Seasonal and pandemic influenza preparedness: science and countermeasures

Influenza has not been treated with the degree of medical attention that the disease warrants. As such, there is not an adequate baseline of preparedness in the United States to deal with the potential of pandemic influenza. The National Institute of Allergy and Infectious Diseases (NIAID) has been working to enact measures to deal more effectively with a potential influenza pandemic and also to assist in the management of seasonal influenza. The majority of the NIAID's efforts have been dedicated to basic research aimed ultimately at developing and testing, in clinical trials, countermeasures in the form of antiviral drugs and vaccines. Some of the NIAID's current and planned antiviral projects include the (1) assessment of oseltamivir therapy in infants, (2) conduct of clinical trials of higher doses of osteltamivir for avian influenza, (3) appraisal of combination therapies, and (4) evaluation of the next generation of neuraminidase inhibitors. In addition, the NIAID is screening potential new antiviral drugs and evaluating novel drug targets. Similarly, significant funding has been committed to vaccine preparedness, and numerous novel candidate influenza vaccines are in various stages of development. Importantly, there is an integral relationship between preparation for seasonal influenza and preparation for pandemic influenza. Until these approaches are firmly linked, the community will not have optimized its preparedness for a pandemic.     

From the Cover: Trust in scientists in times of pandemic: Panel evidence from 12 countries

This article analyzes the specific and critical role of trust in scientists on both the support for and compliance with nonpharmaceutical interventions (NPIs) during the COVID-19 pandemic. We exploit large-scale, longitudinal, and representative surveys for 12 countries over the period from March to December 2020, and we complement the analysis with experimental data. We find that trust in scientists is the key driving force behind individual support for and compliance with NPIs and for favorable attitudes toward vaccination. The effect of trust in government is more ambiguous and tends to diminish support for and compliance with NPIs in countries where the recommendations from scientists and the government were not aligned. Trust in others also has seemingly paradoxical effects: in countries where social trust is high, the support for NPIs is low due to higher expectations that others will voluntary social distance. Our individual-level longitudinal data also allows us to evaluate the effects of within-person changes in trust over the pandemic: we show that trust levels and, in particular, trust in scientists have changed dramatically for individuals and within countries, with important subsequent effects on compliant behavior and support for NPIs. Such findings point out the challenging but critical need to maintain trust in scientists during a lasting pandemic that strains citizens and governments.

