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Jüni P, Rothenbühler M, Bobos P, Thorpe KE, da Costa BR, Fisman DN, Slutsky AS, Gesink D. Effets du climat et des interventions de santé publique sur la pandémie de COVID-19 : une étude de cohorte prospective. CMAJ 2020; 192:E1374-E1382. [PMID: 33139430 DOI: 10.1503/cmaj.200920-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2020] [Indexed: 11/01/2022] Open
Affiliation(s)
- Peter Jüni
- Centre de recherche en santé appliquée (Jüni, Rothenbühler, Bobos, Thorpe, da Costa, Slutsky) Institut du savoir Li Ka Shing, Hôpital St. Michael; Département de médecine et Institut des politiques, de la gestion et de l'évaluation de la santé (Jüni), Université de Toronto, Toronto, Ont.; Ava AG (Rothenbühler), Zürich, Suisse; Département des sciences de la santé et de la réadaptation (Bobos), Université Western, London, Ont.; École Dalla Lana de santé publique (Thorpe, Fisman, Gesink), Université de Toronto, Toronto, Ont.; Institut des soins de santé primaires (da Costa), Université de Berne, Suisse; Division interdépartmentale de médecine de soins intensifs (Slutsky), Université de Toronto, Toronto, Ont.
| | - Martina Rothenbühler
- Centre de recherche en santé appliquée (Jüni, Rothenbühler, Bobos, Thorpe, da Costa, Slutsky) Institut du savoir Li Ka Shing, Hôpital St. Michael; Département de médecine et Institut des politiques, de la gestion et de l'évaluation de la santé (Jüni), Université de Toronto, Toronto, Ont.; Ava AG (Rothenbühler), Zürich, Suisse; Département des sciences de la santé et de la réadaptation (Bobos), Université Western, London, Ont.; École Dalla Lana de santé publique (Thorpe, Fisman, Gesink), Université de Toronto, Toronto, Ont.; Institut des soins de santé primaires (da Costa), Université de Berne, Suisse; Division interdépartmentale de médecine de soins intensifs (Slutsky), Université de Toronto, Toronto, Ont
| | - Pavlos Bobos
- Centre de recherche en santé appliquée (Jüni, Rothenbühler, Bobos, Thorpe, da Costa, Slutsky) Institut du savoir Li Ka Shing, Hôpital St. Michael; Département de médecine et Institut des politiques, de la gestion et de l'évaluation de la santé (Jüni), Université de Toronto, Toronto, Ont.; Ava AG (Rothenbühler), Zürich, Suisse; Département des sciences de la santé et de la réadaptation (Bobos), Université Western, London, Ont.; École Dalla Lana de santé publique (Thorpe, Fisman, Gesink), Université de Toronto, Toronto, Ont.; Institut des soins de santé primaires (da Costa), Université de Berne, Suisse; Division interdépartmentale de médecine de soins intensifs (Slutsky), Université de Toronto, Toronto, Ont
| | - Kevin E Thorpe
- Centre de recherche en santé appliquée (Jüni, Rothenbühler, Bobos, Thorpe, da Costa, Slutsky) Institut du savoir Li Ka Shing, Hôpital St. Michael; Département de médecine et Institut des politiques, de la gestion et de l'évaluation de la santé (Jüni), Université de Toronto, Toronto, Ont.; Ava AG (Rothenbühler), Zürich, Suisse; Département des sciences de la santé et de la réadaptation (Bobos), Université Western, London, Ont.; École Dalla Lana de santé publique (Thorpe, Fisman, Gesink), Université de Toronto, Toronto, Ont.; Institut des soins de santé primaires (da Costa), Université de Berne, Suisse; Division interdépartmentale de médecine de soins intensifs (Slutsky), Université de Toronto, Toronto, Ont
| | - Bruno R da Costa
- Centre de recherche en santé appliquée (Jüni, Rothenbühler, Bobos, Thorpe, da Costa, Slutsky) Institut du savoir Li Ka Shing, Hôpital St. Michael; Département de médecine et Institut des politiques, de la gestion et de l'évaluation de la santé (Jüni), Université de Toronto, Toronto, Ont.; Ava AG (Rothenbühler), Zürich, Suisse; Département des sciences de la santé et de la réadaptation (Bobos), Université Western, London, Ont.; École Dalla Lana de santé publique (Thorpe, Fisman, Gesink), Université de Toronto, Toronto, Ont.; Institut des soins de santé primaires (da Costa), Université de Berne, Suisse; Division interdépartmentale de médecine de soins intensifs (Slutsky), Université de Toronto, Toronto, Ont
