Changes in the incidence of invasive disease due to Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis during the COVID-19 pandemic in 26 countries and territories in the Invasive Respiratory Infection Surveillance Initiative: a prospective analysis of surveillance data

doi:10.1016/S2589-7500(21)00077-7

. 2021 Jun;3(6):e360-e370.

doi: 10.1016/S2589-7500(21)00077-7.

Changes in the incidence of invasive disease due to Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis during the COVID-19 pandemic in 26 countries and territories in the Invasive Respiratory Infection Surveillance Initiative: a prospective analysis of surveillance data

Angela B Brueggemann¹, Melissa J Jansen van Rensburg², David Shaw², Noel D McCarthy³, Keith A Jolley⁴, Martin C J Maiden⁴, Mark P G van der Linden⁵, Zahin Amin-Chowdhury⁶, Désirée E Bennett⁷, Ray Borrow⁸, Maria-Cristina C Brandileone⁹, Karen Broughton¹⁰, Ruth Campbell¹¹, Bin Cao¹², Carlo Casanova¹³, Eun Hwa Choi¹⁴, Yiu Wai Chu¹⁵, Stephen A Clark⁸, Heike Claus¹⁶, Juliana Coelho¹⁰, Mary Corcoran¹⁷, Simon Cottrell¹⁸, Robert J Cunney¹⁷, Tine Dalby¹⁹, Heather Davies²⁰, Linda de Gouveia²¹, Ala-Eddine Deghmane²², Walter Demczuk²³, Stefanie Desmet²⁴, Richard J Drew¹⁷, Mignon du Plessis²¹, Helga Erlendsdottir²⁵, Norman K Fry⁶, Kurt Fuursted¹⁹, Steve J Gray⁸, Birgitta Henriques-Normark²⁶, Thomas Hale²⁷, Markus Hilty¹³, Steen Hoffmann¹⁹, Hilary Humphreys⁷, Margaret Ip²⁸, Susanne Jacobsson²⁹, Jillian Johnston¹¹, Jana Kozakova³⁰, Karl G Kristinsson²⁵, Pavla Krizova³¹, Alicja Kuch³², Shamez N Ladhani⁶, Thiên-Trí Lâm¹⁶, Vera Lebedova³³, Laura Lindholm³⁴, David J Litt¹⁰, Irene Martin²³, Delphine Martiny³⁵, Wesley Mattheus³⁶, Martha McElligott⁷, Mary Meehan⁷, Susan Meiring³⁷, Paula Mölling²⁹, Eva Morfeldt³⁸, Julie Morgan³⁹, Robert M Mulhall⁷, Carmen Muñoz-Almagro⁴⁰, David R Murdoch⁴¹, Joy Murphy¹¹, Martin Musilek³¹, Alexandre Mzabi⁴², Amaresh Perez-Argüello⁴⁰, Monique Perrin⁴², Malorie Perry¹⁸, Alba Redin⁴⁰, Richard Roberts¹⁸, Maria Roberts¹⁸, Assaf Rokney⁴³, Merav Ron⁴³, Kevin J Scott⁴⁴, Carmen L Sheppard¹⁰, Lotta Siira³⁴, Anna Skoczyńska³², Monica Sloan¹¹, Hans-Christian Slotved¹⁹, Andrew J Smith⁴⁴, Joon Young Song⁴⁵, Muhamed-Kheir Taha²², Maija Toropainen³⁴, Dominic Tsang¹⁵, Anni Vainio³⁴, Nina M van Sorge⁴⁶, Emmanuelle Varon⁴⁷, Jiri Vlach³³, Ulrich Vogel¹⁶, Sandra Vohrnova³⁰, Anne von Gottberg²¹, Rosemeire C Zanella⁹, Fei Zhou¹²

