1
|
Hooli S, King C, McCollum ED, Colbourn T, Lufesi N, Mwansambo C, Gregory CJ, Thamthitiwat S, Cutland C, Madhi SA, Nunes MC, Gessner BD, Hazir T, Mathew JL, Addo-Yobo E, Chisaka N, Hassan M, Hibberd PL, Jeena P, Lozano JM, MacLeod WB, Patel A, Thea DM, Nguyen NTV, Zaman SM, Ruvinsky RO, Lucero M, Kartasasmita CB, Turner C, Asghar R, Banajeh S, Iqbal I, Maulen-Radovan I, Mino-Leon G, Saha SK, Santosham M, Singhi S, Awasthi S, Bavdekar A, Chou M, Nymadawa P, Pape JW, Paranhos-Baccala G, Picot VS, Rakoto-Andrianarivelo M, Rouzier V, Russomando G, Sylla M, Vanhems P, Wang J, Basnet S, Strand TA, Neuman MI, Arroyo LM, Echavarria M, Bhatnagar S, Wadhwa N, Lodha R, Aneja S, Gentile A, Chadha M, Hirve S, O'Grady KAF, Clara AW, Rees CA, Campbell H, Nair H, Falconer J, Williams LJ, Horne M, Qazi SA, Nisar YB. In-hospital mortality risk stratification in children aged under 5 years with pneumonia with or without pulse oximetry: A secondary analysis of the Pneumonia REsearch Partnership to Assess WHO REcommendations (PREPARE) dataset. Int J Infect Dis 2023; 129:240-250. [PMID: 36805325 PMCID: PMC10017350 DOI: 10.1016/j.ijid.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 02/01/2023] [Accepted: 02/05/2023] [Indexed: 02/17/2023] Open
Abstract
OBJECTIVES We determined the pulse oximetry benefit in pediatric pneumonia mortality risk stratification and chest-indrawing pneumonia in-hospital mortality risk factors. METHODS We report the characteristics and in-hospital pneumonia-related mortality of children aged 2-59 months who were included in the Pneumonia Research Partnership to Assess WHO Recommendations dataset. We developed multivariable logistic regression models of chest-indrawing pneumonia to identify mortality risk factors. RESULTS Among 285,839 children, 164,244 (57.5%) from hospital-based studies were included. Pneumonia case fatality risk (CFR) without pulse oximetry measurement was higher than with measurement (5.8%, 95% confidence interval [CI] 5.6-5.9% vs 2.1%, 95% CI 1.9-2.4%). One in five children with chest-indrawing pneumonia was hypoxemic (19.7%, 95% CI 19.0-20.4%), and the hypoxemic CFR was 10.3% (95% CI 9.1-11.5%). Other mortality risk factors were younger age (either 2-5 months [adjusted odds ratio (aOR) 9.94, 95% CI 6.67-14.84] or 6-11 months [aOR 2.67, 95% CI 1.71-4.16]), moderate malnutrition (aOR 2.41, 95% CI 1.87-3.09), and female sex (aOR 1.82, 95% CI 1.43-2.32). CONCLUSION Children with a pulse oximetry measurement had a lower CFR. Many children hospitalized with chest-indrawing pneumonia were hypoxemic and one in 10 died. Young age and moderate malnutrition were risk factors for in-hospital chest-indrawing pneumonia-related mortality. Pulse oximetry should be integrated in pneumonia hospital care for children under 5 years.
