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Background Prolonged periods of confined living on a cruise ship increase the risk for respiratory disease transmission. We describe the epidemiology and clinical characteristics of a SARS-CoV-2 outbreak in Australian passengers on the Diamond Princess cruise ship and provide recommendations to mitigate future cruise ship outbreaks. Methods We conducted a retrospective cohort study of Australian passengers who travelled on the Diamond Princess from 20 January until 4 February 2020 and were either hospitalised, remained in Japan or repatriated. The main outcome measures included an epidemic curve, demographics, symptoms, clinical and radiological signs, risk factors and length of time to clear infection. Results Among 223 Australian passengers, 56 were confirmed SARS-CoV-2 positive. Forty-nine cases had data available and of these over 70% had symptoms consistent with COVID-19. Of symptomatic cases, 17% showed signs and symptoms before the ship implemented quarantine and a further two-thirds had symptoms within one incubation period of quarantine commencing. Prior to ship-based quarantine, exposure to a close contact or cabin mate later confirmed SARS-CoV-2 positive was associated with a 3.78 fold (95% CI, 2.24–6.37) higher risk of COVID-19 acquisition compared to non-exposed passengers. Exposure to a positive cabin mate during the ship’s quarantine carried a relative risk of 6.18 (95% CI, 1.96–19.46) of developing COVID-19. Persistently asymptomatic cases represented 29% of total cases. The median time to the first of two consecutive negative PCR-based SARS-CoV-2 assays was 13 days for asymptomatic cases and 19 days for symptomatic cases (p = 0.002). Conclusion Ship based quarantine was effective at reducing transmission of SARS-CoV-2 amongst Australian passengers, but the risk of infection was higher if an individual shared a cabin or was a close contact of a confirmed case. Managing COVID-19 in cruise ship passengers is challenging and requires enhanced health measures and access to onshore quarantine and isolation facilities.

The database of the Global Influenza B Study was created by collecting surveillance datasets from each of the participating countries. These national datasets are owned by the participating countries, and thus cannot be shared publicly. Researchers interested in obtaining the country-specific datasets may contact the individuals listed below for further details regarding data access.Argentina (Santa Fe Province): Gabriela Kusznierz (labconi@yahoo.com.ar)Australia: Kate Pennington (kate.pennington@health.gov.au)Bhutan: Sonam Wangchuk (swangchuk@health.gov.bt)Brazil: Cláudio Maierovitch Pessanha Henriques (claudio.henriques@saude.gov.br)Cameroon: Guy Vernet (vernet@pasteur-yaounde.org)Chile: Rodrigo Fasce (rfasce@ispch.cl)China: Feng Luzhao (fenglz@chinacdc.cn)Costa Rica: Alexey W. Clara (wclara@cdc.gov)Ecuador: Alfredo Bruno (alfredobruno@yahoo.es)El Salvador: Alexey W. Clara (wclara@cdc.gov)England: Maria Zambon (maria.zambon@phe.gov.uk)Guatemala: Alexey W. Clara (wclara@cdc.gov)Honduras: Alexey W. Clara (wclara@cdc.gov)Indonesia: Herman Kosasih (hermaninarespond@gmail.com)Italy: Caterina Rizzo (caterina.rizzo@iss.it)Ivory Coast: Herve A. Kadjo (hervekadjo@pasteur.ci)Kazakhstan: Gulzhan Muratbayeva (hnv2@cdc.gov)Kenya: Joshua Mott (zud9@cdc.gov)Madagascar: Jean-Michel Heraud (jmheraud@pasteur.mg)Morocco: Amal Barakat (amal.barakat@yahoo.fr)New Zealand: Sue Huang (sue.huang@esr.cri.nz)Nicaragua: Alexey W. Clara (wclara@cdc.gov)Panama: Alexey W. Clara (wclara@cdc.gov)Portugal: Ana Paula Rodrigues (ana.rodrigues@insa.min-saude.pt)Singapore: Vernon Lee (vernonljm@hotmail.com)South Africa: Cheryl Cohen (cherylc@nicd.ac.za)Turkey: Meral Akcay Ciblak (ciblakm@yahoo.com)Ukraine: Alla Mironenko (miralla@ukr.net)Viet Nam: Le Thi Quinh Mai (lom9@hotmail.com); International audience; BACKGROUND:Influenza disease burden varies by age and this has important public health implications. We compared the proportional distribution of different influenza virus types within age strata using surveillance data from twenty-nine countries during 1999-2014 (N=358,796 influenza cases).METHODS:For each virus, we calculated a Relative Illness Ratio (defined as the ratio of the percentage of cases in an age group to the percentage of the country population in the same age group) for young children (0-4 years), older children (5-17 years), young adults (18-39 years), older adults (40-64 years), and the elderly (65+ years). We used random-effects meta-analysis models to obtain summary relative illness ratios (sRIRs), and conducted meta-regression and sub-group analyses to explore causes of between-estimates heterogeneity.RESULTS:The influenza virus with highest sRIR was A(H1N1) for young children, B for older children, A(H1N1)pdm2009 for adults, and (A(H3N2) for the elderly. As expected, considering the diverse nature of the national surveillance datasets included in our analysis, between-estimates heterogeneity was high (I2>90%) for most sRIRs. The variations of countries' geographic, demographic and economic characteristics and the proportion of outpatients among reported influenza cases explained only part of the heterogeneity, suggesting that multiple factors were at play.CONCLUSIONS:These results highlight the importance of presenting burden of disease estimates by age group and virus (sub)type.

