-like illness (ILI) symptoms (N=301) between February 1st and March 31st, 2016, which coincided with an influenza epidemic. Laboratory-based testing (standard of care) was used to obtain a diagnosis in February 2016 (pre-POCT cohort) and positive results were confirmed using polymerase chain reaction. The primary endpoint was patient time in the ED.

RESULTS

A total of 169 and 132 patients participated in the pre-POCT phase and POCT phase respectively. A significantly higher proportion of patients received a positive diagnosis in the POCT cohort compared with the pre-POCT cohort (31% versus 5.3%, P<0.01). Mean time spent in the ED and hospitalization rate were significantly lower in the POCT cohort (6.06h versus 4.15h, P=0.03, and 44.4% versus 9.7%, P=0.02, respectively). Despite similar rates in the prescription of antibiotics and antiviral therapies, the proportion of patients who were referred for additional tests was significantly lower in the POCT cohort (78.1% versus 62.1%, P=0.003, and 80.5% versus 63.6%, P=0.01, respectively).

CONCLUSIONS

The Alere i Influenza A & B POCT reduced the length of stay in ED, the hospitalization rates, and the number of additional diagnostic tests compared with standard of care testing.