In their fight against COVID-19, governments around the world have faced different technological constraints but also social hurdles. For more than 1 year, the COVID-19 crisis has put under strain not only trust in government but also trust in scientists and in civil society at large. This trend has had critical implications on individuals’ attitudes toward policy measures and vaccination.Indeed, the COVID-19 crisis has brought into sharp relief the importance of trust at several levels. Trust in scientists lends legibility and credibility to policy recommendations, which should lead to higher support for and compliance with the recommended nonpharmaceutical interventions (NPIs) and vaccination. But the degree to which people support more NPIs or comply with restrictions might also depend on their expectations about the behaviors of others and thus on their level of trust in others. Furthermore, trust in scientists, in government, and in others is not only likely to matter for outcomes during the pandemic, but it is also likely to have been affected and potentially undermined by the crisis, leading to further effects on behaviors and support for NPIs.This paper explores the specific impacts of the levels and the changes in different types of trust on attitudes toward NPIs, on the willingness to be vaccinated, and on compliant behavior over time across individuals and countries during the pandemic. We consider “horizontal” trust (i.e., generalized trust or trust in others) as well as two types of “vertical” trust, namely, trust in the government and in scientists.We exploit representative, large-scale, cross-country, and longitudinal surveys on the evolution of support for NPIs, attitudes toward vaccination, and compliant behaviors over the period from March to December 2020. These surveys took place in four waves (mid-March, mid-April, mid-June, and mid-December 2020) in 12 countries (Australia, Austria, Brazil, Canada, France, Germany, Italy, New Zealand, Poland, Sweden, the United Kingdom, and the United States), which differ in the types and stringency of the NPIs implemented as well as in their levels of trust in others, the government, and scientists. Such data are critical to rigorously study the questions at hand, allowing us to leverage across- and within-country, as well as within-individual, variations over many of the pandemic months.We find that trust in scientists is the key driver of the support for and compliance with NPIs across and within countries. The role of trust in government is much less clear-cut, contrary to findings in the earlier literature. In countries where the governments spoke out against social distancing and restrictions, such as the United States and Brazil, trust in government has negative effects on support for or compliance with NPIs. Trust in others also has more subtle effects. Respondents who trust others more are more willing to be vaccinated, which suggests that they may also be more civically minded and further internalize the social benefits of vaccination. But individuals who trust others more also exhibit lower support for NPIs and lower compliance with restrictions. We show that this is because they are more likely to trust others to respect social distancing and not because of a lack of social- or civic-mindedness.Our individual-level longitudinal data also allows us to evaluate the effects of within-person changes in trust over the pandemic on attitudes and compliance, thus contributing evidence to the literature. We show that trust levels, and in particular trust in scientists, have changed dramatically for individuals and within countries, with important subsequent effects on compliant behavior and support for NPIs. We are also able to check for the robustness of our results with measures of the precrisis levels of trust at the individual level.Finally, we provide experimental evidence of the causal impacts of trust in scientists and government on compliant behavior in the different countries, which confirms that trust in scientists is crucially needed for respondents to support and comply with NPIs.Earlier work has shown the positive impact of the local precrisis level of trust in government on compliance, as measured by mobility reduction using Google mobility rates across European regions during the first lockdown (1). Experimental evidence from Germany during this period has also shown that the more the respondents distrusted government, the more they opposed enforced instead of voluntary implementation of policy measures (2). Further experimental evidence in nine countries (using vignettes with hypothetical “stay-at-home” orders) suggests that a high level of trust in science generates a much larger increase in compliance than trust in government (3). Recent papers have found the level of local civic mindedness—as measured by levels of political participation across US counties (4) or blood donations, newspaper readership, and trust in others in Italian provinces (5)—to be positively associated with a reduction in the Google index of mobility rates. Previous evidence has shown that past epidemics deeply influenced trust in government and scientists (6, 7). Research related directly to the COVID-19 pandemic has focused so far on the evolution of trust in scientists in the United States (8) in the aftermath of the crisis and found little variation. We provide evidence on how the different types of trust have evolved in the longer run during the different phases of the pandemic in a large sample of countries and on how these changes are associated with variation in the support for NPIs and compliant behavior over time. Leveraging this longer-run and large-scale longitudinal data, we can show more precisely that trust in scientists is the critical driver of the support for and compliance with health policy measures, while trust in the government and trust in others have much more complicated effects. We also provide explanations for these patterns.The first two waves of our panel (March and April for eight countries) have already been used to document the existence of a gender gap in attitudes during the pandemic. Women tend to perceive COVID-19 as a more serious health problem and are more compliant with NPIs (9). However, in 10 countries from our sample in Wave 4 (December 2020), women are less willing than men to be vaccinated and to make vaccination compulsory due to more contested beliefs on the origins of the pandemic (10). For France only, among the 12 countries in our sample, the first and the third waves were used to examine how trust in governments is affected by the perceived threats to the country’s public health and economy (11). Finally, in a methodological paper, a list experiment in the third wave of the panel has been used to study how reliable the self-reported answers about compliant behavior are (12).Our paper contributes to the existing literature using this database by exploring the distinct impacts of horizontal (generalized trust) and vertical (trust in the government and in scientists) trust on attitudes toward NPIs, the willingness to be vaccinated, and compliant behavior across individuals, countries, and over time during the pandemic. Our methodology leverages longitudinal data and allows us to estimate the within-person effect of changes in trust on variation in support for NPIs and compliant behavior. Finally, we also exploit experimental data in the fourth wave (December 2020) to distinguish the causal impact of trust in scientists and in government on compliant behavior.     