Affiliations

¹ Nuffield Department of Population Health, Big Data Institute, University of Oxford, Oxford, UK. Electronic address: angela.brueggemann@ndph.ox.ac.uk.
² Nuffield Department of Population Health, Big Data Institute, University of Oxford, Oxford, UK.
³ Trinity College Dublin, Dublin, Ireland.
⁴ Department of Zoology, University of Oxford, Oxford, UK.
⁵ Department of Medical Microbiology, German National Reference Center for Streptococci, University Hospital RWTH Aachen, Aachen, Germany.
⁶ Immunisation and Countermeasures Division, National Infection Service, Public Health England, London, UK.
⁷ Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland.
⁸ Meningococcal Reference Unit, National Infection Service, Public Health England, Manchester Royal Infirmary, Manchester, UK.
⁹ National Laboratory for Meningitis and Pneumococcal Infections, Center of Bacteriology, Institute Adolfo Lutz, São Paulo, Brazil.
¹⁰ Respiratory and Vaccine Preventable Bacteria Reference Unit, National Infection Service, Public Health England, London, UK.
¹¹ Public Health Agency, Belfast, Northern Ireland.
¹² Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, National Clinical Research Center for Respiratory Diseases, Beijing, China.
¹³ Swiss National Reference Centre for invasive Pneumococci, Institute for Infectious Diseases, University of Bern, Bern, Switzerland.
¹⁴ Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea.
¹⁵ Department of Health, Microbiology Division, Public Health Laboratory Services Branch, Centre for Health Protection, Hong Kong Special Administrative Region, China.
¹⁶ German National Reference Center for Meningococci and Haemophilus influenzae, Institute for Hygiene and Microbiology, University of Würzburg, Würzburg, Germany.
¹⁷ Irish Meningitis and Sepsis Reference Laboratory, Children's Health Ireland at Temple Street, Dublin, Ireland; Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland.
¹⁸ Public Health Wales, Cardiff, UK.
¹⁹ Department of Bacteria, Parasites and Fungi, Statens Serum Institut, Copenhagen, Denmark.
²⁰ Meningococcal Reference Laboratory, Institute of Environmental Science and Research Limited, Porirua, New Zealand.
²¹ Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases, Division of the National Health Laboratory Service, Johannesburg, South Africa.
²² Institut Pasteur, Invasive Bacterial Infections Unit and National Reference Centre for Meningococci and Haemophilus influenzae, Paris, France.
²³ National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, MB, Canada.
²⁴ National Reference Centre for Streptococcus pneumoniae, University Hospitals Leuven, Leuven, Belgium; Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.
²⁵ Department of Clinical Microbiology, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland.
²⁶ Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden.
²⁷ Blavatnik School of Government, University of Oxford, Oxford, UK.
²⁸ Department of Microbiology, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China.
²⁹ Department of Laboratory Medicine, National Reference Laboratory for Neisseria meningitidis, Clinical Microbiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
³⁰ National Reference Laboratory for Streptococcal Infections, Centre for Epidemiology and Microbiology, National Institute of Public Health, Prague, Czech Republic.
³¹ National Reference Laboratory for Meningococcal Infections, Centre for Epidemiology and Microbiology, National Institute of Public Health, Prague, Czech Republic.
³² National Reference Centre for Bacterial Meningitis, National Medicines Institute, Warsaw, Poland.
³³ National Reference Laboratory for Haemophilus Infections, Centre for Epidemiology and Microbiology, National Institute of Public Health, Prague, Czech Republic.
³⁴ Finnish Institute for Health and Welfare, Helsinki, Finland.
³⁵ National Reference Centre for Haemophilus influenzae, Laboratoires des Hôpitaux Universitaires de Bruxelles, Universitaire Laboratorium Brussel, Brussels, Belgium; Faculté de Médecine et Pharmacie, Université de Mons, Mons, Belgium.
³⁶ National Reference Centre for Neisseria meningitidis, Sciensano, Brussels, Belgium.
³⁷ Division of Public Health Surveillance and Response, National Institute for Communicable Diseases, Division of the National Health Laboratory Service, Johannesburg, South Africa.
³⁸ Public Health Agency of Sweden, Solna, Sweden.
³⁹ Streptococcal Reference Laboratory, Institute of Environmental Science and Research Limited, Porirua, New Zealand.
⁴⁰ Instituto de Recerca Pediatrica, Hospital Sant Joan de Deu, Barcelona, Spain.
⁴¹ Department of Pathology and Biomedical Science, University of Otago, Christchurch, New Zealand.
⁴² Laboratoire National de Sante, Dudelange, Luxembourg.
⁴³ Government Central Laboratories, Ministry of Health, Jerusalem, Israel.
⁴⁴ Bacterial Respiratory Infection Service, Scottish Microbiology Reference Laboratories, Glasgow, UK.
⁴⁵ Department of Internal Medicine, Division of Infectious Diseases, Korea University Guro Hospital, Korea University College of Medicine, Seoul, South Korea.
⁴⁶ Department of Medical Microbiology and Infection Prevention, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands; Netherlands Reference Laboratory for Bacterial Meningitis, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands.
⁴⁷ Laboratory of Medical Biology and National Reference Centre for Pneumococci, Intercommunal Hospital of Créteil, Créteil, France.

