Global patterns and drivers of influenza decline during the COVID-19 pandemic

Objectives: The influenza circulation reportedly declined during the COVID-19 pandemic in many coun-tries. The occurrence of this change has not been studied worldwide nor its potential drivers.Methods: The change in the proportion of positive influenza samples reported by country and trimester was computed relative to the 2014-2019 period using the FluNet database. Random forests were used to determine predictors of change from demographical, weather, pandemic preparedness, COVID-19 inci-dence, and pandemic response characteristics. Regression trees were used to classify observations accord-ing to these predictors.Results: During the COVID-19 pandemic, the influenza decline relative to prepandemic levels was global but heterogeneous across space and time. It was more than 50% for 311 of 376 trimesters-countries and even more than 99% for 135. COVID-19 incidence and pandemic preparedness were the two most impor-tant predictors of the decline. Europe and North America initially showed limited decline despite high COVID-19 restrictions; however, there was a strong decline afterward in most temperate countries, where pandemic preparedness, COVID-19 incidence, and social restrictions were high; the decline was limited in countries where these factors were low. The "zero-COVID" countries experienced the greatest decline.Conlusion: Our findings set the stage for interpreting the resurgence of influenza worldwide.(c) 2023 The Authors. Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. This is an open access article under the CC BY-NC-ND license ( http://creativecommons.org/licenses/by-nc-nd/4.0/ )