Performance improvement and implementation science: infection prevention competencies for current and future role development

The Association for Professionals in Infection Control and Epidemiology, Inc, developed its first model of infection preventionist (IP) competency in 2011. The model is based on the principles of patient safety, professional and practice standards, and core competencies identified through research conducted by the Certification Board of Infection Control and Epidemiology, Inc. In addition, the model highlights 4 domains that are predicted to be key areas for future competency development. Performance improvement (PI) and implementation represent 1 of the 4 forward-focused domains. Concurrently, the inclusion of implementation science (IS) in the competency model is consistent with the research goals established by the Association for Professionals in Infection Control and Epidemiology, Inc, in its 2020 strategic plan. This article explains the importance of PI and IS and describes their relevance to the current and future IP role development. Significant challenges such as role delineation and compression are discussed. The need for the IP to acquire new competencies at integrating, as well as differentiating, PI and IS are explored in terms of emerging issues and trends.     

Estimates of the impact of a future influenza pandemic in China

Background The next influenza pandemic will create a surge in demand for health resources in China, with its current population of >1·3 billion persons and under‐developed medical care and public health system. However, few pandemic impact data are available for China. Objectives We estimated the effects of a future influenza pandemic in China by examining pandemic scenarios of varying severity and described the time distribution of cases during a first wave. Methods  We used a Monte‐Carlo simulation model and death rates, hospitalizations and outpatient visits for 1918‐ and 1968‐like pandemic scenarios and data from the literature or experts’ opinion to estimate four health outcomes: deaths, hospitalizations, outpatient medical visits and clinical illness for which medical care was not sought. For each of the two scenarios we estimated outcomes by week using a normal distribution. Results We estimated that a 1968 scenario in China would result in 460 000–700 000 deaths, 1·94–2·27 million hospitalizations, 111–117 million outpatient visits and 192–197 million illnesses for which medical care was not sought. Fifty‐two percent of hospitalizations occurred during the two‐peak weeks of the first wave. We estimated that patients at high‐risk of influenza complications (10–17% of the population) would account for 61–75% of all deaths. For a 1918 scenario, we estimated that 4·95–6·95 million deaths, 20·8–22·7 million hospitalizations and 101–108 million outpatient visits could occur. Conclusion Even a 1968 pandemic scenario will pose substantial challenges for the medical and public health system in China, and planning to manage these challenges is essential.     

Managing public health crises: the role of models in pandemic preparedness

Background Given the enormity of challenges involved in pandemic preparedness, design and implementation of effective and cost‐effective public health policies is a major task that requires an integrated approach through engagement of scientific, administrative, and political communities across disciplines. There is ample evidence to suggest that modeling may be a viable approach to accomplish this task. Methods To demonstrate the importance of synergism between modelers, public health experts, and policymakers, the University of Winnipeg organized an interdisciplinary workshop on the role of models in pandemic preparedness in September 2008. The workshop provided an excellent opportunity to present outcomes of recent scientific investigations that thoroughly evaluate the merits of preventive, therapeutic, and social distancing mechanisms, where community structures, priority groups, healthcare providers, and responders to emergency situations are given specific consideration. Results This interactive workshop was clearly successful in strengthening ties between various disciplines and creating venues for modelers to effectively communicate with policymakers. The importance of modeling in pandemic planning was highlighted, and key parameters that affect policy decision‐making were identified. Core assumptions and important activities in Canadian pandemic plans at the provincial and national levels were also discussed. Conclusions There will be little time for thoughtful and rapid reflection once an influenza pandemic strikes, and therefore preparedness is an unavoidable priority. Modeling and simulations are key resources in pandemic planning to map out interdependencies and support complex decision‐making. Models are most effective in formulating strategies for managing public health crises when there are synergies between modelers, planners, and policymakers.     