PMID: 34045002
PMCID: PMC8166576
DOI: 10.1016/S2589-7500(21)00077-7

Changes in the incidence of invasive disease due to Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis during the COVID-19 pandemic in 26 countries and territories in the Invasive Respiratory Infection Surveillance Initiative: a prospective analysis of surveillance data

Angela B Brueggemann et al. Lancet Digit Health. 2021 Jun.

. 2021 Jun;3(6):e360-e370.

doi: 10.1016/S2589-7500(21)00077-7.

Authors

Affiliations

¹ Nuffield Department of Population Health, Big Data Institute, University of Oxford, Oxford, UK. Electronic address: angela.brueggemann@ndph.ox.ac.uk.
² Nuffield Department of Population Health, Big Data Institute, University of Oxford, Oxford, UK.
³ Trinity College Dublin, Dublin, Ireland.
⁴ Department of Zoology, University of Oxford, Oxford, UK.
⁵ Department of Medical Microbiology, German National Reference Center for Streptococci, University Hospital RWTH Aachen, Aachen, Germany.
⁶ Immunisation and Countermeasures Division, National Infection Service, Public Health England, London, UK.
⁷ Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland.
⁸ Meningococcal Reference Unit, National Infection Service, Public Health England, Manchester Royal Infirmary, Manchester, UK.
⁹ National Laboratory for Meningitis and Pneumococcal Infections, Center of Bacteriology, Institute Adolfo Lutz, São Paulo, Brazil.
¹⁰ Respiratory and Vaccine Preventable Bacteria Reference Unit, National Infection Service, Public Health England, London, UK.
¹¹ Public Health Agency, Belfast, Northern Ireland.
¹² Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, National Clinical Research Center for Respiratory Diseases, Beijing, China.
¹³ Swiss National Reference Centre for invasive Pneumococci, Institute for Infectious Diseases, University of Bern, Bern, Switzerland.
¹⁴ Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea.
¹⁵ Department of Health, Microbiology Division, Public Health Laboratory Services Branch, Centre for Health Protection, Hong Kong Special Administrative Region, China.
¹⁶ German National Reference Center for Meningococci and Haemophilus influenzae, Institute for Hygiene and Microbiology, University of Würzburg, Würzburg, Germany.
¹⁷ Irish Meningitis and Sepsis Reference Laboratory, Children's Health Ireland at Temple Street, Dublin, Ireland; Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland.
¹⁸ Public Health Wales, Cardiff, UK.
¹⁹ Department of Bacteria, Parasites and Fungi, Statens Serum Institut, Copenhagen, Denmark.
²⁰ Meningococcal Reference Laboratory, Institute of Environmental Science and Research Limited, Porirua, New Zealand.
²¹ Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases, Division of the National Health Laboratory Service, Johannesburg, South Africa.
²² Institut Pasteur, Invasive Bacterial Infections Unit and National Reference Centre for Meningococci and Haemophilus influenzae, Paris, France.
²³ National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, MB, Canada.
²⁴ National Reference Centre for Streptococcus pneumoniae, University Hospitals Leuven, Leuven, Belgium; Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.
²⁵ Department of Clinical Microbiology, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland.
²⁶ Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden.
²⁷ Blavatnik School of Government, University of Oxford, Oxford, UK.
²⁸ Department of Microbiology, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China.
²⁹ Department of Laboratory Medicine, National Reference Laboratory for Neisseria meningitidis, Clinical Microbiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
³⁰ National Reference Laboratory for Streptococcal Infections, Centre for Epidemiology and Microbiology, National Institute of Public Health, Prague, Czech Republic.
³¹ National Reference Laboratory for Meningococcal Infections, Centre for Epidemiology and Microbiology, National Institute of Public Health, Prague, Czech Republic.
³² National Reference Centre for Bacterial Meningitis, National Medicines Institute, Warsaw, Poland.
³³ National Reference Laboratory for Haemophilus Infections, Centre for Epidemiology and Microbiology, National Institute of Public Health, Prague, Czech Republic.
³⁴ Finnish Institute for Health and Welfare, Helsinki, Finland.
³⁵ National Reference Centre for Haemophilus influenzae, Laboratoires des Hôpitaux Universitaires de Bruxelles, Universitaire Laboratorium Brussel, Brussels, Belgium; Faculté de Médecine et Pharmacie, Université de Mons, Mons, Belgium.
³⁶ National Reference Centre for Neisseria meningitidis, Sciensano, Brussels, Belgium.
³⁷ Division of Public Health Surveillance and Response, National Institute for Communicable Diseases, Division of the National Health Laboratory Service, Johannesburg, South Africa.
³⁸ Public Health Agency of Sweden, Solna, Sweden.
³⁹ Streptococcal Reference Laboratory, Institute of Environmental Science and Research Limited, Porirua, New Zealand.
⁴⁰ Instituto de Recerca Pediatrica, Hospital Sant Joan de Deu, Barcelona, Spain.
⁴¹ Department of Pathology and Biomedical Science, University of Otago, Christchurch, New Zealand.
⁴² Laboratoire National de Sante, Dudelange, Luxembourg.
⁴³ Government Central Laboratories, Ministry of Health, Jerusalem, Israel.
⁴⁴ Bacterial Respiratory Infection Service, Scottish Microbiology Reference Laboratories, Glasgow, UK.
⁴⁵ Department of Internal Medicine, Division of Infectious Diseases, Korea University Guro Hospital, Korea University College of Medicine, Seoul, South Korea.
⁴⁶ Department of Medical Microbiology and Infection Prevention, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands; Netherlands Reference Laboratory for Bacterial Meningitis, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands.
⁴⁷ Laboratory of Medical Biology and National Reference Centre for Pneumococci, Intercommunal Hospital of Créteil, Créteil, France.

