Characteristics of seasonal influenza A and B in Latin America: Influenza surveillance data from ten countries

The Nicaraguan Pediatric Influenza Cohort Study, 2011-2019: Influenza Incidence, Seasonality, and Transmission

BACKGROUND

Children account for a large portion of global influenza burden and transmission, and a better understanding of influenza in children is needed to improve prevention and control strategies.

METHODS

To examine the incidence and transmission of influenza we conducted a prospective community-based study of children aged 0-14 years in Managua, Nicaragua, between 2011 and 2019. Participants were provided with medical care through study physicians and symptomatic influenza was confirmed by reverse-transcription polymerase chain reaction (RT-PCR). Wavelet analyses were used to examine seasonality. Generalized growth models (GGMs) were used to estimate effective reproduction numbers.

RESULTS

From 2011 to 2019, 3016 children participated, with an average of ∼1800 participants per year and median follow-up time of 5 years per child, and 48.3% of the cohort in 2019 had been enrolled their entire lives. The overall incidence rates per 100 person-years were 14.5 symptomatic influenza cases (95% confidence interval [CI]: 13.9-15.1) and 1.0 influenza-associated acute lower respiratory infection (ALRI) case (95% CI: .8-1.1). Symptomatic influenza incidence peaked at age 9-11 months. Infants born during peak influenza circulation had lower incidence in the first year of their lives. The mean effective reproduction number was 1.2 (range 1.02-1.49), and we observed significant annual patterns for influenza and influenza A, and a 2.5-year period for influenza B.

CONCLUSIONS

This study provides important information for understanding influenza epidemiology and informing influenza vaccine policy. These results will aid in informing strategies to reduce the burden of influenza.

Human seasonal influenza under COVID-19 and the potential consequences of influenza lineage elimination

Annual epidemics of seasonal influenza cause hundreds of thousands of deaths, high levels of morbidity, and substantial economic loss. Yet, global influenza circulation has been heavily suppressed by public health measures and travel restrictions since the onset of the COVID-19 pandemic. Notably, the influenza B/Yamagata lineage has not been conclusively detected since April 2020, and A(H3N2), A(H1N1), and B/Victoria viruses have since circulated with considerably less genetic diversity. Travel restrictions have largely confined regional outbreaks of A(H3N2) to South and Southeast Asia, B/Victoria to China, and A(H1N1) to West Africa. Seasonal influenza transmission lineages continue to perish globally, except in these select hotspots, which will likely seed future epidemics. Waning population immunity and sporadic case detection will further challenge influenza vaccine strain selection and epidemic control. We offer a perspective on the potential short- and long-term evolutionary dynamics of seasonal influenza and discuss potential consequences and mitigation strategies as global travel gradually returns to pre-pandemic levels.

COVID-19 control measures have suppressed circulation of other infections including influenza. Here, the authors analyse WHO global influenza sequence and case report data and describe changes in the phylogenetic and geographic distribution of influenza lineages during the COVID-19 pandemic.

Seasonal Influenza Prevention and Control Progress in Latin America and the Caribbean in the Context of the Global Influenza Strategy and the COVID-19 Pandemic

Each year in Latin America and the Caribbean, seasonal influenza is associated with an estimated 36,500 respiratory deaths and 400,000 hospitalizations. Since the 2009 influenza A(H1N1) pandemic, the Region has made significant advances in the prevention and control of seasonal influenza, including improved surveillance systems, burden estimates, and vaccination of at-risk groups. The Global Influenza Strategy 2019–2030 provides a framework to strengthen these advances. Against the backdrop of this new framework, the University of Colorado convened in October 2020 its Immunization Advisory Group of Experts to review and discuss current surveillance, prevention, and control strategies for seasonal influenza in Latin America and the Caribbean, also in the context of the COVID-19 pandemic. This review identified five areas for action and made recommendations specific to each area. The Region should continue its efforts to strengthen surveillance and impact evaluations. Existing data on disease burden, seasonality patterns, and vaccination effectiveness should be used to inform decision-making at the country level as well as advocacy efforts for programmatic resources. Regional and country strategic plans should be prepared and include specific targets for 2030. Existing investments in influenza prevention and control, including for immunization programs, should be optimized. Finally, regional partnerships, such as the regional networks for syndromic surveillance and vaccine effectiveness evaluation (SARInet and REVELAC-i), should continue to play a critical role in continuous learning and standardization by sharing experiences and best practices among countries.