Myocardial-cell replacement: the science, the clinic and the future

The traditional view of the heart is of an organ incapable of self-renewal. Hypotheses on the genesis of pump dysfunction in heart failure include emerging concepts of myocyte deficiency due to attritional ischemia and chronic apoptotic cell loss. In the adult heart, inadequate regenerative capacity was presumed to exist to counterbalance such extensive myocyte depletion. Preliminary animal and human studies now challenge the paradigm of myocardial regenerative inadequacy, with findings suggesting that noncardiac cells implanted in the dysfunctional heart augment myocyte deficiency and contractile mass. Data from these studies remain inconclusive and have generated much debate in the basic science and clinical communities. Controversial issues center on the scientific basis for regeneration in the heart, the mechanism of cell-therapy benefit and the safety and appropriateness of clinical trials based on these concepts. This review will evaluate the scientific basis for myocardial-cell replacement, with emphasis on current experimental and human data. We will explore unresolved questions of experimental design, mechanism of action, therapeutic strategies and safety concerns in an era of rising numbers of human cell-therapy trials. Prospects for more widespread clinical application of myocardial-cell replacement and future hurdles to be overcome in this field will also be addressed.     

Looking at the future of geriatric care in developing countries

During the next 20 years, many less developed countries (LDC) will have age structures approaching those of the present time in more developed countries (MDC). This is occurring more rapidly in the LDC of Asia and Latin America. The future of aging populations in LDC is dependent on the degree of poverty in these countries. Poverty is a major determinant of disability and mortality in older persons. With the march of globalization, diseases in LDC are changing from infectious to noncommunicable diseases, such as diabetes. Nevertheless, infections such as tuberculosis still take a major toll on the elderly. The epidemiological transition in LDC has created a need for health care transitions from systems based on cure to ones that highlight prevention and long-term care. LDC have the opportunity to develop systems that differ from those in MDC by capitalizing on the lack of infrastructure to produce more home-based rather than institution-based long-term care systems. Involvement of the elderly in the planning of their own futures is of paramount importance. Appropriate planning now will decide the future of the elderly in LDC during the next 20 to 40 years.     

Brief Report: Early assessment of the relationship between the COVID-19 pandemic and births in high-income countries

Drawing on past pandemics, scholars have suggested that the COVID-19 pandemic will bring about fertility decline. Evidence from actual birth data has so far been scarce. This brief report uses data on vital statistics from a selection of high-income countries, including the United States. The pandemic has been accompanied by a significant drop in crude birth rates beyond that predicted by past trends in 7 out of the 22 countries considered, with particularly strong declines in southern Europe: Italy (−9.1%), Spain (−8.4%), and Portugal (−6.6%). Substantial heterogeneities are, however, observed.     

The role of non‐pharmaceutical interventions on influenza circulation during the COVID‐19 pandemic in nine tropical Asian countries

BackgroundLow global influenza circulation was reported during the coronavirus‐19 pandemic. We explored relationships between non‐pharmaceutical interventions (NPIs) and influenza in tropical Asian countries.MethodsUsing World Health Organization (WHO) surveillance data from 2015 to 2019 and the WHO shiny app, we constructed expected seasonal influenza epidemic curves from March 2020 to June 2021 and compared the timing, and average percent positivity with observed data. We used multivariate regression to test associations between ordinal NPI data (from the Oxford Stringency Index) 4 weeks before the expected 2020/21 epidemics and present adjusted incidence rate ratio (IRR) or relative proportion ratio (RPR) and 95% confidence intervals (CI).ResultsData from nine countries predicted 18 seasonal epidemics; seven were observed. Five started 6–24 weeks later, and all were 4–21 weeks shorter than expected. Five epidemics had lower maximum peak values (percent positivity), and all but one had lower average percent positivity than expected. All countries implemented NPIs. Each increased level of school closure reduced risk of an epidemic by 43% (IRR = 0.57, CI: 0.34, 0.95). Each increased level of canceling public events reduced the average percent positivity across the season by 44% (RPR = 0.56, CI: 0.39, 0.82) and each increased level in restricting internal movements reduced it by 41% (RPR = 0.59, CI: 0.36, 0.96). Other NPIs were not associated with changes.ConclusionsAmong nine countries, the 2020/21 seasonal epidemics were delayed, shorter, and less intense than expected. Although layered NPIs were difficult to tease apart, school closings, canceling public events, and restricting internal movements before influenza circulation seemed to reduce transmission.     

