Unequal excess mortality during the Spanish Flu pandemic in the Netherlands

A century after the Spanish Flu, the COVID-19 pandemic has brought renewed attention to socioeconomic and occupational differences in mortality in the earlier pandemic. The magnitude of these differences and the pathways between occupation and increased mortality remain unclear, however. In this paper, we explore the relation between occupational characteristics and excess mortality among men during the Spanish Flu pandemic in the Netherlands. By creating a new occupational coding for exposure to disease at work, we separate social status and occupational conditions for viral transmission. We use a new data set based on men’s death certificates to calculate excess mortality rates by region, age group, and occupational group. Using OLS regression models, we estimate whether social position, regular interaction in the workplace, and working in an enclosed space affected excess mortality among men in the Netherlands in the autumn of 1918. We find some evidence that men with occupations that featured high levels of social contact had higher mortality in this period. Above all, however, we find a strong socioeconomic gradient to excess mortality among men during the Spanish Flu pandemic, even after accounting for exposure in the workplace.     

Preparedness and international contribution on H5N1 highly pathogenic avian influenza and pandemic-influenza

Since the end of 2003, simultaneous outbreaks caused by H5N1 highly pathogenic avian influenza viruses (H5N1-HPAIV) occurred in poultries and in wild birds in the East Asia. The outbreaks are spreading now at least 48 countries in the Middle Eastern, African and European countries in addition to the East Asia. During the outbreaks, over 200 human infection cases with 55% fatality are confirmed at the moment and some human-to-human transmission in family clusters have been observed. The outbreaks are no more out of control and pandemic potential caused by H5N1-HPAIV is major concern. Therefore, it is urgently necessary to develop new diagnostic kits and effective vaccines and to stockpile anti-influenza drugs before pandemic alert period phase 4 defined by WHO. Furthermore, international supports to the affected countries for development and improvement of diagnostic system are required in the public health aspect.     

Child health inequality in Sub-Saharan Africa

We investigate child height inequality and inequality of predicted height in the Sub-Saharan Africa (SSA) region by socioeconomic, demographic and geographical factors. We characterize their changes in age-cohorts (from 0‐1 up to 4‐5 years old) and determine the contribution of each factor to these changes. We extract data from the Demographic and Health Surveys (DHS) for 33 SSA countries covering the period from 2009 to 2016. Our measure of health is the standardized height of children below the age of five, adjusted by the age and gender distribution in each country. We show that height inequality is lower for older children than for their younger peers. However, the share of inequality caused by our set of factors rises along the age distribution in more than 80% of countries. We find that family background (reflected by maternal education and the household wealth), followed by home infrastructures related to water, toilet and cooking facilities, and the region of residence contribute to explaining the differences observed in child health inequality along the age distribution in SSA.     

Gender equity in Canada's newly growing religious minorities

Using data from the 2001 Canadian census and the 2002 Ethnic Diversity Survey, we find greater gender inequality in labour force participation among the newly growing religious minorities in Canada relative to mainstream Canadians. This gender inequality is only partly conditioned by the presence of young children. Although greatest among Muslim immigrants, other groups including Hindus and Sikhs also exhibit greater gender inequality in labour force participation relative to mainstream Canadians. These patterns fade with time in Canada. Lastly, the differences in gender inequality among religious groups reflect national cultures in the countries of origin more than differences in religious beliefs per se.     

Lessons from pandemic H1N1 2009 to improve prevention, detection, and response to influenza pandemics from a One Health perspective

In April 2009, a novel influenza A subtype H1N1 triple reassortant virus (novel H1N1 2009), composed of genes from swine, avian, and human influenza A viruses, emerged in humans in the United States and Mexico and spread person-to-person around the world to become the first influenza pandemic of the 21st century. The virus is believed to have emerged from a reassortment event involving a swine virus some time in the past 10 to 20 years, but pigs, pork, and pork products have not been involved with infection or spread of the virus to or among people. Because countries quickly implemented recently developed pandemic influenza plans, the disease was detected and reported and public health authorities instituted control measures in a timely fashion. But the news media's unfortunate and inappropriate naming of the disease as the "swine flu" led to a drop in the demand for pork and several countries banned pork imports from affected countries, resulting in serious negative economic impacts on the pork industry. With the continual circulation and interspecies transmission of human, swine, and avian influenza viruses in countries around the world, there are calls for strengthening influenza surveillance in pigs, birds, and other animals to aid in monitoring and assessing the risk of future pandemic virus emergence involving different species. We identify and discuss several lessons to be learned from pandemic H1N1 2009 from a One Health perspective, as stronger collaboration among human, animal, and environmental health sectors is necessary to more effectively prevent or detect and respond to influenza pandemics and thus improve human, animal, and environmental health and well-being.     