Reduction of Severe Exacerbations of COPD during COVID-19 Pandemic in Portugal: A Protective Role of Face Masks?

Viral infections are known to be the main trigger for Chronic obstructive pulmonary disease (COPD) exacerbations. Face masks are acknowledged for effective viral aerosol shedding reduction. COVID-19 pandemic generated an opportunity to study the impact of face masks and confinement on droplet transmission diseases, usually implicated in acute exacerbations of COPD (AECOPD). We aimed to evaluate the variation on severe AECOPD (sAECOPD) rate in a Portuguese COPD cohort during the first COVID-19 lockdown and following months. This retrospective self-controlled study enrolled 322 adult patients followed at COPD-specialized consultation in a tertiary hospital from February 2016 to July 2020, of whom 286 met inclusion criteria. Severe AECOPD events were registered from March 2020 (beginning of state of emergency) until July 2020. From 2016 to 2019 there was a mean of 38 patients per year with sAECOPD. During 2020, 11 patients experienced sAECOPD. Over the course of 2020 there was a 73.4% (p < 0.001) decrease in sAECOPD events comparing with previous years' average. After the end of State of Emergency, the rate of sAECOPD events also declined by 74.6% (p < 0.001) comparing with the same timeline of previous years. Results were consistent and statistically significant when comparing 2020 with each of previous years for every period of analysis. Our findings suggest a sustained decrease in the rate of sAECOPD during confinement and in the following months. The widespread use of face mask and social distancing during COVID-19 pandemic may play an important role in preventing the transmission of respiratory infections and consequently reducing sAECOPD.

Key Factors That Enable the Pandemic Potential of RNA Viruses and Inter-Species Transmission: A Systematic Review

Viruses play a primary role as etiological agents of pandemics worldwide. Although there has been progress in identifying the molecular features of both viruses and hosts, the extent of the impact these and other factors have that contribute to interspecies transmission and their relationship with the emergence of diseases are poorly understood. The objective of this review was to analyze the factors related to the characteristics inherent to RNA viruses accountable for pandemics in the last 20 years which facilitate infection, promote interspecies jump, and assist in the generation of zoonotic infections with pandemic potential. The search resulted in 48 research articles that met the inclusion criteria. Changes adopted by RNA viruses are influenced by environmental and host-related factors, which define their ability to adapt. Population density, host distribution, migration patterns, and the loss of natural habitats, among others, have been associated as factors in the virus-host interaction. This review also included a critical analysis of the Latin American context, considering its diverse and unique social, cultural, and biodiversity characteristics. The scarcity of scientific information is striking, thus, a call to local institutions and governments to invest more resources and efforts to the study of these factors in the region is key.

National retrospective cohort study to identify risk factors for in-hospital 30-day lethality in laboratory-confirmed cases of influenza

OBJECTIVE

To identify factors associated with the risk of death in adolescent and adult inpatients with laboratory-positive (reverse-transcription polymerase chain reaction) influenza in Mexico during consecutive influenza seasons (2018-2020).

PATIENTS AND METHODS

A retrospective cohort study used national surveillance system data, enrolling 3422 individuals. The association between various risk factors and 30-day in-hospital lethality were evaluated through risk ratios (RR) and 95% confidence intervals (CI).

