Indigenous peoples and pandemics

Death on the permafrost: revisiting the 1918-1920 influenza pandemic in Alaska using death certificates

The 1918-1920 influenza pandemic devastated Alaska's Indigenous populations. We report on quantitative analyses of pandemic deaths due to pneumonia and influenza (P&I) using information from Alaska death certificates dating between 1915 and 1921 (n = 7147). Goals include a reassessment of pandemic death numbers, analysis of P&I deaths beyond 1919, estimates of excess mortality patterns overall and by age using intercensal population estimates based on Alaska's demographic history, and comparisons between Alaska Native (AN) and non-AN residents. Results indicate that ANs experienced 83% of all P&I deaths and 87% of all-cause excess deaths during the pandemic. Alaska Native mortality was 8.1 times higher than non-AN mortality. Analyses also uncovered previously unknown mortality peaks in 1920. Both subpopulations showed characteristically high mortality of young adults, possibly due to imprinting with the 1889-1890 pandemic virus, but their age-specific mortality patterns were different: non-AN mortality declined after age 25-29 and stayed relatively low for the elderly, while AN mortality increased after age 25-29, peaked at age 40-44, and remained high up to age 64. This suggests a relative lack of exposure to H1-type viruses pre-1889 among AN persons. In contrast, non-AN persons, often temporary residents, may have gained immunity before moving to Alaska.

Beyond COVID: towards a transdisciplinary synthesis for understanding responses and developing pandemic preparedness in Alaska

Pandemics are regularly occurring events, and there are foundational principles of pandemic preparation upon which communities, regions, states, and nations may draw upon for elevated preparedness against an inevitable future infectious disease threat. Many disciplines within the social sciences can provide crucial insight and transdisciplinary thinking for the development of preparedness measures. In 2023, the National Science Foundation funded a conference of circumpolar researchers and Indigenous partners to reflect on COVID-19-related research. In this article, we synthesise our diverse social science perspectives to: (1) identify potential areas of future pandemic-related research in Alaska, and (2) pose new research questions that elevate the needs of Alaska and its people, pursuant of a specific body of pandemic knowledge that takes into account the ecological and sociocultural contexts of the region. In doing so, we highlight important domains of research in the social sciences from transdisciplinary perspectives, including the centering of Indigenous knowledges and needs, the contexts of risk perception and resilience, food and housing security, and more. We highlight the contributions of social sciences to pandemic knowledge and provide a foundation for future pandemic-related research in Alaska.

Risk perception and reappraisal during the COVID-19 pandemic in southeast Alaska: Self-identified determinants of risk and protective health behaviors

Social and cultural context shapes how communities perceive health, well-being, and risk. Risk reappraisal can occur over time as a product of new information and improved understanding. We investigate risk perception and protective behaviors in Lingít Aaní (Southeast Alaska) during the first year of the COVID-19 pandemic. Surveys were circulated at two time points: (1) April-June 2020, before COVID-19 reached epidemic levels in the region, and (2) November 2020-February 2021. Ordinary least squares (OLS) regression models were used to analyze how demographic characteristics of the respondent population were related to risk perception. OLS models were again used to predict how individuals engaged in protective behaviors while controlling for risk perceptions. Controlling for demographic characteristics, risk perception increased as age increased for perceived risk of getting sick and dying from COVID-19, males perceived lower risk in general for all tested variables, and Alaska Native respondents perceived higher risk than non-Alaska Native respondents. Controlling for risk perception, results for protective behaviors were mixed; however, the strongest association identified was that knowing someone with a positive COVID-19 diagnosis increased protective behaviors. Between the two time points, risk perceptions increased significantly for variables related to oneself, others, and community members becoming infected with COVID-19. Protective behaviors like traveling less than normal, buying more cleaning products, and engaging in more subsistence gathering significantly increased. Identifying patterns of risk perception and protective behaviors, and especially how they change over time, are critical to developing place-specific public health recommendations, action, and preparedness plans against future infectious threats.