Phylogeography and evolutionary history of reassortant H9N2 viruses with potential human health implications

Avian influenza viruses of the H9N2 subtype have seriously affected the poultry industry of the Far and Middle East since the mid-1990s and are considered one of the most likely candidates to cause a new influenza pandemic in humans. To understand the genesis and epidemiology of these viruses, we investigated the spatial and evolutionary dynamics of complete genome sequences of H9N2 viruses circulating in nine Middle Eastern and Central Asian countries from 1998 to 2010. We identified four distinct and cocirculating groups (A, B, C, and D), each of which has undergone widespread inter- and intrasubtype reassortments, leading to the generation of viruses with unknown biological properties. Our analysis also suggested that eastern Asia served as the major source for H9N2 gene segments in the Middle East and Central Asia and that in this geographic region within-country evolution played a more important role in shaping viral genetic diversity than migration between countries. The genetic variability identified among the H9N2 viruses was associated with specific amino acid substitutions that are believed to result in increased transmissibility in mammals, as well as resistance to antiviral drugs. Our study highlights the need to constantly monitor the evolution of H9N2 viruses in poultry to better understand the potential risk to human health posed by these viruses.     

The Geography of Gender Inequality

Reducing gender inequality is a major policy concern worldwide, and one of the Sustainable Development Goals. However, our understanding of the magnitude and spatial distribution of gender inequality results either from limited-scale case studies or from national-level statistics. Here, we produce the first high resolution map of gender inequality by analyzing over 689,000 households in 47 countries. Across these countries, we find that male-headed households have, on average, 13% more asset wealth and 303% more land for agriculture than do female-headed households. However, this aggregate global result masks a high degree of spatial heterogeneity, with bands of both high inequality and high equality apparent in countries and regions of the world. Further, areas where inequality is highest when measured by land ownership generally are not the same areas that have high inequality as measured by asset wealth. Our metrics of gender inequality in land and wealth are not strongly correlated with existing metrics of poverty, development, and income inequality, and therefore provide new information to increase the understanding of one critical dimension of poverty across the globe.     

The low-pH stability discovered in neuraminidase of 1918 pandemic influenza A virus enhances virus replication

The "Spanish" pandemic influenza A virus, which killed more than 20 million worldwide in 1918-19, is one of the serious pathogens in recorded history. Characterization of the 1918 pandemic virus reconstructed by reverse genetics showed that PB1, hemagglutinin (HA), and neuraminidase (NA) genes contributed to the viral replication and virulence of the 1918 pandemic influenza virus. However, the function of the NA gene has remained unknown. Here we show that the avian-like low-pH stability of sialidase activity discovered in the 1918 pandemic virus NA contributes to the viral replication efficiency. We found that deletion of Thr at position 435 or deletion of Gly at position 455 in the 1918 pandemic virus NA was related to the low-pH stability of the sialidase activity in the 1918 pandemic virus NA by comparison with the sequences of other human N1 NAs and sialidase activity of chimeric constructs. Both amino acids were located in or near the amino acid resides that were important for stabilization of the native tetramer structure in a low-pH condition like the N2 NAs of pandemic viruses that emerged in 1957 and 1968. Two reverse-genetic viruses were generated from a genetic background of A/WSN/33 (H1N1) that included low-pH-unstable N1 NA from A/USSR/92/77 (H1N1) and its counterpart N1 NA in which sialidase activity was converted to a low-pH-stable property by a deletion and substitutions of two amino acid residues at position 435 and 455 related to the low-pH stability of the sialidase activity in 1918 NA. The mutant virus that included "Spanish Flu"-like low-pH-stable NA showed remarkable replication in comparison with the mutant virus that included low-pH-unstable N1 NA. Our results suggest that the avian-like low-pH stability of sialidase activity in the 1918 pandemic virus NA contributes to the viral replication efficiency.     