| | - David N Fisman
- Centre de recherche en santé appliquée (Jüni, Rothenbühler, Bobos, Thorpe, da Costa, Slutsky) Institut du savoir Li Ka Shing, Hôpital St. Michael; Département de médecine et Institut des politiques, de la gestion et de l'évaluation de la santé (Jüni), Université de Toronto, Toronto, Ont.; Ava AG (Rothenbühler), Zürich, Suisse; Département des sciences de la santé et de la réadaptation (Bobos), Université Western, London, Ont.; École Dalla Lana de santé publique (Thorpe, Fisman, Gesink), Université de Toronto, Toronto, Ont.; Institut des soins de santé primaires (da Costa), Université de Berne, Suisse; Division interdépartmentale de médecine de soins intensifs (Slutsky), Université de Toronto, Toronto, Ont
| | - Arthur S Slutsky
- Centre de recherche en santé appliquée (Jüni, Rothenbühler, Bobos, Thorpe, da Costa, Slutsky) Institut du savoir Li Ka Shing, Hôpital St. Michael; Département de médecine et Institut des politiques, de la gestion et de l'évaluation de la santé (Jüni), Université de Toronto, Toronto, Ont.; Ava AG (Rothenbühler), Zürich, Suisse; Département des sciences de la santé et de la réadaptation (Bobos), Université Western, London, Ont.; École Dalla Lana de santé publique (Thorpe, Fisman, Gesink), Université de Toronto, Toronto, Ont.; Institut des soins de santé primaires (da Costa), Université de Berne, Suisse; Division interdépartmentale de médecine de soins intensifs (Slutsky), Université de Toronto, Toronto, Ont
| | - Dionne Gesink
- Centre de recherche en santé appliquée (Jüni, Rothenbühler, Bobos, Thorpe, da Costa, Slutsky) Institut du savoir Li Ka Shing, Hôpital St. Michael; Département de médecine et Institut des politiques, de la gestion et de l'évaluation de la santé (Jüni), Université de Toronto, Toronto, Ont.; Ava AG (Rothenbühler), Zürich, Suisse; Département des sciences de la santé et de la réadaptation (Bobos), Université Western, London, Ont.; École Dalla Lana de santé publique (Thorpe, Fisman, Gesink), Université de Toronto, Toronto, Ont.; Institut des soins de santé primaires (da Costa), Université de Berne, Suisse; Division interdépartmentale de médecine de soins intensifs (Slutsky), Université de Toronto, Toronto, Ont
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Jüni P, Rothenbühler M, Bobos P, Thorpe KE, da Costa BR, Fisman DN, Slutsky AS, Gesink D. Impact of climate and public health interventions on the COVID-19 pandemic: a prospective cohort study. CMAJ 2020; 192:E566-E573. [PMID: 32385067 DOI: 10.1503/cmaj.200920] [Citation(s) in RCA: 134] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND It is unclear whether seasonal changes, school closures or other public health interventions will result in a slowdown of the current coronavirus disease 2019 (COVID-19) pandemic. We aimed to determine whether epidemic growth is globally associated with climate or public health interventions intended to reduce transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). METHODS We performed a prospective cohort study of all 144 geopolitical areas worldwide (375 609 cases) with at least 10 COVID-19 cases and local transmission by Mar. 20, 2020, excluding China, South Korea, Iran and Italy. Using weighted random-effects regression, we determined the association between epidemic growth (expressed as ratios of rate ratios [RRR] comparing cumulative counts of COVID-19 cases on Mar. 27, 2020, with cumulative counts on Mar. 20, 2020) and latitude, temperature, humidity, school closures, restrictions of mass gatherings, and measures of social distancing during an exposure period 14 days previously (Mar. 7 to 13, 2020). RESULTS In univariate analyses, there were no associations of epidemic growth with latitude and temperature, but weak negative associations with relative humidity (RRR per 10% 0.91, 95% confidence interval [CI] 0.85-0.96) and absolute humidity (RRR per 5 g/m3 0.92, 95% CI 0.85-0.99). Strong associations