key: cord-0734744-654rd38j
authors: Chan, Khee-Siang; Liang, Fu-Wen; Tang, Hung-Jen; Toh, Han Siong; Wen-Liang, Yu
title: Collateral Benefits on Other Respiratory Infections during Fighting COVID-19
date: 2020-06-05
journal: Med Clin (Barc)
DOI: 10.1016/j.medcli.2020.05.026
sha: b719a6715e4cb45cbefe9d50ca9747595877c882
doc_id: 734744
cord_uid: 654rd38j

Abstract Purpose: Influenza virus infection is associated with a high disease burden. COVID-19 caused by SARS-CoV-2 has become a pandemic outbreak since January 2020. Taiwan has effectively contained COVID-19 community transmission. We aimed to validate whether fighting COVID-19 could help to control other respiratory infections in Taiwan. Method: We collected week-case data of severe influenza, invasive Streptococcus pneumoniae disease and death toll from pneumonia among 25 calendar weeks of the influenza season for four years (2016-2020), which were reported to Taiwan CDC. Trend and slope differences between years were compared. Result: A downturn trend of severe influenza, invasive Streptococcus pneumoniae disease and the death toll from pneumonia per week in 2019/2020 season and significant trend difference in comparison to previous seasons were noted, especially after initiation of several disease prevention measures to fight potential COVID-19 outbreak in Taiwan. Conclusions: Fighting COVID-19 achieved collateral benefits on significant reductions of severe influenza burden, invasive Streptococcus pneumoniae disease activity, and the death toll from pneumonia reported to CDC in Taiwan.

Resumen Propósitos: COVID-19 causado por SARS-CoV-2 se ha convertido en un brote de pandemia desde enero de 2020. Taiwán ha contenido efectivamente la transmisión comunitaria de COVID-19. Por otra mano, la influenza tambien es una enfermedad se asocia con una alta carga y morbilidades. El objetivo del estudio es para validar si combatir la COVID-19 podría ayudar a controlar otras infecciones respiratorias en Taiwán.

Métodos: Recopilamos datos semanales de casos de influenza grave, infecciones invasivas por Streptococcus pneumoniae y número de muertes por neumonía, que se informaron a los CDC de Taiwán, entre las 25 semanas de la temporada de influenza durante cuatro años (2016) (2017) (2018) (2019) (2020) . Comparamos las diferencias de tendencia y pendiente entre los años.

Resultados: Se observó una tendencia a la baja de la influenza grave, la infecciones invasivas por Streptococcus pneumoniae, y el número de muertes por neumonía por semana en la temporada de infleunza de 2019/2020. Se observaron diferencias significativas en la tendencia en comparación con las temporadas anteriores, especialmente después del inicio de varias medidas de prevención de enfermedades para combatir el posible brote de COVID -19 en Taiwán.

Conclusiones: Por el número de casos reportados a los CDC de Taiwán, encontramos que la lucha contra COVID-19 logró beneficios colaterales en reducciones significativas de la carga de la influenza grave, la infecciones invasivas por Streptococcus pneumoniae, y el número de muertes por neumonía.

Palabras clave: COVID-19, influenza, mascarilla, SARS-CoV-2, Streptococcus pneumoniae A recent study in Japan reported that influenza activity was significantly lower in the 2019/2020 season versus the 2014 to 2019 seasons [2] . The reasons for changing influenza activity might include the closure of schools, suspension of large events, and measures to reduce the risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission among the Japanese public from early in the year.

In January 2020, the Taiwan government assembled a taskforce to contain the outbreak We proposed that collateral benefits on changing influenza activity and other respiratory infection activity (invasive Streptococcus pneumoniae disease) and outcome (death toll from pneumonia) would have happened in Taiwan.

We use Taiwan CDC national data (https://nidss.cdc.gov.tw/en/ and https://nidss.cdc.gov.tw/ch/misc_query.aspx?dc=death_flu&dt=4&position=5) recording the number of PCR-confirmed severe influenza cases requiring admission to an intensive care unit (ICU), invasive S. pneumoniae disease and overall patients died in pneumonia per week among 25 calendar weeks of the influenza season each year (2016-2020). Theil-Sen trend test was used to calculate the trend of each whole influenza season and slope difference in comparison between years (http://www.singlecaseresearch.org/calculators/theil-sen). The slope between the upward trend (before the peak) or downward trend (after the peak) was compared season by season of each year using linear trend estimation method. SAS 9.4 for Windows (SAS Institute, Inc., Cary, NC, USA) was used for statistical analyses. 