PMID: 34045002
PMCID: PMC8166576
DOI: 10.1016/S2589-7500(21)00077-7

Erratum in

Correction to Lancet Digit Health 2021; 3: e360-70.
[No authors listed] [No authors listed] Lancet Digit Health. 2021 Jul;3(7):e413. doi: 10.1016/S2589-7500(21)00103-5. Epub 2021 May 26. Lancet Digit Health. 2021. PMID: 34052209 Free PMC article. No abstract available.

Abstract

Background: Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis, which are typically transmitted via respiratory droplets, are leading causes of invasive diseases, including bacteraemic pneumonia and meningitis, and of secondary infections subsequent to post-viral respiratory disease. The aim of this study was to investigate the incidence of invasive disease due to these pathogens during the early months of the COVID-19 pandemic.

Methods: In this prospective analysis of surveillance data, laboratories in 26 countries and territories across six continents submitted data on cases of invasive disease due to S pneumoniae, H influenzae, and N meningitidis from Jan 1, 2018, to May, 31, 2020, as part of the Invasive Respiratory Infection Surveillance (IRIS) Initiative. Numbers of weekly cases in 2020 were compared with corresponding data for 2018 and 2019. Data for invasive disease due to Streptococcus agalactiae, a non-respiratory pathogen, were collected from nine laboratories for comparison. The stringency of COVID-19 containment measures was quantified using the Oxford COVID-19 Government Response Tracker. Changes in population movements were assessed using Google COVID-19 Community Mobility Reports. Interrupted time-series modelling quantified changes in the incidence of invasive disease due to S pneumoniae, H influenzae, and N meningitidis in 2020 relative to when containment measures were imposed.

Findings: 27 laboratories from 26 countries and territories submitted data to the IRIS Initiative for S pneumoniae (62 837 total cases), 24 laboratories from 24 countries submitted data for H influenzae (7796 total cases), and 21 laboratories from 21 countries submitted data for N meningitidis (5877 total cases). All countries and territories had experienced a significant and sustained reduction in invasive diseases due to S pneumoniae, H influenzae, and N meningitidis in early 2020 (Jan 1 to May 31, 2020), coinciding with the introduction of COVID-19 containment measures in each country. By contrast, no significant changes in the incidence of invasive S agalactiae infections were observed. Similar trends were observed across most countries and territories despite differing stringency in COVID-19 control policies. The incidence of reported S pneumoniae infections decreased by 68% at 4 weeks (incidence rate ratio 0·32 [95% CI 0·27-0·37]) and 82% at 8 weeks (0·18 [0·14-0·23]) following the week in which significant changes in population movements were recorded.

Interpretation: The introduction of COVID-19 containment policies and public information campaigns likely reduced transmission of S pneumoniae, H influenzae, and N meningitidis, leading to a significant reduction in life-threatening invasive diseases in many countries worldwide.