The 2009 influenza season was considered a significant season triggered by the April 2009 emergence of a novel influenza A virus prompting a World Health Organization (WHO) declaration of a public health emergency of international concern. The overall number of notifications in the Australian 2009 influenza season was the highest since national reporting to the National Notifiable Diseases Surveillance System (NNDSS) began in 2001, and substantially higher than in prior years. Over 59,000 notifications were reported to the NNDSS, almost ten times the five year mean and representing a crude notification rate of 272.1 per 100,000. Australia's first case of confirmed influenza A(H1N1) pdm09 was identified in early May 2009. By the end of 2009, there were 37,755 laboratory confirmed cases, including 5,085 hospitalisations and 188 deaths notified. Traditionally the age distribution of influenza notifications has rates highest in very young children and the elderly, however in 2009 with the predominance of the pandemic virus, notifications were highest in older children and younger adults. Although influenza can cause very severe and fatal illness, particularly in the elderly, the impact of influenza A(H1N1) pdm09 in younger healthy adults, Aboriginal and Torres Strait Islander peoples, pregnant women and people with existing medical co-morbidities was proportionally greater than normal seasonal outbreaks, even though the absolute number of such cases remained low.1 The establishment of a number of surveillance systems during the pandemic enabled an enhanced assessment of the epidemiological, clinical and virological characteristics to inform public health responses.

The 2010 influenza season was moderate overall, with more laboratory-confirmed cases than in earlier years (with the exception of 2009). That said, self-reported influenza-like illness (ILI) was equal to or lower than 2008 and earlier years. In 2010, the number of laboratory-confirmed notifications for influenza was 0.8 times the 5-year mean. High notification rates were reflected in an increase in presentations with ILI to sentinel general practices and emergency departments. Notification rates were highest in the 0-4 year age group. Infections during the season were predominantly due to influenza A(H1N1)pdm09, with 90% of notifications being influenza A (56% A(H1N)1pdm09, 30% A(unsubtyped) and 4% A(H3N2)) and 10% being influenza B. The A(H1), A(H3) and B influenza viruses circulating during the 2010 season were antigenically similar to the respective 2010 vaccine strains. Almost all (99%) of the circulating influenza B viruses that were analysed were from the B/Victoria lineage.