RESULTS

The lethality rate was 18.1%. Flu vaccination history (RR = 0.56, 95% CI 0.42-0.78), early antiviral drug administration (≤ two days from symptom onset [reference ≥ 5 days], RR = 0.68, 95% CI 0.58-0.81), and a history of asthma (RR = 0.66, 95% CI 0.47-0.95) showed protective effects against influenza-attributable death. Mechanical ventilator support produced the highest increase in death risk (RR = 3.31, 95% CI 2.89-3.79). Male sex, older age, AH1N1 subtype, and other chronic diseases were also associated with fatal in-hospital influenza-related outcomes.

CONCLUSIONS

Our findings highlight the major relevance of promoting immunization in high-risk individuals, together with ensuring early and effective antiviral management in suspected influenza cases.

Completeness of open access FluNet influenza surveillance data for Pan-America in 2005-2019

For several decades, the World Health Organization has collected, maintained, and distributed invaluable country-specific disease surveillance data that allow experts to develop new analytical tools for disease tracking and forecasting. To capture the extent of available data within these sources, we proposed a completeness metric based on the effective time series length. Using FluNet records for 29 Pan-American countries from 2005 to 2019, we explored whether completeness was associated with health expenditure indicators adjusting for surveillance system heterogeneity. We observed steady improvements in completeness by 4.2–6.3% annually, especially after the A(H1N1)-2009 pandemic, when 24 countries reached > 95% completeness. Doubling in decadal health expenditure per capita was associated with ~ 7% increase in overall completeness. The proposed metric could navigate experts in assessing open access data quality and quantity for conducting credible statistical analyses, estimating disease trends, and developing outbreak forecasting systems.

National retrospective cohort study to identify risk factors for in-hospital 30-day lethality in laboratory-confirmed cases of influenza

OBJECTIVE

To identify factors associated with the risk of death in adolescent and adult inpatients with laboratory-positive (reverse-transcription polymerase chain reaction) influenza in Mexico during consecutive influenza seasons (2018-2020).

METHODS

A retrospective cohort study used national surveillance system data, enrolling 3.422 individuals. The association between various risk factors and 30-day in-hospital lethality were evaluated through risk ratios (RRs) and 95% confidence intervals (CIs).

RESULTS

The lethality rate was 18.1%. Flu vaccination history (RR=0.56, 95% CI 0.42-0.78), early antiviral drug administration (≤2 days from symptom onset [reference ≥5 days], RR=0.68, 95% CI 0.58-0.81), and a history of asthma (RR=0.66, 95% CI 0.47-0.95) showed protective effects against influenza-attributable death. Mechanical ventilator support produced the highest increase in death risk (RR=3.31, 95% CI 2.89-3.79). Male sex, older age, AH1N1 subtype, and other chronic diseases were also associated with fatal in-hospital influenza-related outcomes.

CONCLUSIONS

Our findings highlight the major relevance of promoting immunization in high-risk individuals, together with ensuring early and effective antiviral management in suspected influenza cases.

Impact of quadrivalent influenza vaccines in Brazil: a cost-effectiveness analysis using an influenza transmission model

BACKGROUND

Influenza epidemics significantly weight on the Brazilian healthcare system and its society. Public health authorities have progressively expanded recommendations for vaccination against influenza, particularly to the pediatric population. However, the potential mismatch between the trivalent influenza vaccine (TIV) strains and those circulating during the season remains an issue. Quadrivalent vaccines improves vaccines effectiveness by preventing any potential mismatch on influenza B lineages.

METHODS

We evaluate the public health and economic benefits of the switch from TIV to QIV for the pediatric influenza recommendation (6mo-5yo) by using a dynamic epidemiological model able to consider the indirect impact of vaccination. Results of the epidemiological model are then imputed in a health-economic model adapted to the Brazilian context. We perform deterministic and probabilistic sensitivity analysis to account for both epidemiological and economical sources of uncertainty.