One hundred years of influenza A evolution

Leveraging the simplicity of nucleotide mismatch distributions, we provide an intuitive window into the evolution of the human influenza A 'nonstructural' (NS) gene segment. In an analysis suggested by the eminent Danish biologist Freddy B. Christiansen, we illustrate the existence of a continuous genetic "backbone" of influenza A NS sequences, steadily increasing in nucleotide distance to the 1918 root over more than a century. The 2009 influenza A/H1N1 pandemic represents a clear departure from this enduring genetic backbone. Utilizing nucleotide distance maps and phylogenetic analyses, we illustrate remaining uncertainties regarding the origin of the 2009 pandemic, highlighting the complexity of influenza evolution. The NS segment is interesting precisely because it experiences less pervasive positive selection, and departs less strongly from neutral evolution than e.g. the HA antigen. Consequently, sudden deviations from neutral diversification can indicate changes in other genes via the hitchhiking effect. Our approach employs two measures based on nucleotide mismatch counts to analyze the evolutionary dynamics of the NS gene segment. The rooted Hamming map of distances between a reference sequence and all other sequences over time, and the unrooted temporal Hamming distribution which captures the distribution of genotypic distances between simultaneously circulating viruses, thereby revealing patterns of nucleotide diversity and epi-evolutionary dynamics.

Comparative analysis of COVID-19 diagnoses and mortality among hospitalized indigenous and non-indigenous populations in Chile: 2020-2021

BACKGROUND

Current literature presents mixed effects of the COVID-19 pandemic on Indigenous communities. We aim to highlight potential disparities and temporal shifts in both the impact of COVID-19 and vaccine uptake among hospitalized Indigenous populations in Chile.

METHODS

We conducted an observational analysis utilizing 1,598,492 hospitalization records from 2020 to 2021 based on publicly accessible hospital discharge data spanning 65 healthcare facilities of medium and high complexity funded through the Diagnosis-Related Groups (DRG) mechanism in Chile, representing roughly 70% of the country's total hospitalizations. This was supplemented with publicly available municipal data on COVID-19 vaccinations and socio-demographic variables. We performed logistic regression analysis at 0.05 level of significance to assess the bivariate and multivariable association of Indigenous status with COVID-19 diagnosis and COVID-19 deaths among hospitalized populations. We also performed univariate and multiple linear regression to assess the association of COVID-19 vaccination rate and Indigenous status at the municipality level. In addition, we report the distribution of top 10 secondary diagnoses among hospitalized COVID-19 cases and deaths separately for Indigenous and non-Indigenous populations.

RESULTS

Indigenous populations displayed lower adjusted odds for both COVID-19 diagnosis (OR: 0.76, 95% CI: 0.74, 0.77) and death (OR: 0.91, 95% CI: 0.85, 0.97) when compared to non-Indigenous groups. Notably, the adjusted odds ratio for COVID-19 diagnosis in Indigenous populations rose from 0.59 (95% CI: 0.57, 0.61) in 2020 to 1.17 (95% CI: 1.13, 1.21) in 2021. Factors such as the significantly higher median age and greater number of comorbidities in the non-Indigenous hospitalized groups could account for their increased odds of COVID-19 diagnosis and mortality. Additionally, our data indicates a significantly negative adjusted association between COVID-19 vaccination rates and the proportion of Indigenous individuals.

CONCLUSION

Although Indigenous populations initially showed lower odds of COVID-19 diagnosis and mortality, a marked rise in diagnosis odds among these groups in 2021 underscores the urgency of targeted interventions. The observed negative association between the proportion of Indigenous populations and vaccination rates further underscores the necessity to tackle vaccine access barriers and work towards equitable distribution.