Erratum in - Correction: Temporal Patterns of Influenza A and B in Tropical and Temperate Countries: What Are the Lessons for Influenza Vaccination? PLoS One. 2016 May 2;11(5):e0155089. doi: 10.1371/journal.pone.0155089. Introduction: Determining the optimal time to vaccinate is important for influenza vaccination programmes. Here, we assessed the temporal characteristics of influenza epidemics in the Northern and Southern hemispheres and in the tropics, and discuss their implications for vaccination programmes. Methods: This was a retrospective analysis of surveillance data between 2000 and 2014 from the Global Influenza B Study database. The seasonal peak of influenza was defined as the week with the most reported cases (overall, A, and B) in the season. The duration of seasonal activity was assessed using the maximum proportion of influenza cases during three consecutive months and the minimum number of months with 80% of cases in the season. We also assessed whether co-circulation of A and B virus types affected the duration of influenza epidemics. Results: 212 influenza seasons and 571,907 cases were included from 30 countries. In tropical countries, the seasonal influenza activity lasted longer and the peaks of influenza A and B coincided less frequently than in temperate countries. Temporal characteristics of influenza epidemics were heterogeneous in the tropics, with distinct seasonal epidemics observed only in some countries. Seasons with co-circulation of influenza A and B were longer than influenza A seasons, especially in the tropics. Discussion: Our findings show that influenza seasonality is less well defined in the tropics than in temperate regions. This has important implications for vaccination programmes in these countries. High-quality influenza surveillance systems are needed in the tropics to enable decisions about when to vaccinate. The Global Influenza B Study is supported by an unrestricted research grant from Sanofi Pasteur. info:eu-repo/semantics/publishedVersion

Please cite this paper as: Van Kerkhove et al. (2011) Epidemiologic and virologic assessment of the 2009 influenza A (H1N1) pandemic on selected temperate countries in the Southern Hemisphere: Argentina, Australia, Chile, New Zealand and South Africa. Influenza and Other Respiratory Viruses 5(6), e487–e498. Introduction and Setting Our analysis compares the most comprehensive epidemiologic and virologic surveillance data compiled to date for laboratory-confirmed H1N1pdm patients between 1 April 2009 - 31 January 2010 from five temperate countries in the Southern Hemisphere–Argentina, Australia, Chile, New Zealand, and South Africa. Objective We evaluate transmission dynamics, indicators of severity, and describe the co-circulation of H1N1pdm with seasonal influenza viruses. Results In the five countries, H1N1pdm became the predominant influenza strain within weeks of initial detection. South Africa was unique, first experiencing a seasonal H3N2 wave, followed by a distinct H1N1pdm wave. Compared with the 2007 and 2008 influenza seasons, the peak of influenza-like illness (ILI) activity in four of the five countries was 3-6 times higher with peak ILI consultation rates ranging from 35/1,000 consultations/week in Australia to 275/100,000 population/week in New Zealand. Transmission was similar in all countries with the reproductive rate ranging from 1.2–1.6. The median age of patients in all countries increased with increasing severity of disease, 4–14% of all hospitalized cases required critical care, and 26–68% of fatal patients were reported to have ≥1 chronic medical condition. Compared with seasonal influenza, there was a notable downward shift in age among severe cases with the highest population-based hospitalization rates among children

Please cite this paper as: Van Kerkhove et al. (2011) Epidemiologic and virologic assessment of the 2009 influenza A (H1N1) pandemic on selected temperate countries in the Southern Hemisphere: Argentina, Australia, Chile, New Zealand and South Africa. Influenza and Other Respiratory Viruses 5(6), e487–e498. Introduction and Setting Our analysis compares the most comprehensive epidemiologic and virologic surveillance data compiled to date for laboratory‐confirmed H1N1pdm patients between 1 April 2009 ‐ 31 January 2010 from five temperate countries in the Southern Hemisphere–Argentina, Australia, Chile, New Zealand, and South Africa. Objective We evaluate transmission dynamics, indicators of severity, and describe the co‐circulation of H1N1pdm with seasonal influenza viruses. Results In the five countries, H1N1pdm became the predominant influenza strain within weeks of initial detection. South Africa was unique, first experiencing a seasonal H3N2 wave, followed by a distinct H1N1pdm wave. Compared with the 2007 and 2008 influenza seasons, the peak of influenza‐like illness (ILI) activity in four of the five countries was 3‐6 times higher with peak ILI consultation rates ranging from 35/1,000 consultations/week in Australia to 275/100,000 population/week in New Zealand. Transmission was similar in all countries with the reproductive rate ranging from 1.2–1.6. The median age of patients in all countries increased with increasing severity of disease, 4–14% of all hospitalized cases required critical care, and 26–68% of fatal patients were reported to have ≥1 chronic medical condition. Compared with seasonal influenza, there was a notable downward shift in age among severe cases with the highest population‐based hospitalization rates among children

