Important changes in the timing of influenza epidemics in the WHO European Region over the past 20 years: virological surveillance 1996 to 2016.

IntroductionThe global epidemiology of many infectious diseases is changing, but little attention has been paid to whether the timing of seasonal influenza epidemics changed in recent years. This study investigated whether the timing of the peak of influenza epidemics has changed in countries of the World Health Organization (WHO) European Region between 1996 and 2016. 
 Surveillance data were obtained from the WHO FluNet database. For each country and season (July to June of the next year), the peak was defined as the week with the highest 3-week moving average for reported cases. Linear regression models were used to test for temporal trends in the timing of the epidemic peak in each country and to determine whether this differed geographically. 
 More than 600,000 influenza cases were included from 38 countries of the WHO European Region. The timing of the epidemic peak changed according to a longitudinal gradient, occurring progressively later in Western Europe (e.g. by 2.8 days/season in Spain) and progressively earlier in Eastern Europe (e.g. by 3.5 days/season in the Russian Federation). 
 These results were confirmed in several sensitivity analyses. Our findings have implications for influenza control and prevention measures in the WHO European Region, for instance for the implementation of influenza vaccination campaigns.