RESULTS

Our results show that switching from TIV to QIV in the Brazilian pediatric population would prevent 406,600 symptomatic cases, 11,300 hospitalizations and almost 400 deaths by influenza season. This strategy would save 3400 life-years yearly for an incremental direct cost of R$169 million per year, down to R$86 million from a societal perspective. Incremental cost-effectiveness ratios for the switch would be R$49,700 per life-year saved and R$26,800 per quality-adjusted life-year gained from a public payer perspective, and even more cost-effective from a societal perspective. Our results are qualitatively similar in our sensitivity analysis.

CONCLUSIONS

Our analysis shows that switching from TIV to QIV to protect children aged 6mo to 5yo in the Brazilian influenza epidemiological context could have a strong public health impact and represent a cost-effective strategy from a public payer perspective, and a highly cost-effective one from a societal perspective.

Weathering the pandemic: How the Caribbean Basin can use viral and environmental patterns to predict, prepare, and respond to COVID-19

The 2020 coronavirus pandemic is developing at different paces throughout the world. Some areas, like the Caribbean Basin, have yet to see the virus strike at full force. When it does, there is reasonable evidence to suggest the consequent COVID‐19 outbreaks will overwhelm healthcare systems and economies. This is particularly concerning in the Caribbean as pandemics can have disproportionately higher mortality impacts on lower and middle‐income countries. Preliminary observations from our team and others suggest that temperature and climatological factors could influence the spread of this novel coronavirus, making spatiotemporal predictions of its infectiousness possible. This review studies geographic and time‐based distribution of known respiratory viruses in the Caribbean Basin in an attempt to foresee how the pandemic will develop in this region. This review is meant to aid in planning short‐ and long‐term interventions to manage outbreaks at the international, national, and subnational levels in the region.

Inter‐tropical regions have seen a slower spread of SARS‐CoV‐2 compared to temperate ones, suggesting viral spreading could likely be influenced by environmental factors.

Other coronaviruses also seem to respond to environmental factors, with peaks closely following the geotemporal patterns of influenza.

In the Caribbean, timing interventions to fight COVID‐19 around the projected peaks of influenza is a reasonable public health approach.

Epidemiology and Genetic Variability of Circulating Influenza B Viruses in Uruguay, 2012-2019

Influenza B viruses (IBV) are an important cause of morbidity and mortality during interpandemic periods in the human population. Two phylogenetically distinct IBV lineages, B/Yamagata and B/Victoria, co-circulate worldwide and they present challenges for vaccine strain selection. Until the present study, there was little information regarding the pattern of the circulating strains of IBV in Uruguay. A subset of positive influenza B samples from influenza-like illness (ILI) outpatients and severe acute respiratory illness (SARI) inpatients detected in sentinel hospitals in Uruguay during 2012–2019 were selected. The sequencing of the hemagglutinin (HA) and neuraminidase (NA) genes showed substitutions at the amino acid level. Phylogenetic analysis reveals the co-circulation of both lineages in almost all seasonal epidemics in Uruguay, and allows recognizing a lineage-level vaccine mismatch in approximately one-third of the seasons studied. The epidemiological results show that the proportion of IBV found in ILI was significantly higher than the observed in SARI cases across different groups of age (9.7% ILI, 3.2% SARI) and patients between 5–14 years constituted the majority (33%) of all influenza B infection (p < 0.05). Interestingly, we found that individuals >25 years were particularly vulnerable to Yamagata lineage infections.

Seasonal pattern of influenza and the association with meteorological factors based on wavelet analysis in Jinan City, Eastern China, 2013-2016

Background

Influenza is a disease under surveillance worldwide with different seasonal patterns in temperate and tropical regions. Previous studies have conducted modeling of influenza seasonality using climate variables. This study aimed to identify potential meteorological factors that are associated with influenza seasonality in Jinan, China.

Methods

Data from three influenza sentinel hospitals and respective climate factors (average temperature, relatively humidity (RH), absolute humidity (AH), sunshine duration, accumulated rainfall and speed of wind), from 2013 to 2016, were collected. Statistical and wavelet analyses were used to explore the epidemiological characteristics of influenza virus and its potential association with climate factors.