Prevalence and factors associated with healthcare avoidance during the COVID-19 pandemic among the Sámi in Sweden: the SámiHET study

The aim of this population-based cross-sectional study was to assess the prevalence of healthcare avoidance during the COVID-19 pandemic and its associated factors among the Sámi population in Sweden. Data from the "Sámi Health on Equal Terms" (SámiHET) survey conducted in 2021 were used. Overall, 3,658 individuals constituted the analytical sample. Analysis was framed using the social determinants of health framework. The association between healthcare avoidance and several sociodemographic, material, and cultural factors was explored through log-binomial regression analyses. Sampling weights were applied in all analyses. Thirty percent of the Sámi in Sweden avoided healthcare during the COVID-19 pandemic. Sámi women (PR: 1.52, 95% CI: 1.36-1.70), young adults (PR: 1.22, 95% CI:1.05-1.47), Sámi living outside Sápmi (PR: 1.17, 95% CI: 1.03-1.34), and those having low income (PR: 1.42, 95% CI:1.19-1.68) and experiencing economic stress (PR: 1.48, 95% CI: 1.31-1.67) had a higher prevalence of healthcare avoidance. The pattern shown in this study can be useful for planning future pandemic responses, which should address healthcare avoidance, particularly among the identified vulnerable groups, including the active participation of the Sámi themselves.

Age-specific mortality and the role of living remotely: The 1918-20 influenza pandemic in Kautokeino and Karasjok, Norway

The 1918-20 pandemic influenza killed 50-100 million people worldwide, but mortality varied by ethnicity and geography. In Norway, areas dominated by Sámi experienced 3-5 times higher mortality than the country's average. We here use data from burial registers and censuses to calculate all-cause excess mortality by age and wave in two remote Sámi areas of Norway 1918-20. We hypothesise that geographic isolation, less prior exposure to seasonal influenza, and thus less immunity led to higher Indigenous mortality and a different age distribution of mortality (higher mortality for all) than was typical for this pandemic in non-isolated majority populations (higher young adult mortality & sparing of the elderly). Our results show that in the fall of 1918 (Karasjok), winter of 1919 (Kautokeino), and winter of 1920 (Karasjok), young adults had the highest excess mortality, followed by also high excess mortality among the elderly and children. Children did not exhibit excess mortality in the second wave in Karasjok in 1920. It was not the young adults alone who produced the excess mortality in Kautokeino and Karasjok. We conclude that geographic isolation caused higher mortality among the elderly in the first and second waves, and among children in the first wave.

Indigenous communities and influenza: protocol for a systematic review and meta-analysis

BACKGROUND

Several studies have documented that specific Indigenous groups have been disproportionately affected by previous pandemics. The objective of this paper is to describe the protocol to be used in a review and meta-analysis of the literature on Indigenous groups and influenza. Using this protocol as a guide, a future study will provide a comprehensive historical overview of pre-COVID impact of influenza on Indigenous groups by combining data from the last five influenza pandemics and seasonal influenza up to date.

METHODS/PRINCIPLE FINDINGS

The review will include peer-reviewed original studies published in English, Spanish, Portuguese, Swedish, Danish, and Norwegian. Records will be identified through systematic literature search in eight databases: Embase, MEDLINE, CINAHL, Web of Science, Academic Search Ultimate, SocINDEX, ASSIA, and Google Scholar. Results will be summarized narratively and using meta-analytic strategies.

DISCUSSION

To our knowledge, there is no systematic review combining historical data on the impact of both seasonal and pandemic influenza on Indigenous populations. By summarizing results within and across Indigenous groups, different countries, and historical periods, as well as research in six different languages, we aim to provide information on how strong the risk for influenza is among Indigenous groups and how consistent this risk is across groups, regions, time, and seasonal versus the specific pandemic influenza strains.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021246391.