In 2008, 65 communicable diseases and conditions were nationally notifiable in Australia. States and territories reported a total of 160,508 notifications of communicable diseases to the National Notifiable Diseases Surveillance System, an increase of 9% on the number of notifications in 2007. In 2008, the most frequently notified diseases were sexually transmissible infections (69,459 notifications, 43% of total notifications), vaccine preventable diseases (34,225 notifications, 21% of total notifications) and gastrointestinal diseases (27,308 notifications, 17% of total notifications). There were 18,207 notifications of bloodborne diseases; 8,876 notifications of vectorborne diseases; 1,796 notifications of other bacterial infections; 633 notifications of zoonoses and 4 notifications of quarantinable diseases.

The 2008 influenza season was moderate overall, with fewer laboratory-confirmed cases and influenza-like illness (ILI) presentations than in 2007, which was the most severe influenza season since national reporting of influenza began in 2001. In 2008, the number of laboratory-confirmed notifications for influenza was 1.9 times higher than the 5-year mean. High notification rates were reflected in an increase in presentations with ILI to sentinel general practices and emergency departments. Notification rates were highest in the 0-4 year age group. Unusually, the season was predominantly due to influenza B, with 54% of notifications being influenza B and 43% being influenza A (3% type unknown). The rate of influenza B was higher among the younger age groups, compared with influenza A, which was more common in the older age groups. Of influenza viruses circulating during the 2008 season, A(H3) viruses were predominant and were antigenically similar to the 2008 A(H3) vaccine strain, while the majority of A(H1) strains showed significant drift away from the 2008 A(H1) vaccine strain. There were approximately equal proportions of viruses from the 2 influenza B lineages B/Yamagata and B/Victoria.

Dr. James Bishop and colleagues write that key lessons from Australia's experience with the spread of H1N1 suggest that important elements of a response were a national coordination of efforts and the use and modification of a national pandemic plan framework.

In 2007, 69 diseases and conditions were nationally notifiable in Australia. States and territories reported a total of 146,991 notifications of communicable diseases to the National Notifiable Diseases Surveillance System, an increase of 5% on the number of notifications in 2006. In 2007, the most frequently notified diseases were sexually transmissible infections (62,474 notifications, 43% of total notifications), gastrointestinal diseases (30,325 notifications, 21% of total notifications) and vaccine preventable diseases (25,347 notifications, 17% of total notifications). There were 19,570 notifications of bloodborne diseases; 6,823 notifications of vectorborne diseases; 1,762 notifications of other bacterial infections; 687 notifications of zoonoses and 3 notifications of quarantinable diseases.

In 2006, 66 diseases and conditions were nationally notifiable in Australia. States and territories reported a total of 138,511 cases of communicable diseases to the National Notifiable Diseases Surveillance System: an increase of 10.4% on the number of notifications in 2005. In 2006, the most frequently notified diseases were sexually transmissible infections (57,941 notifications, 42% of total notifications), gastrointestinal diseases (27,931 notifications, 20% of total notifications) and vaccine preventable diseases (22,240 notifications, 16% of total notifications). There were 19,111 notifications of bloodborne diseases; 8,606 notifications of vectorborne diseases; 1,900 notifications of other bacterial infections; 767 notifications of zoonoses and 3 notifications of quarantinable diseases.