were found for restrictions of mass gatherings (RRR 0.65, 95% CI 0.53-0.79), school closures (RRR 0.63, 95% CI 0.52-0.78) and measures of social distancing (RRR 0.62, 95% CI 0.45-0.85). In a multivariable model, there was a strong association with the number of implemented public health interventions (p for trend = 0.001), whereas the association with absolute humidity was no longer significant. INTERPRETATION Epidemic growth of COVID-19 was not associated with latitude and temperature, but may be associated weakly with relative or absolute humidity. Conversely, public health interventions were strongly associated with reduced epidemic growth.
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Affiliation(s)
- Peter Jüni
- Applied Health Research Centre (Jüni, Rothenbühler, Bobos, Thorpe, da Costa, Slutsky) Li Ka Shing Knowledge Institute of St. Michael's Hospital; Department of Medicine and Institute of Health Policy, Management and Evaluation (Jüni), University of Toronto, Toronto, Ont.; Ava AG (Rothenbühler), Zürich, Switzerland; Department of Health and Rehabilitation Sciences (Bobos), Western University, London, Ont.; Dalla Lana School of Public Health (Thorpe, Fisman, Gesink), University of Toronto, Toronto, Ont.; Institute of Primary Health Care (da Costa), University of Bern, Switzerland; Interdepartmental Division of Critical Care Medicine (Slutsky), University of Toronto, Toronto, Ont.
| | - Martina Rothenbühler
- Applied Health Research Centre (Jüni, Rothenbühler, Bobos, Thorpe, da Costa, Slutsky) Li Ka Shing Knowledge Institute of St. Michael's Hospital; Department of Medicine and Institute of Health Policy, Management and Evaluation (Jüni), University of Toronto, Toronto, Ont.; Ava AG (Rothenbühler), Zürich, Switzerland; Department of Health and Rehabilitation Sciences (Bobos), Western University, London, Ont.; Dalla Lana School of Public Health (Thorpe, Fisman, Gesink), University of Toronto, Toronto, Ont.; Institute of Primary Health Care (da Costa), University of Bern, Switzerland; Interdepartmental Division of Critical Care Medicine (Slutsky), University of Toronto, Toronto, Ont
| | - Pavlos Bobos
- Applied Health Research Centre (Jüni, Rothenbühler, Bobos, Thorpe, da Costa, Slutsky) Li Ka Shing Knowledge Institute of St. Michael's Hospital; Department of Medicine and Institute of Health Policy, Management and Evaluation (Jüni), University of Toronto, Toronto, Ont.; Ava AG (Rothenbühler), Zürich, Switzerland; Department of Health and Rehabilitation Sciences (Bobos), Western University, London, Ont.; Dalla Lana School of Public Health (Thorpe, Fisman, Gesink), University of Toronto, Toronto, Ont.; Institute of Primary Health Care (da Costa), University of Bern, Switzerland; Interdepartmental Division of Critical Care Medicine (Slutsky), University of Toronto, Toronto, Ont
| | - Kevin E Thorpe
- Applied Health Research Centre (Jüni, Rothenbühler, Bobos, Thorpe, da Costa, Slutsky) Li Ka Shing Knowledge Institute of St. Michael's Hospital; Department of Medicine and Institute of Health Policy, Management and Evaluation (Jüni), University of Toronto, Toronto, Ont.; Ava AG (Rothenbühler), Zürich, Switzerland; Department of Health and Rehabilitation Sciences (Bobos), Western University, London, Ont.; Dalla Lana School of Public Health (Thorpe, Fisman, Gesink), University of Toronto, Toronto, Ont.; Institute of Primary Health Care (da Costa), University of Bern, Switzerland; Interdepartmental Division of Critical Care Medicine (Slutsky), University of Toronto, Toronto, Ont
| | - Bruno R da Costa
- Applied Health Research Centre (Jüni, Rothenbühler, Bobos, Thorpe, da Costa, Slutsky) Li Ka Shing Knowledge Institute of St. Michael's Hospital; Department of Medicine and Institute of Health Policy, Management and Evaluation (Jüni), University of Toronto, Toronto, Ont.; Ava AG (Rothenbühler), Zürich, Switzerland; Department of Health and Rehabilitation Sciences (Bobos), Western University, London, Ont.; Dalla Lana School of Public Health (Thorpe, Fisman, Gesink), University of Toronto, Toronto, Ont.; Institute of Primary Health Care (da Costa), University of Bern, Switzerland; Interdepartmental Division of Critical Care Medicine (Slutsky), University of Toronto, Toronto, Ont