An evolutionary model of influenza A with drift and shift

Influenza A virus evolves through two types of evolutionary mechanisms – drift and shift. These two evolutionary mechanisms allow the pathogen to infect us repeatedly, as well as occasionally create pandemics with large morbidity and mortality. Here we introduce a novel model that incorporates both evolutionary mechanisms. This necessitates the modelling of three types of strains – seasonal human strains, bird-to-human transmittable H5N1 strains and evolved pandemic H5N1 strain. We define reproduction and invasion reproduction numbers and use them to establish the presence of dominant and coexistence equilibria. We find that the amino acid substitution structure of human influenza can destabilize the human influenza equilibrium and sustained oscillations are possible. We find that for low levels of infection in domestic birds, these oscillations persist, inducing oscillations in the number of humans infected with the avian flu strain. The oscillations have a period of 365 days, similar to the one that can be observed in the cumulative number of human H5N1 cases reported by the World Health Organization (WHO). Furthermore, we establish some partial global results on the competition of the strains.     

Breaking the HxNy outbreak

The latest emergence of influenza A (H1N1) virus outbreak demonstrated how swiftly a new strain of flu can evolve and spread around the globe. The A/H1N1 flu has been spreading at unprecedented speed, and further spread within the countries being affected and to other adjacent or far way countries is considered inevitable due to the rapid emigration of infected individuals across the world. In this bioinformation, we discuss the mechanism of evolution of a new HxNy strain and the essential criteria for potentially breaking the outbreak of these extremely harmful and rapidly evolving viral strains in the near future by taking the recent H1N1 pandemic as a classical paradigm.     

Mortality Burden of the 2009 A/H1N1 Influenza Pandemic in France: Comparison to Seasonal Influenza and the A/H3N2 Pandemic

Background

The mortality burden of the 2009 A/H1N1 pandemic remains unclear in many countries due to delays in reporting of death statistics. We estimate the age- and cause-specific excess mortality impact of the pandemic in France, relative to that of other countries and past epidemic and pandemic seasons.

Methods

We applied Serfling and Poisson excess mortality approaches to model weekly age- and cause-specific mortality rates from June 1969 through May 2010 in France. Indicators of influenza activity, time trends, and seasonal terms were included in the models. We also reviewed the literature for country-specific estimates of 2009 pandemic excess mortality rates to characterize geographical differences in the burden of this pandemic.

Results

The 2009 A/H1N1 pandemic was associated with 1.0 (95% Confidence Intervals (CI) 0.2–1.9) excess respiratory deaths per 100,000 population in France, compared to rates per 100,000 of 44 (95% CI 43–45) for the A/H3N2 pandemic and 2.9 (95% CI 2.3–3.7) for average inter-pandemic seasons. The 2009 A/H1N1 pandemic had a 10.6-fold higher impact than inter-pandemic seasons in people aged 5–24 years and 3.8-fold lower impact among people over 65 years.

Conclusions

The 2009 pandemic in France had low mortality impact in most age groups, relative to past influenza seasons, except in school-age children and young adults. The historical A/H3N2 pandemic was associated with much larger mortality impact than the 2009 pandemic, across all age groups and outcomes. Our 2009 pandemic excess mortality estimates for France fall within the range of previous estimates for high-income regions. Based on the analysis of several mortality outcomes and comparison with laboratory-confirmed 2009/H1N1 deaths, we conclude that cardio-respiratory and all-cause mortality lack precision to accurately measure the impact of this pandemic in high-income settings and that use of more specific mortality outcomes is important to obtain reliable age-specific estimates.     

Infection with seasonal influenza virus elicits CD4 T cells specific for genetically conserved epitopes that can be rapidly mobilized for protective immunity to pandemic H1N1 influenza virus

In recent years, influenza viruses with pandemic potential have been a major concern worldwide. One unresolved issue is how infection or vaccination with seasonal influenza virus strains influences the ability to mount a protective immune response to novel pandemic strains. In this study, we developed a mouse model of primary and secondary influenza infection by using a widely circulating seasonal H1N1 virus and the pandemic strain of H1N1 that emerged in Mexico in 2009, and we evaluated several key issues. First, using overlapping peptide libraries encompassing the entire translated sequences of 5 major influenza virus proteins, we assessed the specificity of CD4 T cell reactivity toward epitopes conserved among H1N1 viruses or unique to the seasonal or pandemic strain by enzyme-linked immunospot (ELISpot) assays. Our data show that CD4 T cells reactive to both virus-specific and genetically conserved epitopes are elicited, allowing separate tracking of these responses. Populations of cross-reactive CD4 T cells generated from seasonal influenza infection were found to expand earlier after secondary infection with the pandemic H1N1 virus than CD4 T cell populations specific for new epitopes. Coincident with this rapid CD4 T cell response was a potentiated neutralizing-antibody response to the pandemic strain and protection from the pathological effects of infection with the pandemic virus. This protection was not dependent on CD8 T cells. Together, our results indicate that exposure to seasonal vaccines and infection elicits CD4 T cells that promote the ability of the mammalian host to mount a protective immune response to pandemic strains of influenza virus.     