The year 2007 saw the most severe influenza season since national reporting of influenza began in 2001. Early in the season the National Incident Room was activated to provide effective national surveillance, reporting and management of the 2007 seasonal influenza outbreak. A surveillance team were tasked with establishing enhanced surveillance for the 2007 season and investigating unusual events in this outbreak. Key data required to comprehensively describe the number of cases, morbidity, mortality and virology of the influenza outbreak and the possible sources of these data were identified. In 2007 the number of laboratory-confirmed notifications for influenza was 3.1 times higher than the five-year mean. Forty-four per cent of notifications occurred in Queensland. High notification rates were reflected in an increase in presentations with influenza-like illness to sentinel general practices and Emergency Departments. Notifications and notification rates were highest in the 0-4 and 5-9 years age groups, possibly due to a bias towards testing in these age groups. The clinical morbidity of the infection in terms of complications or most affected groups cannot be determined but anecdotal reports indicate this season may have impacted young adults more than is usual. The available data suggest influenza has caused a significant burden on workplaces and the health care system as indicated by data on absenteeism and presentations for health care. The proportion of H1 strains of influenza circulating varied across Australia but was higher than 2006 in most jurisdictions. In 2007, 1,406 influenza isolates from Australia were antigenically analysed at the World Health Organization Collaborating Centre for Reference and Research on Influenza in Melbourne: 58.7% were A(H3N2), 34.4% were A(H1N1) and 6.9% were influenza B viruses. Antigenic drift away from the vaccine strain A/Wisconsin/67/2005 was observed with the A(H3N2) viruses and was also seen with most of the A(H1N1) viruses when compared with the vaccine strain A/New Caledonia/20/99. The small number of influenza B viruses examined were predominately of the B/Yamagata-lineage. Monitoring influenza through the National Incident Room during the 2007 season offered an excellent opportunity to conduct enhanced surveillance under conditions that were real and potentially serious but not an emergency. It enabled the current state of our surveillance systems to be assessed and opportunities for improvement to be identified.

In 2005, 60 diseases and conditions were nationally notifiable in Australia. States and territories reported a total of 125,461 cases of communicable diseases to the National Notifiable Diseases Surveillance System: an increase of 10% on the number of notifications in 2004. In 2005, the most frequently notified diseases were sexually transmissible infections (51,557 notifications, 41% of total notifications), gastrointestinal diseases (29,422 notifications, 23%) and bloodborne diseases (19,278 notifications, 15%). There were 17,753 notifications of vaccine preventable diseases; 4,935 notifications of vectorborne diseases; 1,826 notification of other bacterial infections (legionellosis, leprosy, meningococcal infections and tuberculosis) and 687 notifications of zoonotic diseases.