| | - David N Fisman
- Applied Health Research Centre (Jüni, Rothenbühler, Bobos, Thorpe, da Costa, Slutsky) Li Ka Shing Knowledge Institute of St. Michael's Hospital; Department of Medicine and Institute of Health Policy, Management and Evaluation (Jüni), University of Toronto, Toronto, Ont.; Ava AG (Rothenbühler), Zürich, Switzerland; Department of Health and Rehabilitation Sciences (Bobos), Western University, London, Ont.; Dalla Lana School of Public Health (Thorpe, Fisman, Gesink), University of Toronto, Toronto, Ont.; Institute of Primary Health Care (da Costa), University of Bern, Switzerland; Interdepartmental Division of Critical Care Medicine (Slutsky), University of Toronto, Toronto, Ont
| | - Arthur S Slutsky
- Applied Health Research Centre (Jüni, Rothenbühler, Bobos, Thorpe, da Costa, Slutsky) Li Ka Shing Knowledge Institute of St. Michael's Hospital; Department of Medicine and Institute of Health Policy, Management and Evaluation (Jüni), University of Toronto, Toronto, Ont.; Ava AG (Rothenbühler), Zürich, Switzerland; Department of Health and Rehabilitation Sciences (Bobos), Western University, London, Ont.; Dalla Lana School of Public Health (Thorpe, Fisman, Gesink), University of Toronto, Toronto, Ont.; Institute of Primary Health Care (da Costa), University of Bern, Switzerland; Interdepartmental Division of Critical Care Medicine (Slutsky), University of Toronto, Toronto, Ont
| | - Dionne Gesink
- Applied Health Research Centre (Jüni, Rothenbühler, Bobos, Thorpe, da Costa, Slutsky) Li Ka Shing Knowledge Institute of St. Michael's Hospital; Department of Medicine and Institute of Health Policy, Management and Evaluation (Jüni), University of Toronto, Toronto, Ont.; Ava AG (Rothenbühler), Zürich, Switzerland; Department of Health and Rehabilitation Sciences (Bobos), Western University, London, Ont.; Dalla Lana School of Public Health (Thorpe, Fisman, Gesink), University of Toronto, Toronto, Ont.; Institute of Primary Health Care (da Costa), University of Bern, Switzerland; Interdepartmental Division of Critical Care Medicine (Slutsky), University of Toronto, Toronto, Ont
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Matsuoka T, Sato T, Akita T, Yanagida J, Ohge H, Kuwabara M, Tanaka J. High Vaccination Coverage among Children during Influenza A(H1N1)pdm09 as a Potential Factor of Herd Immunity. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2016; 13:ijerph13101017. [PMID: 27763532 PMCID: PMC5086756 DOI: 10.3390/ijerph13101017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 10/05/2016] [Accepted: 10/06/2016] [Indexed: 11/24/2022]
Abstract
The objective of this study was to identify factors related to the expansion of infection and prevention of influenza A(H1N1)pdm09. A retrospective non-randomized cohort study (from June 2009 to May 2010) on influenza A(H1N1)pdm09 was conducted in a sample of residents from Hiroshima Prefecture, Japan. The cumulative incidence of the influenza A(H1N1)pdm09 and the pandemic vaccine effectiveness (VE) were estimated. The response rate was 53.5% (178,669/333,892). Overall, the odds ratio of non-vaccinated group to vaccinated group for cumulative incidence of influenza A(H1N1)pdm09 was 2.18 (95% confidence interval (CI): 2.13–2.23) and the VE was 43.9% (CI: 42.8–44.9). The expansion of infection, indicating the power of transmission from infected person to susceptible person, was high in the 7–15 years age groups in each area. In conclusion, results from this survey suggested that schoolchildren-based vaccination rate participates in determining the level of herd immunity to influenza and children might be the drivers of influenza transmission. For future pandemic preparedness, vaccination of schoolchildren may help to prevent disease transmission during influenza outbreak.