Phylogenetic analysis of H1N1 sequences from pandemic infections during 2009 in India

Since April 2009, a serious pandemic infection has been rapidly spread across the world. These infections are caused due to the novel swine origin influenza A (H1N1) virus and hence these are commonly called as "Swine Flu". This new virus is the reassortment of avian, human and swine influenza viruses and thus it has a unique genome composition. There are 16 different types of hemagglutinin (HA) and 9 different types of neuraminidase (NA) that can be genetically and antigenetically differentiated. The first influenza A virus isolated from pigs was of the H1N1 subtype and these viruses have been reported to cause infection in pigs in many countries. The outbreak of this virus has been transmitted from pigs to humans. This new reassorted (exchange of genes) virus which is the cause of 2009 pandemic infections has the ability to spread from human to human. This spread of infection should be brought to an end. In this study, a phylogenetic analysis of the nucleotide sequences of the RNA segments of human H1N1 viruses was carried using MEGA version 4.0 to demonstrate the route map of infection to India. Phylogenetic analysis of the sequences from India, published in Influenza Virus Resource (a database that integrates information gathered from the Influenza Genome Sequencing Project of the National Institute of Allergy and Infectious diseases (NIAID) and the genbank of the (NCBI)) was retrieved and used for the analysis. The results showed that the various segments of the Indian isolates clustered well with the sequences from American, Asian and European countries and thus indicating the transmission of viruses from these places to India.     

The Lao Experience in Deploying Influenza A(H1N1)pdm09 Vaccine: Lessons Made Relevant in Preparing for Present Day Pandemic Threats

The Lao PDR, as did most countries of the Mekong Region, embarked on a pandemic vaccine initiative to counter the threat posed by influenza A(H1N1)pdm09. Overall, estimated vaccine coverage of the Lao population was 14%, with uptake in targeted health care workers and pregnant women 99% and 41%, respectively. Adverse Events Following Immunization accounted for only 6% of survey driven, reported vaccination experiences, with no severe consequences or deaths. Public acceptability of the vaccine campaign was high (98%). Challenges to vaccine deployment included: 1) no previous experience in fielding a seasonal influenza vaccine, 2) safety and efficacy concerns, and 3) late arrival of vaccine 10 months into the pandemic. The Lao success in surmounting these hurdles was in large measure attributed to the oversight assigned the National Immunization Program, and national sensitivities in responding to the avian influenza A(H5N1) crisis in the years leading up to the pandemic. The Lao “lessons learned” from pandemic vaccine deployment are made even more relevant four years on, given the many avian influenza strains circulating in the region, all with pandemic potential.     

Monuments outlive history: Confederate monuments,the legacy of slavery,and black-white inequality

ABSTRACT

The conceptual linkages among Confederate monuments, slavery, and race suggest that Confederate monuments are relevant for explaining contemporary black–white inequality, yet we have little evidence on these relationships. I aim to further develop these possible connections. My analysis relies on a unique data set of Confederate monuments located in public spaces in the US South. I find that counties with Confederate monuments – specifically monuments inscribed with rhetoric glorifying either the soldiers as “heroes” or the cause as “pure” – have higher than expected levels of black–white poverty inequality. However, this relationship is stronger where the legacy of slavery is weaker, namely in counties with smaller historical concentrations of slaves. Confederate monuments are intertwined with a complex history, one that may continue to be reflected in the contemporary landscape of black–white inequality. The presented results are only suggestive, but they provide guidance for important avenues of future research.     

