Objectives: To assess the extent to which the 2018-19 New South Wales summer influenza epidemic was associated with overseas or domestic travel and with seasonal influenza vaccination status.
Design, setting: Unmatched case-control study, based on an online survey distributed from the NSW Notifiable Conditions Information Management System (NCIMS) to people for whom mobile phone numbers were available.
Participants: A case was defined as a person with notified laboratory-confirmed influenza with onset of illness between 1 December 2018 and 21 March 2019. People with notified pertussis infections (confirmed or probable) were selected as controls.
Main outcome measures: Notified influenza infection, by travel and contact with unwell overseas travellers in the week before onset of illness and seasonal influenza vaccination status (as the primary exposures).
Results: Valid survey responses were provided by 648 of 2806 invited people with notified influenza (23%) and 257 of 796 invited people with notified pertussis (32%). The demographic characteristics of the respondents were similar to those of the source population (7251 cases, 2254 controls). During the first two months of the summer of 2018-19, notified influenza was more likely for people who had travelled overseas or had contact with an ill overseas traveller in the week before symptom onset (adjusted OR [aOR], 6.99; 95% CI, 3.59-13.6), but not during the second two months (aOR, 1.63; 95% CI, 0.79-3.35). Influenza vaccination status was not associated with the likelihood of notified influenza.
Conclusions: Travel-related factors were early drivers of the 2018-19 NSW summer influenza epidemic; local transmission sustained the outbreak despite unfavourable conditions later in summer. Our findings prompted re-evaluation of recommendations for pre-travel vaccination in NSW. The role of travel in out-of-season influenza outbreaks should be considered in other temperate zones.