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Affiliation(s)
- Toshihiko Matsuoka
- Department of Epidemiology, Infectious Disease Control and Prevention, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8551, Japan.
| | - Tomoki Sato
- Department of Epidemiology, Infectious Disease Control and Prevention, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8551, Japan.
| | - Tomoyuki Akita
- Department of Epidemiology, Infectious Disease Control and Prevention, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8551, Japan.
| | - Jiturou Yanagida
- Hiroshima City Funairi Citizens Hospital, Hiroshima 730-0844, Japan.
| | - Hiroki Ohge
- Department of Infectious Diseases, Hiroshima University Hospital, Hiroshima 734-8551, Japan.
| | - Masao Kuwabara
- Hiroshima Prefectural Center for Disease Control and Prevention, Hiroshima 734-0007, Japan.
| | - Junko Tanaka
- Department of Epidemiology, Infectious Disease Control and Prevention, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8551, Japan.
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Uchida M, Kaneko M, Yamamoto H, Honda T, Kawa S. [Effects of school closure during influenza A/H1N1 pandemic in 2009 in Japan]. Nihon Eiseigaku Zasshi 2013; 68:103-117. [PMID: 23718972 DOI: 10.1265/jjh.68.103] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Schools were closed worldwide during the 2009 influenza A/H1N1 pandemic to prevent the viral spread; however, to date, there has been insufficient evidence to conclude that the closures were beneficial. Therefore, in the present review, we evaluated the effects of school closure during the 2009 influenza A/H1N1 pandemic in Japan. A search of PubMed and Japanese journals identified 24 articles that evaluated the effects of school closure using the following methods: descriptive epidemiology, changes in absenteeism rate, a simulation model, and reproductive number. Almost all of the retrieved studies showed that school closure effectively reduced the number of new infections and thus subsequently suppressed the epidemic. On the other hand, two major sets of confounding variables were identified. First, the effect of school closure was confounded by the methods used to measure, viral infectivity, subject characteristics, increased immunization rates, nonpharmaceutical interventions, antiviral administration, student contact patterns during school closure, and individual household environments. Secondly, school closure implementation was affected by differences between proactive and reactive closures, differences between seasonal and pandemic influenza, decision factors regarding school closure, socioeconomic cost, and ethics of imposing restrictions on individuals. Therefore, a comprehensive, longitudinal study is necessary to clarify the effects of school closure during viral pandemics.