Results

The dynamic of influenza was characterized by annual cycle, with remarkable winter epidemic peaks from December to February. Spearman's correlation and wavelet coherence analysis illuminated that temperature, AH and atmospheric pressure were main influencing factors. Multiple wavelet coherence analysis showed that temperature and atmospheric pressure might be the main influencing factors of influenza virus A(H3N2) and influenza virus B, whereas temperature and AH might best shape the seasonality of influenza virus A(H1N1)pdm09. During the epidemic season, the prevalence of influenza virus lagged behind the change of temperature by 1-8 weeks and atmospheric pressure by 0.5-3 weeks for different influenza viruses.

Conclusion

Climate factors were significantly associated with influenza seasonality in Jinan during the influenza epidemic season and the optional time for influenza vaccination is before November. These finding should be considered in influenza planning of control and prevention.

Patterns of influenza B circulation in Latin America and the Caribbean, 2010-2017

OBJECTIVE

There are limited published data about the circulation of influenza B/Victoria and B/Yamagata in Latin America and the Caribbean (LAC) and most countries have a vaccine policy that includes the use of the trivalent influenza vaccine. We analyzed influenza surveillance data to inform decision-making in LAC about prevention strategies, such as the use of the quadrivalent influenza vaccine.

METHODS

There are a total of 28 reference laboratories and National Influenza Centers in LAC that conduct influenza virologic surveillance according to global standards, and on a weekly basis upload their surveillance data to the open-access World Health Organization (WHO) platform FluNet. These data include the number of specimens tested for influenza and the number of specimens positive for influenza by type, subtype and lineage, all by the epidemiologic week of specimen collection. We invited these laboratories to provide additional epidemiologic data about the hospitalized influenza B cases. We conducted descriptive analyses of patterns of influenza circulation and characteristics of hospitalized cases. We compared the predominant B lineage each season to the lineage in the vaccine applied, to determine vaccine mismatch. A Chi-square and Wilcoxan statistic were used to assess the statistical significance of differences in proportions and medians at the P<0.05 level.

FINDINGS

During 2010-2017, the annual number of influenza B cases in LAC was ~4500 to 7000 cases. Since 2011, among the LAC-laboratories reporting influenza B lineage using molecular methods, both B/Victoria and B/Yamagata were detected annually. Among the hospitalized influenza B cases, there were statistically significant differences observed between B/Victoria and B/Yamagata cases when comparing age and the proportion with underlying co-morbid conditions and with history of oseltamivir treatment (P<0.001). The proportion deceased among B/Victoria and B/Yamagata hospitalized cases did not differ significantly. When comparing the predominant influenza B lineage detected, as part of surveillance activities during 63 seasons among 19 countries, to the lineage of the influenza B virus included in the trivalent influenza vaccine used during that season, there was a vaccine mismatch noted during 32% of the seasons analyzed.

CONCLUSIONS

Influenza B is important in LAC with both B/Victoria and B/Yamagata circulating annually in all sub regions. During approximately one-third of the seasons, an influenza B vaccine mismatch was identified. Further analyses are needed to better characterize the medical and economic burden of each influenza B lineage, to examine the potential cross-protection of one vaccine lineage against the other circulating virus lineage, and to determine the potential impact and cost-effectiveness of using the quadrivalent vaccine rather than the trivalent influenza vaccine.

Influenza in Latin America: A report from the Global Influenza Initiative (GII)