Incorporating resilience when assessing pandemic risk in the Arctic: a case study of Alaska

The discourse on vulnerability to COVID-19 or any other pandemic is about the susceptibility to the effects of disease outbreaks. Over time, vulnerability has been assessed through various indices calculated using a confluence of societal factors. However, categorising Arctic communities, without considering their socioeconomic, cultural and demographic uniqueness, into the high and low continuum of vulnerability using universal indicators will undoubtedly result in the underestimation of the communities' capacity to withstand and recover from pandemic exposure. By recognising vulnerability and resilience as two separate but interrelated dimensions, this study reviews the Arctic communities' ability to cope with pandemic risks. In particular, we have developed a pandemic vulnerability-resilience framework for Alaska to examine the potential community-level risks of COVID-19 or future pandemics. Based on the combined assessment of the vulnerability and resilience indices, we found that not all highly vulnerable census areas and boroughs had experienced COVID-19 epidemiological outcomes with similar severity. The more resilient a census area or borough is, the lower the cumulative death per 100 000 and case fatality ratio in that area. The insight that pandemic risks are the result of the interaction between vulnerability and resilience could help public officials and concerned parties to accurately identify the populations and communities at most risk or with the greatest need, which, in turn, helps in the efficient allocation of resources and services before, during and after a pandemic. A resilience-vulnerability-focused approach described in this paper can be applied to assess the potential effect of COVID-19 and similar future health crises in remote regions or regions with large Indigenous populations in other parts of the world.

Risk perception, adaptation, and resilience during the COVID-19 pandemic in Southeast Alaska Natives

Indigenous communities worldwide are at higher risk of negative pandemic outcomes, and communities Indigenous to the Arctic are disproportionately affected compared to national majorities. Despite this, their experiences have scarcely been investigated qualitatively and from their own perspectives. We collected and analyzed 22 structured interviews in three Southeast Alaska island communities (Sitka, Hoonah, and Kake) to learn about their perceptions of and experiences with the COVID-19 pandemic. Interviews were analyzed with thematic qualitative analysis in Dedoose. Four primary categories were identified within which to discuss risk and resilience in Southeast Alaska: (1) risk perception, (2) socioeconomic impacts, (3) reactions to public health guidelines, and (4) coping. Primary findings indicate that Southeast Alaska Native communities display considerable resilience and adaptive flexibility despite the significant adversity imposed by the COVID-19 pandemic. Southeast Alaska Native people use historical and traditional knowledge to culturally ground adaptive behaviors to cope with the threat of COVID-19. Interviewees expressed that adaptive, community-centered, and non-individualistic behaviors strongly tied to Native culture minimized the negative epidemiological impacts of the pandemic. Future research can more deeply explore the root causes of the need for adaptiveness and resilience, such as histories of colonialism and marginalization, to emergency situations in Indigenous communities.

Investigating COVID-19 transmission and mortality differences between indigenous and non-indigenous populations in Mexico

OBJECTIVES

Indigenous populations have been disproportionately affected during pandemics. We investigated COVID-19 mortality estimates among indigenous and non-indigenous populations at national and sub-national levels in Mexico.

METHODS

We obtained data from the Ministry of Health, Mexico, on 2,173,036 laboratory-confirmed RT-PCR positive COVID-19 cases and 238,803 deaths. We estimated mortality per 1000 person-weeks, mortality rate ratio (RR) among indigenous vs. non-indigenous groups, and hazard ratio (HR) for COVID-19 deaths across four waves of the pandemic, from February 2020 to March 2022. We also assessed differences in the reproduction number (R_t).

RESULTS

The mortality rate among indigenous populations of Mexico was 68% higher than that of non-indigenous groups. Out of 32 federal entities, 23 exhibited higher mortality rates among indigenous groups (P < 0.05 in 13 entities). The fourth wave showed the highest RR (2.40). The crude HR was 1.67 (95% CI: 1.62, 1.72), which decreased to 1.08 (95% CI: 1.04, 1.11) after controlling for other covariates. During the intense fourth wave, the R_t among the two groups was comparable.

CONCLUSION

Indigenous status is a significant risk factor for COVID-19 mortality in Mexico. Our findings may reflect disparities in non-pharmaceutical (e.g., handwashing and using facemasks), and COVID-19 vaccination interventions among indigenous and non-indigenous populations in Mexico.