Abstract
BACKGROUND: The seasonal cycle of the influenza virus causes substantial morbidity and mortality globally. The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on the circulation of influenza viruses can influence influenza-associated excess mortality. Given the few studies that have explored this topic, the objective of this study was to evaluate influenza-associated excess mortality in the Chinese mainland from 2012 to 2021 and quantify the changes from 2020 to 2021 compared with 2012-2019. METHODS: Using data from national influenza surveillance report and disease surveillance points, we fitted a generalized additive model on all-cause (AC), pneumonia & influenza (P&I), and respiratory (R) mortality rates. In this model, we included data of influenza activity (A/H1N1, A/H3N2 and B), temperature, absolute humidity, the COVID-19 pandemic, and time trends. The excess mortality was estimated by subtracting the fitted baseline mortality from the predicted mortality, which set influenza activity to zero. RESULTS: The respiratory mortality model explained more than 90% of the variance, indicating the good performance. We found that the influenza-associated mortality was generally decreasing from 2020 to 2021, for instance, influenza A/H1N1-associated excess respiratory mortality (ERM) decreased from 2.62 per 100,000 persons (95% confidence interval: 0.16-5.21) to 0.31 (0.02-0.60) in the northern region and from 3.79 (0.09-7.05) to 0.24 (0.02-0.46) in the southern region between 2012-2019 and 2020-2021. A similar pattern was observed for A/H3N2-associated ERM. While the influenza B remained similar scale, for instance, the ERM was 2.90 (0.72-4.3) and 2.26 (1.76-2.76) in the southern region between 2012-2019 and 2020-2021, respectively. Distinct pattern was observed for the AC and P&I outcomes. CONCLUSIONS: The COVID-19 pandemic has reduced influenza-associated excess mortality, which may be a result of the reduced activity of the influenza virus caused by nonpharmaceutical interventions. Different patterns of regional differences differed for influenza-associated AC, P&I and R mortality. It should be noticed that the contribution of influenza B was generally similar when comparing 2012-2019 and 2020-2021, which highlighted the attention on the influenza B activity. Additional studies are needed to explore the changes in influenza-associated excess mortality afterwards.