The Global Influenza Initiative (GII) is a global expert group that aims to raise acceptance and uptake of influenza vaccines globally and provides recommendations and strategies to address challenges at local, national, regional, and global levels. This article provides a consolidated estimation of disease burden in Latin America, currently lacking in published literature, and delivers the GII recommendations specific to Latin America that provide guidance to combat existing vaccination challenges. While many countries worldwide, especially in the tropics and subtropics, do not have a seasonal influenza policy, 90% of Latin American countries have a seasonal influenza policy in place. Local governments in the Latin American countries and The Pan American Health Organization's Technical Advisory Group on Vaccine-preventable Diseases play a major role in improving the vaccination coverage and reducing the overall disease burden. Influenza seasonality poses the biggest challenge in deciding on optimal timing for vaccination in Latin America, as in temperate climates seasonal influenza activity peaks during the winter months (November-February and May-October) in the northern and southern hemispheres, respectively, while in the tropics and subtropical regions it usually occurs throughout the year, but especially during the rainy season. Besides this, vaccine mismatch with circulating strains, misconception concerning influenza vaccine effectiveness, and poor disease and vaccine awareness among the public are also key challenges that need to be overcome. Standardization of clinical case definitions is important across all Latin American countries. Surveillance (mostly passive) has improved substantially in the Latin American countries over the past decade, but more is still required to better understand the disease burden and help inform policies.

Epidemiology and timing of seasonal influenza epidemics in the Asia-Pacific region, 2010-2017: implications for influenza vaccination programs

Background

Description of the epidemiology of influenza is needed to inform influenza vaccination policy. Here we examined influenza virus circulation in countries in the Asia-Pacific region and compared the timing of seasonal epidemics with the timing of influenza vaccination.

Methods

Data were obtained from the World Health Organization (WHO) FluNet database for 2010–2017 for countries in the WHO Asia-Pacific region. Data from countries covering ≥5 consecutive seasons and ≥ 100 influenza positive cases per year were included. Median proportions of cases for each influenza virus type were calculated by country and season. The timing and amplitude of the epidemic peaks were determined by Fourier decomposition. Vaccination timing was considered appropriate for each country if it was recommended ≤4 months before the primary peak of influenza circulation.

Results

Seven hundred eleven thousand seven hundred thirty-four influenza cases were included from 19 countries. Peak circulation coincided with the winter seasons in most countries, although patterns were less clear in some countries in the inter-tropical area due to substantial secondary peaks. Influenza A/H3N2 dominated overall, but proportions of A and B strains varied by year and by country. Influenza B represented 31.4% of all cases. The WHO-recommended timing for influenza vaccination was appropriate in 12 countries. Vaccination timing recommendations were considered inappropriate in Laos, Cambodia, and Thailand, and were inconclusive for India, Sri Lanka, Singapore, and Vietnam due to unclear seasonality of influenza virus circulation.

Conclusions

Influenza virus circulation varied considerably across the Asia-Pacific region with an unusually high burden of influenza B. The recommended timing for vaccination was appropriate in most countries, except for several countries with unclear seasonality, mainly located in the inter-tropical area.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6647-y) contains supplementary material, which is available to authorized users.

[Mortality attributable to influenza in pre-vaccination and post-vaccination periods in Argentina: an ecological study (2002-2016)Mortalidade atribuível à gripe no período pré-vacinal e pós-vacinal na Argentina: estudo ecológico (2002-2016)]

Objetivos

Comparar las tasas de mortalidad por infección respiratoria aguda grave atribuible a gripe (IRAG) entre los períodos antes de la vacunación (AV) y después de la vacunación (DV), conocer la evolución histórica y estacionalidad de serie histórica entre 2002-2016 y estimar el riesgo de morir de niños entre 6 y 23 meses mediante el empleo de un modelo estadístico.

Métodos

Estudio de serie histórica con datos oficiales de mortalidad del informe estadístico de defunción. Se consideraron como IRAG los códigos de CIE-10 entre J09-18.9 y J22X. Se calcularon tasas brutas (TB) y ajustadas por edad (TAE) y se compararon los períodos AV (2002-2009) y DV (2010-2016) con prueba de χ2. El mejor modelo estadístico fue el que comparó las defunciones por IRAG en niños durante el 2002 con otros años. Se analizaron los datos con programa R, nivel de significancia P <0,05.