Funding: Wellcome Trust (UK), Robert Koch Institute (Germany), Federal Ministry of Health (Germany), Pfizer, Merck, Health Protection Surveillance Centre (Ireland), SpID-Net project (Ireland), European Centre for Disease Prevention and Control (European Union), Horizon 2020 (European Commission), Ministry of Health (Poland), National Programme of Antibiotic Protection (Poland), Ministry of Science and Higher Education (Poland), Agencia de Salut Pública de Catalunya (Spain), Sant Joan de Deu Foundation (Spain), Knut and Alice Wallenberg Foundation (Sweden), Swedish Research Council (Sweden), Region Stockholm (Sweden), Federal Office of Public Health of Switzerland (Switzerland), and French Public Health Agency (France).

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Conflict of interest statement

Declaration of interests The following authors received support for work unrelated to this study: MPGvdL has received grants from Pfizer, Merck, and the Robert Koch Institut; RB has done contract research on behalf of Public Health England for GlaxoSmithKline, Pfizer, and Sanofi Pasteur, but received no personal remuneration; MC has received grants from Pfizer; SAC has done contract research on behalf of Public Health England for GlaxoSmithKline, Pfizer, and Sanofi Pasteur, but received no personal remuneration; SD has received a grant from Pfizer; SJG did contract research (carriage studies) for vaccine manufacturers (GlaxoSmithKline and Pfizer) on behalf of Public Health England, but received no personal remuneration; MH has received grants from Pfizer and the Federal Office of Public Health, and personal fees (for being on an advisory board) from Pfizer and Merck Sharp & Dohme; HH has received grants from Astellas and Pfizer; KAJ has received a grant from Wellcome Trust and personal fees from GlaxoSmithKline; SNL has done contract research for vaccine manufacturers (GlaxoSmithKline, Pfizer, and Sanofi Pasteur) on behalf of St. George's University of London, but received no personal remuneration; DJL has received grants from GlaxoSmithKline and Pfizer; SM has received a grant from Sanofi Pasteur; CM-A has received grants from Quiastat, Roche, Pfizer, and Genomica, and personal fees from Roche, Pfizer, and Qiagen; LS has received a grant from GlaxoSmithKline; H-CS has received a grant from Pfizer; MI has received non-financial support from GlaxoSmithKline and Pfizer, personal fees from Pfizer (speaker fees) and Merck Sharp & Dohme (speaker fees), and grants from Merck Sharp & Dohme; M-KT has received grants from GlaxoSmithKline, Pfizer, and Sanofi Pasteur; ASk has received grants and non-financial support from Pfizer, and personal fees from Pfizer, Merck Sharp & Dohme, and Sanofi Pasteur; CLS has received grants from Pfizer and GlaxoSmithKline for investigator-led research; EV has received grants on behalf of her institution (Intercommunal Hospital of Créteil) from Pfizer and Merck Sharp & Dohme; MT has received grants from GlaxoSmithKline and Pfizer; NKF's institution (Public Health England) has received funding for investigator-initiated research from GlaxoSmithKline, Pfizer, and other vaccine manufacturers (GlaxoSmithKline, Pfizer, and Affinivax), but NKF received no personal remuneration; AvG has received a grant from Sanofi Pasteur; NMvS has received a grant from Pfizer, a fee for service paid to their institution from Merck Sharp & Dohme and GlaxoSmithKline, and also has a patent (WO 2013/020090 A3) on vaccine development against Streptococcus pyogenes, unrelated to this study, with royalties paid to University of California San Diego, CA, USA; and MKT has a patent (630133) for a vaccine for serogroup X meningococcus with GlaxoSmithKline. All other authors declare no competing interests.

Figures

**Figure 1**
Cumulative number of invasive disease cases collected by Invasive Respiratory Infection Surveillance laboratories each week from Jan 1, 2018, to May 31, 2020 Data for *Streptococcus pneumoniae, Haemophilus influenzae*, and *Neisseria meningitidis* were obtained from Belgium, Brazil, Canada (*S pneumoniae* only), China (*S pneumoniae* and *H influenzae* only), Czech Republic, Denmark, England, Finland, France, Germany, Hong Kong, Iceland, Ireland, Israel (*S pneumoniae* and *H influenzae* only), Luxembourg, the Netherlands, New Zealand, Northern Ireland, Poland, Scotland, South Africa, South Korea (*S pneumoniae* and *H influenzae* only), Spain (*S pneumoniae* and *N meningitidis* only), Sweden, Switzerland (*S pneumoniae* and *H influenzae* only), and Wales. Data for *Streptococcus agalactiae* were obtained from Denmark, England, Finland, Germany, Iceland, Ireland, Israel, the Netherlands, and Poland. The grey dotted line (on week 11) shows when WHO officially declared the COVID-19 pandemic. ISO=International Organization for Standardization.