The healthcare systems should report severe influenza cases to CDC in their clinical practice by the law on the prevention and control of infectious diseases in Taiwan. The decreasing influenza activity in February 2020 was not due to the negligence of physicians while focusing on fighting COVID-19 events, because substantial cases of severe influenzalike illness were still reported to the CDC in the same period, and they were turned out to be negative influenza tests. In addition, the reported death toll from pneumonia during late influenza seasons in 2020 was similar to or even higher than those in the same period of previous seasons. Finally, as COVID-19 outbreak prevailed in Wuhan, the influenza-like illness surveillance was suspended to handle the COVID-19 epidemic from the calendar week 3 (January) in Wuhan, China [7] . Meanwhile, the COVID-19 pandemic did not really happen in Taiwan, so the CDC did not suspend the usual reporting practice. These facts would not support considering whether fighting against COVID-19 might have an influence on the physicians to report less for other respiratory infections.

Page 10 of 19 J o u r n a l P r e -p r o o f 10 The Theil-Sen slope, also known as the nonparametric linear regression slope, is an alternative to the standard linear regression slope and has relatively strong power and precision when data are non-normal and skewed [8] . Therefore, we first use this method to measure the weekly case number of diseases through an influenza season. We found a significant downward trend and slope difference of severe influenza, invasive S. pneumoniae disease and death toll of pneumonia in comparison to previous seasons. Then we use the standard linear trend estimation to measure different periods before and after the peak of an influenza season, and we documented significant downward slope difference occurring after initiation of fighting COVID-19 in February 2020.

The Taiwan government did not lockdown cities nor close schools, restaurants, and nursing institutes. Why Taiwan could effectively contain the COVID-19 outbreak? SARS-CoV-2 was not tested by mass screening but was tested for risk persons who exposed to Taiwan government has made several policies to integrate individual information to health care systems and the eMask ordering system [3] [4] [5] [6] . What other measures did Taiwanese public do with additional contributions to the significant reduction of severe influenza burden, invasive S. pneumoniae disease activity and the death toll from pneumonia?

We herein sum up the preparedness and response to the Taiwan essential bundles according to published literatures as follows: traffic flow control in hospitals to separate patients who were infected; alcohol sanitizer dispensers broadly used for hand washing and disinfection; isolation and quarantine persons confirmed or suspected to be infected; wearing mask in public for everyone while entering a hospital or in the crowd; aerosol transmission reduced by social distancing; and no touch the face by hand and keeping safe on mask removal [3] [4] [5] [6] .

The limitation of the study included retrospective data analysis and thus we are unable to discern which measure of the disease prevention bundles, such as universal masking practice or hand hygiene was an independent factor responsible for the successful containment of other respiratory infections. During fighting COVID-19, patients might avoid visiting a hospital for relatively mild respiratory tract infections. However, this would not influence reported severe influenza cases requiring ICU admission.

We found collateral benefits of a significant reduction of weekly cases from severe influenza, invasive S. pneumoniae disease and the death toll from pneumonia during fighting in Taiwan. People raising public awareness, participating in disease prevention measures, together with hospital preparedness and response, helped Taiwan government to contain transmission of respiratory infectious diseases and the outcome of pneumonia during the epidemic of COVID-19. The collateral benefit of nearly eradicating severe influenza supports to further study on the critical step of the disease prevention bundles, which may offer enormous help to prevent the epidemic influenza burden in the future. 

Estimated influenza illnesses, medical visits, hospitalizations, and deaths and estimated influenza illnesses, medical visits, hospitalizations, and deaths averted by vaccination in the United States

Seasonal influenza activity during the SARS-CoV-2 outbreak in Japan

Response to COVID-19 in Taiwan: Big Data Analytics, New Technology, and Proactive Testing

Initial rapid and proactive response for the COVID-19 outbreak -Taiwan's experience

Policy decisions and use of information technology to fight 2019 novel Coronavirus disease

Interrupting COVID-19 transmission by implementing enhanced traffic control bundling: Implications for global prevention and control efforts

SARS-CoV-2 detection in patients with influenza-like illness

Traditional and proposed tests of slope homogeneity for non-normal and heteroscedastic data

Author Contributions: Dr Yu 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: Dr Yu

Invasive Streptococcus pneumoniae disease Mean (n/week) + SD

Theil-Sen trend (slope, 90% C.I.) -0

Theil-Sen trend (slope, 90% C.I.)

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.