Resultados

El 4,6% (301 747) de las defunciones fueron por IRAG, con una edad mediana de 82 años, el porcentaje de fallecidos menores de dos años disminuyó en el período DV (2,34% a 0,99%, P < 0,05). Se presentó una marcada estacionalidad en invierno. Las TAE en gerontes pasaron de 259,8 AV a 328,6 por 100 000 personas DV (P < 0,05). En los niños, la TB disminuyó de manera significativa, estimando que el riesgo de morir por IRAG, comparado con el año 2 002, fue significativamente menor durante 3 años DV.

Conclusiones

La disminución de la mortalidad por gripe en Argentina fue más evidente en niños, con un descenso estimado de 3,5 niños fallecidos por IRAG por mes.

An Integrated Influenza Surveillance Framework Based on National Influenza-Like Illness Incidence and Multiple Hospital Electronic Medical Records for Early Prediction of Influenza Epidemics: Design and Evaluation

BACKGROUND

Influenza is a leading cause of death worldwide and contributes to heavy economic losses to individuals and communities. Therefore, the early prediction of and interventions against influenza epidemics are crucial to reduce mortality and morbidity because of this disease. Similar to other countries, the Taiwan Centers for Disease Control and Prevention (TWCDC) has implemented influenza surveillance and reporting systems, which primarily rely on influenza-like illness (ILI) data reported by health care providers, for the early prediction of influenza epidemics. However, these surveillance and reporting systems show at least a 2-week delay in prediction, indicating the need for improvement.

OBJECTIVE

We aimed to integrate the TWCDC ILI data with electronic medical records (EMRs) of multiple hospitals in Taiwan. Our ultimate goal was to develop a national influenza trend prediction and reporting tool more accurate and efficient than the current influenza surveillance and reporting systems.

METHODS

First, the influenza expertise team at Taipei Medical University Health Care System (TMUHcS) identified surveillance variables relevant to the prediction of influenza epidemics. Second, we developed a framework for integrating the EMRs of multiple hospitals with the ILI data from the TWCDC website to proactively provide results of influenza epidemic monitoring to hospital infection control practitioners. Third, using the TWCDC ILI data as the gold standard for influenza reporting, we calculated Pearson correlation coefficients to measure the strength of the linear relationship between TMUHcS EMRs and regional and national TWCDC ILI data for 2 weekly time series datasets. Finally, we used the Moving Epidemic Method analyses to evaluate each surveillance variable for its predictive power for influenza epidemics.

RESULTS

Using this framework, we collected the EMRs and TWCDC ILI data of the past 3 influenza seasons (October 2014 to September 2017). On the basis of the EMRs of multiple hospitals, 3 surveillance variables, TMUHcS-ILI, TMUHcS-rapid influenza laboratory tests with positive results (RITP), and TMUHcS-influenza medication use (IMU), which reflected patients with ILI, those with positive results from rapid influenza diagnostic tests, and those treated with antiviral drugs, respectively, showed strong correlations with the TWCDC regional and national ILI data (r=.86-.98). The 2 surveillance variables-TMUHcS-RITP and TMUHcS-IMU-showed predictive power for influenza epidemics 3 to 4 weeks before the increase noted in the TWCDC ILI reports.

CONCLUSIONS

Our framework periodically integrated and compared surveillance data from multiple hospitals and the TWCDC website to maintain a certain prediction quality and proactively provide monitored results. Our results can be extended to other infectious diseases, mitigating the time and effort required for data collection and analysis. Furthermore, this approach may be developed as a cost-effective electronic surveillance tool for the early and accurate prediction of epidemics of influenza and other infectious diseases in densely populated regions and nations.

The epidemiology and severity of respiratory viral infections in a tropical country: Ecuador, 2009-2016

BACKGROUND

Respiratory viral infections (RVI) are a leading cause of mortality worldwide. We compared the epidemiology and severity of RVI in Ecuador during 2009-2016.