**Figure 2**
Annual invasive *Streptococcus pneumoniae* cases submitted to Invasive Respiratory Infection Surveillance laboratories in 26 countries and territories from Jan 1, 2018, to May 31, 2020 Coloured bars represent the mean weekly Oxford COVID-19 Government Response Tracker (OxCGRT) stringency index values on a scale from 0 to 100, with larger (darker) values indicating that higher stringency measures were enacted within a country. Data for South Korea were submitted from two surveillance networks, one of which started invasive disease surveillance in September, 2018, so data presented here for that hospital are only from September, 2018, onwards, whereas the data from the other hospital are from January, 2018, onwards. ISO=International Organization for Standardization.

**Figure 3**
Estimated country-specific incidence rate ratios for invasive disease due to *Streptococcus pneumoniae* following interruptions in population mobility during the COVID-19 pandemic Estimated country-specific incidence rate ratios calculated using an interrupted time series model that allows for a step (A) or slope (B) reduction in invasive disease. Estimated country-specific incidence rate ratios after 4 weeks (C) or 8 weeks (D) from the point at which national mobility was significantly interrupted (appendix p 4).

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Comment in

COVID-19 containment measures and incidence of invasive bacterial disease.
Smith DRM, Opatowski L. Smith DRM, et al. Lancet Digit Health. 2021 Jun;3(6):e331-e332. doi: 10.1016/S2589-7500(21)00085-6. Lancet Digit Health. 2021. PMID: 34044998 Free PMC article. No abstract available.

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References

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1. O'Brien KL, Wolfson LJ, Watt JP. Burden of disease caused by Streptococcus pneumoniae in children younger than 5 years: global estimates. Lancet. 2009;374:893–902. - PubMed
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[1] Weiser JN, Ferreira DM, Paton JC. Streptococcus pneumoniae: transmission, colonization and invasion. Nat Rev Microbiol. 2018;16:355–367. - PMC - PubMed

[2] Weiser JN, Ferreira DM, Paton JC. Streptococcus pneumoniae: transmission, colonization and invasion. Nat Rev Microbiol. 2018;16:355–367. - PMC - PubMed

[3] O'Brien KL, Wolfson LJ, Watt JP. Burden of disease caused by Streptococcus pneumoniae in children younger than 5 years: global estimates. Lancet. 2009;374:893–902. - PubMed

[4] O'Brien KL, Wolfson LJ, Watt JP. Burden of disease caused by Streptococcus pneumoniae in children younger than 5 years: global estimates. Lancet. 2009;374:893–902. - PubMed

[5] Marangu D, Zar HJ. Childhood pneumonia in low-and-middle-income countries: an update. Paediatr Respir Rev. 2019;32:3–9. - PMC - PubMed

[6] Marangu D, Zar HJ. Childhood pneumonia in low-and-middle-income countries: an update. Paediatr Respir Rev. 2019;32:3–9. - PMC - PubMed

[7] Acevedo R, Bai X, Borrow R. The Global Meningococcal Initiative meeting on prevention of meningococcal disease worldwide: epidemiology, surveillance, hypervirulent strains, antibiotic resistance and high-risk populations. Expert Rev Vaccines. 2019;18:15–30. - PubMed

[8] Acevedo R, Bai X, Borrow R. The Global Meningococcal Initiative meeting on prevention of meningococcal disease worldwide: epidemiology, surveillance, hypervirulent strains, antibiotic resistance and high-risk populations. Expert Rev Vaccines. 2019;18:15–30. - PubMed

[9] Troeger C, Blacker B, Khalil IA. Estimates of the global, regional, and national morbidity, mortality, and aetiologies of lower respiratory infections in 195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Infect Dis. 2018;18:1191–1210. - PMC - PubMed

[10] Troeger C, Blacker B, Khalil IA. Estimates of the global, regional, and national morbidity, mortality, and aetiologies of lower respiratory infections in 195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Infect Dis. 2018;18:1191–1210. - PMC - PubMed

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Changes in the incidence of invasive disease due to Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis during the COVID-19 pandemic in 26 countries and territories in the Invasive Respiratory Infection Surveillance Initiative: a prospective analysis of surveillance data

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Changes in the incidence of invasive disease due to Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis during the COVID-19 pandemic in 26 countries and territories in the Invasive Respiratory Infection Surveillance Initiative: a prospective analysis of surveillance data

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