This study analyzes data from 19 countries (from April 2009 to Jan 2010), comprising some 70,000 hospitalized patients with severe H1N1 infection, to reveal risk factors for severe pandemic influenza, which include chronic illness, cardiac disease, chronic respiratory disease, and diabetes., Background Since the start of the 2009 influenza A pandemic (H1N1pdm), the World Health Organization and its member states have gathered information to characterize the clinical severity of H1N1pdm infection and to assist policy makers to determine risk groups for targeted control measures. Methods and Findings Data were collected on approximately 70,000 laboratory-confirmed hospitalized H1N1pdm patients, 9,700 patients admitted to intensive care units (ICUs), and 2,500 deaths reported between 1 April 2009 and 1 January 2010 from 19 countries or administrative regions—Argentina, Australia, Canada, Chile, China, France, Germany, Hong Kong SAR, Japan, Madagascar, Mexico, the Netherlands, New Zealand, Singapore, South Africa, Spain, Thailand, the United States, and the United Kingdom—to characterize and compare the distribution of risk factors among H1N1pdm patients at three levels of severity: hospitalizations, ICU admissions, and deaths. The median age of patients increased with severity of disease. The highest per capita risk of hospitalization was among patients, Editors' Summary Background In April 2009, a new strain of influenza A H1N1 was first identified in Mexico and the United States and subsequently spread around the world. In June 2009, the World Health Organization (WHO) declared a pandemic alert phase 6, which continued until August 2010. Throughout the pandemic, WHO and member states gathered information to characterize the patterns of risk associated with the new influenza A H1N1 virus infection and to assess the clinical picture. Although risk factors for severe disease following seasonal influenza infection have been well documented in many countries (for example, pregnancy; chronic medical conditions such as pulmonary, cardiovascular, renal, hepatic, neuromuscular, hematologic, and metabolic disorders; some cognitive conditions; and immunodeficiency), risk factors for severe disease following infection early in the 2009 H1N1 pandemic were largely unknown. Why Was This Study Done? Many countries have recently reported data on the association between severe H1N1 influenza and a variety of underlying risk factors, but because these data are presented in different formats, making direct comparisons across countries is difficult, with no clear consensus for some conditions. Therefore, to assess the frequency and distribution of known and new potential risk factors for severe H1N1 infection, this study was conducted to collect data (from 1 April 2009 to 1 January 2010) from surveillance programs of the Ministries of Health or National Public Health Institutes in 19 countries―Argentina, Australia, Canada, Chile, China, France, Germany, Hong Kong (special administrative region), Japan, Madagascar, Mexico, the Netherlands, New Zealand, Singapore, South Africa, Spain, Thailand, the United States, and the United Kingdom. What Did the Researchers Do and Find? As part of routine surveillance, countries were asked to provide risk factor data on laboratory-confirmed H1N1 in patients who were admitted to hospital, admitted to the intensive care unit (ICU), or had died because of their infection, using a standardized format. The researchers grouped potential risk conditions into four categories: age, chronic medical illnesses, pregnancy (by trimester), and other conditions that were not previously considered as risk conditions for severe influenza outcomes, such as obesity. For each risk factor (except pregnancy), the researchers calculated the percentage of each group of patients using the total number of cases reported in each severity category (hospitalization, admission to ICU, and death). To evaluate the risk associated with pregnancy, the researchers used the ratio of pregnant women to all women of childbearing age (age 15–49 years) at each level of severity to describe the differences between levels. The researchers were able to collect data on approximately 70,000 patients requiring hospitalization, 9,700 patients admitted to the ICU, and 2,500 patients who died from H1N1 infection. The proportion of patients with H1N1 with one or more reported chronic conditions increased with severity—the median was 31.1% of hospitalized patients, 52.3% of patients admitted to the ICU, and 61.8% of patients who died. For all levels of severity, pregnant women in their third trimester consistently accounted for the majority of the total of pregnant women. The proportion of patients with obesity increased with increasing disease severity—median of 6% of hospitalized patients, 11.3% of patients admitted to the ICU, and 12.0% of all deaths from H1N1. What Do These Findings Mean? These findings show that risk factors for severe H1N1 infection are similar to those for seasonal influenza, with some notable differences: a substantial proportion of people with severe and fatal cases of H1N1 had pre-existing chronic illness, which indicates that the presence of chronic illness increases the likelihood of death. Cardiac disease, chronic respiratory disease, and diabetes are important risk factors for severe disease that will be especially relevant for countries with high rates of these illnesses. Approximately 2/3 of hospitalized people and 40% of people who died from H1N1 infection did not have any identified pre-existing chronic illness, but this study was not able to comprehensively assess how many of these cases had other risk factors, such as pregnancy, obesity, smoking, and alcohol misuse. Because of large differences between countries, the role of risk factors such as obesity and pregnancy need further study—although there is sufficient evidence to support vaccination and early intervention for pregnant women. Overall, the findings of this study reinforce the need to identify and target high-risk groups for interventions such as immunization, early medical advice, and use of antiviral medications. Additional Information Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001053. WHO provides a Global Alert and Response (GAR) with updates on a number of influenza-related topics The US Centers for Disease Control and Prevention provides information on risk factors and H1N1

Assessment of the severity of disease due to the 2009 pandemic influenza A(H1N1) in Australian states and territories has been hampered by the absence of denominator data on population exposure. We compared antibody reactivity to the pandemic virus using haemagglutination inhibition assays performed on plasma specimens taken from healthy adult blood donors (older than 16 years) before and after the influenza pandemic that occurred during the southern hemisphere winter. Pre-influenza season samples (April – May 2009, n=496) were taken from donation collection centres in North Queensland (in Cairns and Townsville); post-outbreak specimens (October – November 2009, n=779) were from donors at seven centres in five states. Using a threshold antibody titre of 40 as a marker of recent infection, we observed an increase in the influenza-seropositive proportion of donors from 12% to 22%, not dissimilar to recent reports of influenza A(H1N1)-specific immunity in adults from the United Kingdom. No significant differences in seroprevalence were observed between Australian states, although the ability to detect minor variations was limited by the sample size. On the basis of these figures and national reporting data, we estimate that approximately 0.23% of all individuals in Australia exposed to the pandemic virus required hospitalisation and 0.01% died. The low seroprevalence reported here suggests that some degree of prior immunity to the virus, perhaps mediated by broadly reactive T-cell responses to conserved influenza viral antigens, limited transmission among adults and thus constrained the pandemic in Australia.