METHODS

Respiratory specimens collected within the national surveillance system were tested for influenza viruses, respiratory syncytial virus (RSV), adenovirus, parainfluenza virus, and human metapneumovirus. Overall and virus-specific positive detection rate (PDR) were calculated and compared the timing of epidemics caused by the different viruses. Logistic regression models were used to compare the age distribution and risk of death across respiratory viruses.

RESULTS

A total of 41,172 specimens were analyzed: influenza (PDR=14.3%) and respiratory syncytial virus (RSV) (PDR=9.5%) were the most frequently detected viruses. Influenza epidemics typically peaked in December-January and RSV epidemics in March; seasonality was less evident for the other viruses. Compared to adults, children were more frequently infected with RSV, adenovirus, parainfluenza, and influenza B, while the elderly were less frequently infected with influenza A(H1N1)p. The age-adjusted risk of death was highest for A(H1N1)p (odds ratio [OR] 1.73, 95% confidence intervals [CI] 1.38-2.17), and lowest for RSV (OR 0.75, 95%CI 0.57-0.98).

CONCLUSIONS

Whilst influenza and RSV were the most frequently detected pathogens, the risk of death differed by RVI, being highest for pandemic influenza and lowest for RSV.

Epidemiology of seasonal influenza in the Middle East and North Africa regions, 2010-2016: Circulating influenza A and B viruses and spatial timing of epidemics

BACKGROUND

There is a limited knowledge regarding the epidemiology of influenza in Middle East and North Africa.

OBJECTIVES

We described the patterns of influenza circulation and the timing of seasonal epidemics in countries of Middle East and North Africa.

METHODS

We used virological surveillance data for 2010-2016 from the WHO FluNet database. In each country, we calculated the median proportion of cases that were caused by each virus type and subtype; determined the timing and amplitude of the primary and secondary peaks; and used linear regression models to test for spatial trends in the timing of epidemics.

RESULTS

We included 70 532 influenza cases from seventeen countries. Influenza A and B accounted for a median 76.5% and 23.5% of cases in a season and were the dominant type in 86.8% and 13.2% of seasons. The proportion of influenza A cases that were subtyped was 85.9%, while only 4.4% of influenza B cases were characterized. For most countries, influenza seasonality was similar to the Northern Hemisphere, with a single large peak between January and March; exceptions were the countries in the Arabian Peninsula and Jordan, all of which showed clear secondary peaks, and some countries had an earlier primary peak (in November-December in Bahrain and Qatar). The direction of the timing of influenza activity was east to west and south to north in 2012-2013 and 2015-2016, and west to east in 2014-2015.

CONCLUSIONS

The epidemiology of influenza is generally uniform in countries of Middle East and North Africa, with influenza B playing an important role in the seasonal disease burden.

Implications of and lessons learned from external assurance of eight influenza diagnostics in China

This study evaluated the ability of laboratories in the Chinese mainland to conduct molecular detection of seasonal A(H1N1), A(H1N1)pdm09, A(H3N2), A(H5N1), A(H7N9), A(H9N2), B(Victoria), and B(Yamagata). Based on a genetically engineered system of virus-like particles (VLPs), the National Center for Clinical Laboratories of China (NCCLs) developed an external quality assessment (EQA) panel. The panel was distributed to 35 laboratories in mainland China to investigate the proficiency of the 16 assays for influenza molecular detection. Using genetic engineering technology, VLPs encapsulating the 37 target genes of 8 influenza viruses were generated. After verification and quantification, 26 influenza virus surrogates with different concentrations were prepared for EQA. Among the 35 participating laboratories, 319 datasets were returned to the NCCLs. Overall, 95.6% (305/319) of datasets correctly reported all 30 samples, while 2.2% (7/319) of datasets with more than one incorrect result were considered as "improvable". A total of 16 misdiagnosed and 18 undiagnosed results were reported. The data analyzed in this study showed good reproducibility in China, but improvements are needed to decrease misdiagnosed and undiagnosed cases, particularly for the A(H9N2) NA gene. Moreover, VLPs are a good alternative specimen type for assay training and proficiency testing purposes.