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Affiliation(s)
- Mitsuo Uchida
- Center for Health, Safety and Environmental Management, Shinshu University
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Pascalis H, Temmam S, Wilkinson DA, Dsouli N, Turpin M, de Lamballerie X, Dellagi K. Molecular evolutionary analysis of pH1N1 2009 influenza virus in Reunion Island, South West Indian Ocean region: a cohort study. PLoS One 2012; 7:e43742. [PMID: 22952752 PMCID: PMC3428279 DOI: 10.1371/journal.pone.0043742] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Accepted: 07/23/2012] [Indexed: 01/08/2023] Open
Abstract
Background/Objectives Molecular epidemiology is a powerful tool to decipher the dynamics of viral transmission, quasispecies temporal evolution and origins. Little is known about the pH1N1 molecular dynamics in general population. A prospective study (CoPanFlu-RUN) was carried out in Reunion Island to characterize pH1N1 genetic variability and molecular evolution occurring in population during the pH1N1 Influenza pandemic in 2009. Methodology We directly amplified pH1N1 genomes from 28 different nasal swabs (26 individuals from 21 households). Fifteen strains were fully sequenced and 13 partially. This includes pairs of sequences from different members of 5 separate households; and two pairs from individuals, collected at different times. We assessed the molecular evolution of pH1N1 by genetic variability and phylogenetic analyses. Principal Findings We found that i) Reunion pH1N1 sequences stemmed from global “clade 7” but shaped two phylogenetic sub-clades; ii) D239E mutation was identified in the hemagglutinin protein of all Reunion sequences, a mutation which has been associated elsewhere with mild-, upper-respiratory tract pH1N1 infecting strains; iii) Date estimates from molecular phylogenies predicted clade emergence some time before the first detection of pH1N1 by the epidemiological surveillance system; iv) Phylogenetic relatedness was observed between Reunion pH1N1 viruses and those from other countries in South-western Indian Ocean area; v) Quasispecies populations were observed within households and individuals of the cohort-study. Conclusions Surveillance and/or prevention systems presently based on Influenza virus sequence variation should take into account that the majority of studies of pH1N1 Influenza generate genetic data for the HA/NA viral segments obtained from hospitalized-patients, which is potentially non-representative of the overall viral diversity within whole populations. Our observations highlight the importance of collecting unbiased data at the community level and conducting whole genome analysis to accurately understand viral dynamics.
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Affiliation(s)
- Hervé Pascalis
- GIS CRVOI, Centre de Recherche et de Veille sur maladies émergentes dans l'Océan Indien, Plateforme technologique CYROI, Saint-Denis, La Réunion, France.
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Kom Mogto CA, De Serres G, Douville Fradet M, Lebel G, Toutant S, Gilca R, Ouakki M, Janjua NZ, Skowronski DM. School absenteeism as an adjunct surveillance indicator: experience during the second wave of the 2009 H1N1 pandemic in Quebec, Canada. PLoS One 2012; 7:e34084. [PMID: 22479531 PMCID: PMC3316605 DOI: 10.1371/journal.pone.0034084] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Accepted: 02/21/2012] [Indexed: 11/26/2022] Open
Abstract
Background A school absenteeism surveillance system was implemented in the province of Quebec, Canada during the second wave of the 2009 H1N1pandemic. This paper compares this surveillance approach with other available indicators. Method All (3432) elementary and high schools from Quebec were included. Each school was required to report through a web-based system any day where the proportion of students absent for influenza-like illness (ILI) exceeded 10% of current school enrolment. Results Between October 18 and December 12 2009, 35.6% of all schools met the 10% absenteeism threshold. This proportion was greater in elementary compared to high schools (40% vs 19%) and in smaller compared to larger schools (44% vs 22%). The maximum absenteeism rate was reached the first day of reporting or within the next two days in 55% and 31% of schools respectively. The first reports and subsequent peak in school absenteeism provincially preceded the peak in paediatric hospitalization by two and one weeks, respectively. Trends in school surveillance otherwise mirrored other indicators. Conclusion During a pandemic, school outbreak surveillance based on a 10% threshold appears insufficient to trigger timely intervention within a given affected school. However, school surveillance appears well-correlated and slightly anticipatory compared to other population indicators. As such, school absenteeism warrants further evaluation as an adjunct surveillance indicator whose overall utility will depend upon specified objectives, and other existing capacity for monitoring and response.
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