Antigenic drift and subtype interference shape A(H3N2) epidemic dynamics in the United States

Reviewer #1 (Public Review):

Summary:
The authors aimed to investigate the contribution of antigenic drift in the HA and NA genes of seasonal influenza A(H3N2) virus to their epidemic dynamics. Analyzing 22 influenza seasons before the COVID-19 pandemic, the study explored various antigenic and genetic markers, comparing them against indicators characterizing the epidemiology of annual outbreaks. The central findings highlight the significant influence of genetic distance on A(H3N2) virus epidemiology and emphasize the role of A(H1N1) virus incidence in shaping A(H3N2) epidemics, suggesting subtype interference as a key factor.

Major Strengths:
The paper is well-organized, written with clarity, and presents a comprehensive analysis. The study design, incorporating a span of 22 seasons, provides a robust foundation for understanding influenza dynamics. The inclusion of diverse antigenic and genetic markers enhances the depth of the investigation, and the exploration of subtype interference adds valuable insights.

Major Weaknesses:
While the analysis is thorough, some aspects require deeper interpretation, particularly in the discussion of certain results. Clarity and depth could be improved in the presentation of findings. Furthermore, the evolving dynamics of H3N2 predominance post-2009 need better elucidation.

Reviewer #2 (Public Review):

Summary: This paper aims to achieve a better understanding of how the antigenic or genetic compositions of the dominant influenza A viruses in circulation at a given time are related to key features of seasonal influenza epidemics in the US. To this end, the authors analyse an extensive dataset with a range of statistical, data science and machine learning methods. They find that the key drivers of influenza A epidemiological dynamics are interference between influenza A subtypes and genetic divergence, relative to the previous one or two seasons, in a broader range of antigenically related sites than previously thought.

Strengths: A thorough investigation of a large and complex dataset.

Weaknesses: The dataset covers a 21 year period which is substantial by epidemiological standards, but quite small from a statistical or machine learning perspective. In particular, it was not possible to follow the usual process and test predictive performance of the random forest model with an independent dataset.

Reviewer #3 (Public Review):

Summary:
This paper explores the relationships among evolutionary and epidemiological quantities in influenza, using a wide range of datasets and features, and using both correlations and random forests to examine, primarily, what are the drivers of influenza epidemics. It's a strong paper representing a thorough and fascinating exploration of potential drivers, and it makes a trove of relevant data readily available to the community.

Strengths:
This paper makes links between epidemiological and evolutionary data for influenza. Placing each in the context of the other is crucial for understanding influenza dynamics and evolution and this paper does a thorough job of this, with many analyses and nuances. The results on the extent to which evolutionary factors relate to epidemic burden, and on interference among influenza types, are particularly interesting. The github repository associated with the paper is clear, comprehensive, and well-documented.

Weaknesses:
The format of the results section can be hard to follow, and we suggest improving readability by restructuring and simplifying in some areas. There are a range of choices made about data preparation and scaling; the authors could explore sensitivity of the results to some of these.