Characterization of Oseltamivir-Resistant 2009 H1N1 Pandemic Influenza A Viruses

Influenza viruses resistant to antiviral drugs emerge frequently. Not surprisingly, the widespread treatment in many countries of patients infected with 2009 pandemic influenza A (H1N1) viruses with the neuraminidase (NA) inhibitors oseltamivir and zanamivir has led to the emergence of pandemic strains resistant to these drugs. Sporadic cases of pandemic influenza have been associated with mutant viruses possessing a histidine-to-tyrosine substitution at position 274 (H274Y) in the NA, a mutation known to be responsible for oseltamivir resistance. Here, we characterized in vitro and in vivo properties of two pairs of oseltaimivir-sensitive and -resistant (possessing the NA H274Y substitution) 2009 H1N1 pandemic viruses isolated in different parts of the world. An in vitro NA inhibition assay confirmed that the NA H274Y substitution confers oseltamivir resistance to 2009 H1N1 pandemic viruses. In mouse lungs, we found no significant difference in replication between oseltamivir-sensitive and -resistant viruses. In the lungs of mice treated with oseltamivir or even zanamivir, 2009 H1N1 pandemic viruses with the NA H274Y substitution replicated efficiently. Pathological analysis revealed that the pathogenicities of the oseltamivir-resistant viruses were comparable to those of their oseltamivir-sensitive counterparts in ferrets. Further, the oseltamivir-resistant viruses transmitted between ferrets as efficiently as their oseltamivir-sensitive counterparts. Collectively, these data indicate that oseltamivir-resistant 2009 H1N1 pandemic viruses with the NA H274Y substitution were comparable to their oseltamivir-sensitive counterparts in their pathogenicity and transmissibility in animal models. Our findings highlight the possibility that NA H274Y-possessing oseltamivir-resistant 2009 H1N1 pandemic viruses could supersede oseltamivir-sensitive viruses, as occurred with seasonal H1N1 viruses.     

Geographic distribution and risk factors of the initial adult hospitalized cases of 2009 pandemic influenza A (H1N1) virus infection in mainland China

Background

As of 31^st March 2010, more than 127,000 confirmed cases of 2009 pandemic influenza A (H1N1), including 800 deaths, were reported in mainland China. The distribution and characteristics of the confirmed cases in the initial phase of this pandemic in this country are largely unknown. The present study aimed to characterize the geographic distribution and patient characteristics of H1N1 infection in the 2009 pandemic as well as to identify potential risk factors associated with adverse patient outcome in China, through retrospective analyses of 885 hospitalized cases with confirmed H1N1 infection.

Methodology/Principal Findings

The proportional hazards model was employed to detect risk factors for adverse outcome; the geo-statistical maps were used to characterize the distribution of all 2668 confirmed H1N1 patients throughout mainland China. The number of new cases increased slowly in May, 2009, but rapidly between June and August of the year. Confirmed cases were reported in 26 provinces; Beijing, Guangdong, Shanghai, Zhejiang and Fujian were the top five regions of the incidence of the virus infection. After being adjusted for gender, age, chronic pulmonary disease and other general symptoms, delay for more than two days before hospital admission (HR: 0.6; 95%CI: 0.5–0.7) and delayed onset of the H1N1-specific respiratory symptoms (HR: 0.3; 95%CI: 0.2–0.4) were associated with adverse patient outcome.

Conclusions/Significance

The 2009 pandemic influenza A affected east and southeast coastal provinces and most populous cities more severely than other regions in mainland China due to higher risk of high level traffic-, high population density-, and high population mobility-associated H1N1 transmission.The clinical symptoms were mild in the initial phase of infection. Delayed hospital admission and delayed appearance of respiratory symptoms were among the major risk factors for poor patient outcome. These findings may have significant implications in the future pandemic preparedness and response.     

新甲型H1N1流感病毒小鼠致死模型的建立

建立新甲型H1N1流感病毒小鼠致死模型,为研究致病性、宿主适应性以及疫苗保护性提供动物模型,并寻找病毒在适应宿主过程中影响毒力和适应性的关键位点。将新甲型H1N1流感病毒A/四川/SWL1/2009 H1N1在小鼠中连续传15代,各代次毒株均在MDCK细胞上增殖后进行测序,根据序列分析结果选择6个传代毒株感染小鼠,连续监测14 d体重和死亡情况;并对第14代和15代病毒在噬斑实验纯化后克隆和测序分析。原代病毒不致死BABL/C小鼠,经动物体内连续传代适应宿主动物后,其毒力增强,具体表现为所选的6个传代毒株中第7、11、15代毒株可以100%致死试验小鼠;分析这6个传代毒株的全基因组表明这些毒株的部分氨基酸位点发生突变。新甲型H1N1流感病毒经小鼠体内连续传代后,建立了小鼠致死模型,病毒毒力增强可能与某些氨基酸位点的改变有关。