NZ a ‘unique laboratory’ for influenza research

Thanks to a generous $11.3 million grant from the US-based Flu Lab, a national consortium of researchers led by the University of Auckland has spent the past three years trying to better understand a virus that’s estimated to cause 1 billion cases and 650,000 deaths annually.

At the Faculty of Medical and Health Sciences, Professor John Fraser notes that New Zealand is a “unique laboratory for infectious diseases” because of its small population and national database.

“We can view things on a collective level nationally in a way that most other countries can’t.”

Known as SHIVERS-V, the research was conducted as part of the longitudinal Southern Hemisphere Influenza, Vaccine Effectiveness, Research & Surveillance study, which began in 2012. What made this project different was the fact that flu was eliminated from the population for two years because of New Zealand’s closed borders in response to Covid-19.

“It was a fascinating natural experiment,” says Professor Nikki Turner from the University of Auckland’s Department of General Practice and Primary Health Care. “We had the ability to get surveillance rapidly in place to measure and monitor respiratory illness through the pandemic, which was pretty challenging.”

Those challenges ranged from gaining data access and permissions to the collection of flu swabs by nurses at major Auckland hospitals, general practices and MIQ facilities, which required researchers to be extremely sensitive to the workload of a stretched health sector.

Covid restrictions also forced some adaptation of traditional data collection and led to a pilot study among six general practices where 4,135 patients were screened for Covid-19, flu and RSV. This in turn led to the use of a novel multi-virus RAT, which simultaneously screened for all three.

One of the aims was to assess the impact of non-pharmaceutical interventions, such as point-of care RAT tests and masks, on perceptions about respiratory illness.

“Nobody had ever heard of the word RAT before,” says Nikki. “And now there is a huge awareness of respiratory illness, diagnosing, transmission, mask-wearing, staying at home when sick – new language, new behaviours – so communities have learnt a lot.”

The main focal point of data collection was in underserved communities, particularly South Auckland, to determine what flu and RSV looked like before – and after – it returned when borders reopened. To that end, researchers analysed data collected from the Severe Acute Respiratory Illness (SARI) surveillance of more than 27,000 patients in the Auckland region and 10.4 million GP interactions nationally.

“We were able to conclusively demonstrate that there was no influenza circulation across the whole country between the early part of 2020 and 2022,” says Principal Investigator Professor PeterMcIntyre from the University of Otago. “And then, lo and behold, within a couple of months of the borders being open, influenza arrived.”

Surprisingly, the data revealed that a significant number of elderly Māori and Pacific people were hospitalised – most likely because they were living with large extended families. “They had a really big spike in influenza cases in that period, which wasn’t seen in the same age group who were European or Asian,” says Peter.

Another surprise was a surge in RSV cases and hospitalisation for babies less than a year old after the trans-Tasman ‘bubble’ opened in 2021, something Peter puts down to the lack of immunity in mothers. “You could see that it was more than ten times higher than any peak that had occurred in previous years.”

A major focus for the team was to better understand how community groups engage in behaviours to prevent the spread of respiratory illness. The so-called mixed-methods approach involved studies including a Samoan church group, a Kōhanga Reo preschool centre and other groups to improve ‘winter preparedness’ for flu.“

We did have fantastic engagement with Māori and Pacific communities for the studies, really focused on equity, the group’s most vulnerable and most at risk,” says Nikki.

Yet another SHIVERS-V project involved the use of machine learning and customised algorithmsin general practice and hospital settings to better forecast how influenza and other respiratory illnesses will behave in future winter seasons.“ Then we could potentially say for your high-risk local community, it’s coming within the next couple of weeks, how can we all be prepared?” she says.

Through the 28 different projects completed since 2021, the SHIVERS-V team believe they’ve delivered a diversity of outcomes and internationally unique insights that will have local, regional and global impact – such as the use of rapid assessment tools and the ‘in time’ surveillance undertaken by GPs.

Given that Covid-19 is also likely to be an ongoing problem for the elderly and very young babies, Peter says “it’s a good idea for mothers to continue to have their whooping cough and flu shots when they’re pregnant. And add to that a Covid shot to protect your newborn during those first months.”

Praising the collaboration between researchers from the Universities of Auckland and Otago, Te Whatu Ora Health New Zealand – Counties Manukau, the Institute of Environmental Science and Research (ESR) and community groups, John says that Flu Lab was consistently supportive of leveraging available funding for the advancement of students and early career researchers.

Through SHIVERS-V, Peter says the Flu Lab funding has bolstered the research infrastructure and demonstrated New Zealand’s strength of understanding in respiratory infections.

“It’s also brought a group of new and emerging researchers into this field and given more secure funding than just the year-to-year stuff, so that’s certainly a good outcome for supporting research in New Zealand.”

Nikki is also particularly grateful that the importance of mixed methodology research was recognised.

“You can have the best results in the world, but if you don’t know how to listen to communities and apply them – what a waste of time. I think that’s where we will be leading edge going forward.”

Looking ahead, Flu Lab has granted additional funding, which the team wants to prioritise for collaborative and ‘participatory action research’.

“What we want to do now is capitalise on what we’ve learned, turn it into a risk measure for an individual, for a family and for a community, and then utilise it with high-needs, high-risk communities to help them mitigate and manage flu and respiratory illness in general.”

The main concern for Peter is what lies ahead. 

“Obviously, we don’t know what the next pandemic might look like. Are we talking avian flu, some new coronavirus or one of the other viruses we don’t yet know about?”

Together, this multidisciplinary team strives to uncover new influenza insights and address this annual challenge to health systems and individuals at risk for severe illness.

“We have to live with flu,” says John. “We have to maintain that constant level of surveillance and protection through vaccination to ensure that flu doesn’t erupt into another pandemic like Covid did.”