title: Was rurality protective in the 1918 influenza pandemic in New Zealand?
abstract: OBJECTIVE
  This study aimed to examine the impact of rurality on mortality rates from pandemic influenza in New Zealand in 1918.
  
  
  METHODS
  Mortality data was obtained from death certificates (in a published source) and denominator population data from the 1916 census (for the European population only). Analyses were conducted on cities (n = 4), towns (n = 111), counties (n = 97).
  
  
  RESULTS
  The influenza mortality rate for the towns and cities was more than twice that of the counties that represented rural settings (rate ratio (RR) = 2.13, 95% CI = 2.00-2.27). However, larger towns (population >2000 people) had a significantly lower mortality rate than smaller towns (RR = 0.81, 95%CI = 0.74-0.88). Similarly, cities had a lower mortality rate than larger towns (RR = 0.89, 95%CI = 0.83-0.95).
  
  
  CONCLUSIONS
  These results are suggestive that rurality may have provided some protection from mortality during this influenza pandemic. This may have been due to a mix of remoteness and greater social distancing among rural residents. However, the differences in mortality rates between towns and cities may have reflected other factors such as the more organised provision of community care in the larger towns and cities, when compared to smaller towns.
authors.affiliation: University of Otago, Wellington.
authors.forename: Kirsten
authors.initials: K
authors.lastname: McSweeny
authors.forename: Atalie
authors.initials: A
authors.lastname: Colman
authors.forename: Nick
authors.initials: N
authors.lastname: Fancourt
authors.forename: Melinda
authors.initials: M
authors.lastname: Parnell
authors.forename: Sara
authors.initials: S
authors.lastname: Stantiall
authors.forename: Geoffrey
authors.initials: G
authors.lastname: Rice
authors.forename: Michael
authors.initials: M
authors.lastname: Baker
authors.forename: Nick
authors.initials: N
authors.lastname: Wilson
mesh_terms: D000293:Adolescent; D000328:Adult; D017677:Age Distribution; D000368:Aged; D002423:Cause of Death; D016001:Confidence Intervals; D004196:Disease Outbreaks; D005260:Female; D006801:Humans; D015994:Incidence; D007251:Influenza, Human / Q000453:epidemiology* / Q000517:prevention & control*; D008297:Male; D008875:Middle Aged; D009520:New Zealand / Q000453:epidemiology; D011336:Probability; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment; D012423:Rural Health; D012424:Rural Population; D017678:Sex Distribution; D014504:Urban Health