Changing the future of obesity: science, policy, and action

The global obesity epidemic has been escalating for four decades, yet sustained prevention efforts have barely begun. An emerging science that uses quantitative models has provided key insights into the dynamics of this epidemic, and enabled researchers to combine evidence and to calculate the effect of behaviours, interventions, and policies at several levels--from individual to population. Forecasts suggest that high rates of obesity will affect future population health and economics. Energy gap models have quantified the association of changes in energy intake and expenditure with weight change, and have documented the effect of higher intake on obesity prevalence. Empirical evidence that shows interventions are effective is limited but expanding. We identify several cost-effective policies that governments should prioritise for implementation. Systems science provides a framework for organising the complexity of forces driving the obesity epidemic and has important implications for policy makers. Many parties (such as governments, international organisations, the private sector, and civil society) need to contribute complementary actions in a coordinated approach. Priority actions include policies to improve the food and built environments, cross-cutting actions (such as leadership, healthy public policies, and monitoring), and much greater funding for prevention programmes. Increased investment in population obesity monitoring would improve the accuracy of forecasts and evaluations. The integration of actions within existing systems into both health and non-health sectors (trade, agriculture, transport, urban planning, and development) can greatly increase the influence and sustainability of policies. We call for a sustained worldwide effort to monitor, prevent, and control obesity.     

Pancreatoscopy: Present and future role

Current imaging modalities do not allow for direct access to the pancreatic duct. Because of this limitation, diagnosis and assessment of pancreatic diseases require radiographic imaging and cytologic analysis. Although many of these techniques have excellent specificity for the detection of pancreatic cancer, they offer no therapeutic capabilities and are relatively poor in early detection of cancer and in differentiating chronic pancreatitis from malignancy, particularly when the conditions coexist. Currently available cholangioscopes are too large to access the pancreatic duct without sphincterotomy or balloon dilation, increasing the risk of instrumentation trauma to the pancreas. Novel, dedicated pancreatoscopes have recently been developed and are under investigation in clinical trials. Preliminary evidence suggests that these new technologies allow for direct visualization of the pancreatic ducts, with the potential for forceps biopsy in suspected malignancy and endotherapy for pancreatic calculi. Future and ongoing clinical trials will better define the utility and roles of these new endoscopy tools.     

Predominant role of bacterial pneumonia as a cause of death in pandemic influenza: implications for pandemic influenza preparedness

Background. @nbsp; Despite the availability of published data on 4 pandemics that have occurred over the past 120 years, there is little modern information on the causes of death associated with influenza pandemics. Methods. @nbsp; We examined relevant information from the most recent influenza pandemic that occurred during the era prior to the use of antibiotics, the 1918-1919 "Spanish flu" pandemic. We examined lung tissue sections obtained during 58 autopsies and reviewed pathologic and bacteriologic data from 109 published autopsy series that described 8398 individual autopsy investigations. Results. @nbsp; The postmortem samples we examined from people who died of influenza during 1918-1919 uniformly exhibited severe changes indicative of bacterial pneumonia. Bacteriologic and histopathologic results from published autopsy series clearly and consistently implicated secondary bacterial pneumonia caused by common upper respiratory-tract bacteria in most influenza fatalities. Conclusions. @nbsp; The majority of deaths in the 1918-1919 influenza pandemic likely resulted directly from secondary bacterial pneumonia caused by common upper respiratory-tract bacteria. Less substantial data from the subsequent 1957 and 1968 pandemics are consistent with these findings. If severe pandemic influenza is largely a problem of viral-bacterial copathogenesis, pandemic planning needs to go beyond addressing the viral cause alone (e.g., influenza vaccines and antiviral drugs). Prevention, diagnosis, prophylaxis, and treatment of secondary bacterial pneumonia, as well as stockpiling of antibiotics and bacterial vaccines, should also be high priorities for pandemic planning.