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Seasonal Influenza Activity During the SARS-CoV-2 Outbreak in Japan

Educational Objective
To understand how precautions taken to decrease the spread of COVID-19 also decrease the spread of other infectious diseases
1 Credit CME

Since the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak began, measures for avoiding disease transmission have been widely promoted in Japan, such as use of masks and handwashing, remote work, and cancellation of large events. If effective, these measures may also reduce the spread of other infectious diseases, such as seasonal influenza. We compared the weekly influenza activity in the 2019/2020 season vs 5 previous seasons.

We used data from 2014 to 2020 from the National Institute of Infectious Diseases Japan, which gathers the number of cases of seasonal influenza weekly, diagnosed by physicians based on clinical symptoms or laboratory findings, from approximately 5000 sentinel centers, including hospitals and clinics (60% pediatrics and 40% internal or general medicine clinics).1,2 We grouped the weekly reports into seasons (week 40 of the year through week 11 of the following year [September 30, 2019, through March 15, 2020, for the 2019/2020 season]; the season was truncated after week 11 because this was the latest available data for 2020). In each season we assessed the weekly influenza activity, presented as a crude standardized estimate of influenza activity nationally, calculated by multiplying the mean number of reported cases per sentinel center with a constant number (n = 72 201) representing the number of outpatient visits to hospitals and clinics in the country in 20193 vs the health care institutions in the surveillance system.1,4 We estimated the change in influenza activity after the SARS-CoV-2 outbreak using a “difference-in-difference” regression model that included a variable for each week, a variable representing the average difference in influenza activity per week for the 2019/2020 season vs the 2014 to 2019 seasons before the outbreak (week 1-11), and interaction variables for each week after the outbreak and the 2019/2020 season. The difference-in-difference value was considered statistically significant if the 95% CI did not overlap 0. Approximately 10% of the sentinel centers provided samples from a subset of influenza cases from week 36 through week 7 in the 2019/2020 season and from week 36 through week 35 in the 2014 to 2019 seasons for analysis using polymerase chain reaction (PCR) testing. Using these data we assessed the predominant subtype of the influenza virus and compared the distribution of cases by age group (aged <15, 15-54, and ≥55 y) in the 2019/2020 season vs the 2014 to 2019 seasons (not including the 2015/2016 season, for which age-specific data were not available) using the χ2 test. Stata version 16.1 (StataCorp) was used. Institutional board review was not required because no individual-level data were used.

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Article Information

Corresponding Author: Peter Ueda, MD, PhD, Department of Global Health Policy, Graduate School of Medicine, University of Tokyo, 113-0033, Tokyo, Japan (peter.ueda@gmail.com).

Accepted for Publication: April 6, 2020.

Published Online: April 10, 2020. doi:10.1001/jama.2020.6173

Author Contributions: Dr Ueda had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Sakamoto, Ueda.

Administrative, technical, or material support: Sakamoto, Ishikane.

Supervision: Sakamoto, Ishikane.

Conflict of Interest Disclosures: None reported.

References
1.
Infectious diseases weekly reports. National Institute of Infectious Diseases website. Accessed March 2, 2020. https://www.niid.go.jp/niid/ja/idwr.html
2.
Okabe  N .  [Influenza surveillance in Japan].   Kansenshogaku Zasshi. 2006;80(2):59-63. doi:10.11150/kansenshogakuzasshi1970.80.59PubMedGoogle ScholarCrossref
3.
Ministry of Health, Labour and Welfare. National survey of health care institutions. Published March 26, 2019. Accessed March 2, 2020. https://www.mhlw.go.jp/toukei/saikin/hw/iryosd/m19/is1901.html
4.
Ministry of Health, Labour and Welfare. Regarding the change in methods for estimating the number of patients with seasonal influenza. Published 2018. https://www.niid.go.jp/niid/images/epi/flu/levelmap/suikei181207.pdf
5.
Deyle  ER , Maher  MC , Hernandez  RD , Basu  S , Sugihara  G .  Global environmental drivers of influenza.   Proc Natl Acad Sci U S A. 2016;113(46):13081-13086. doi:10.1073/pnas.1607747113PubMedGoogle ScholarCrossref
6.
Livingston  E , Bucher  K , Rekito  A .  Coronavirus disease 2019 and influenza.   JAMA. Published February 26, 2020. doi:10.1001/jama.2020.2633PubMedGoogle Scholar
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