Collapse
Affiliation(s)
- Shubhada Hooli
- Division of Pediatric Emergency Medicine, Texas Children's Hospital/Baylor College of Medicine, Houston, United States of America
| | - Carina King
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden and Institute for Global Health, University College London, London, United Kingdom
| | - Eric D McCollum
- Global Program in Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, United States of America and Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States of America
| | - Tim Colbourn
- Institute for Global Health, University College London, London, United Kingdom
| | | | | | - Christopher J Gregory
- Division of Vector-Borne Diseases, US Centers for Disease Control and Prevention, Fort Collins, United States of America
| | - Somsak Thamthitiwat
- Division of Global Health Protection, Thailand Ministry of Public Health-US Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | - Clare Cutland
- African Leadership in Vaccinology Expertise (Alive), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Shabir Ahmed Madhi
- South African Medical Research Council: Vaccines and Infectious Diseases Analytics Research Unit, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Marta C Nunes
- South African Medical Research Council: Vaccines and Infectious Diseases Analytics Research Unit, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases Unit, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Tabish Hazir
- The Children's Hospital, (Retired), Pakistan Institute of Medical Sciences (PIMS), Islamabad, Pakistan (deceased)
| | - Joseph L Mathew
- Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Emmanuel Addo-Yobo
- Kwame Nkrumah University of Science & Technology/Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Noel Chisaka
- World Bank, Washington DC, United States of America
| | - Mumtaz Hassan
- The Children's Hospital, Pakistan Institute of Medical Sciences (PIMS), Islamabad, Pakistan (deceased)
| | - Patricia L Hibberd
- Department of Global Health, Boston University School of Public Health, Boston, United States of America
| | | | - Juan M Lozano
- Florida International University, Miami, United States of America
| | - William B MacLeod
- Department of Global Health, Boston University School of Public Health, Boston, United States of America
| | - Archana Patel
- Lata Medical Research Foundation, Nagpur and Datta Meghe Institute of Medical Sciences, Sawangi, India
| | - Donald M Thea
- Department of Global Health, Boston University School of Public Health, Boston, United States of America
| | | | - Syed Ma Zaman
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Raul O Ruvinsky
- Dirección de Control de Enfermedades Inmunoprevenibles, Ministerio de Salud de la Nación, Buenos Aires, Argentina
| | - Marilla Lucero
- Research Institute for Tropical Medicine, Manila, Philippines
| | - Cissy B Kartasasmita
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | | | - Rai Asghar
- Rawalpindi Medical College, Rawalpindi, Pakistan
| | | | - Imran Iqbal
- Combined Military Hospital Institute of Medical Sciences, Multan, Pakistan
| | - Irene Maulen-Radovan
- Instituto Nacional de Pediatria Division de Investigacion Insurgentes, Mexico City, Mexico
| | - Greta Mino-Leon
- Children's Hospital Dr Francisco de Ycaza Bustamante, Head of Department, Infectious diseases, Guayaquil, Ecuador
| | - Samir K Saha
- Child Health Research Foundation and Dhaka Shishu Hospital, Dhaka, Bangladesh
| | - Mathuram Santosham
- International Vaccine Access Center (IVAC), Department of International Health, Johns Hopkins University, Baltimore, United States of America
| | | | - Shally Awasthi
- King George's Medical University, Department of Pediatrics, Lucknow, India
| | | | - Monidarin Chou
- University of Health Sciences, Rodolph Mérieux Laboratory & Ministry of Environment, Phom Phen, Cambodia
| | - Pagbajabyn Nymadawa
- Mongolian Academy of Sciences, Academy of Medical Sciences, Ulaanbaatar, Mongolia
| | | | | | | | | | | | - Graciela Russomando
- Universidad Nacional de Asuncion, Departamento de Biología Molecular y Genética, Instituto de Investigaciones en Ciencias de la Salud, Asuncion, Paraguay
| | - Mariam Sylla
- Gabriel Touré Hospital, Department of Pediatrics, Bamako, Mali
| | - Philippe Vanhems
- Unité d'Hygiène, Epidémiologie, Infectiovigilance et Prévention, Hospices Civils de Lyon, Lyon, France and Centre International de Recherche en Infectiologie, Institut National de la Santé et de la Recherche Médicale U1111, CNRS Unité Mixte de Recherche 5308, École Nationale Supérieure de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Jianwei Wang
- Chinese Academy of Medical Sciences & Peking Union, Medical College Institute of Pathogen Biology, MOH Key Laboratory of Systems Biology of Pathogens and Dr Christophe Mérieux Laboratory, Beijing, China
| | - Sudha Basnet
- Center for Intervention Science in Maternal and Child Health, University of Bergen, Norway and Department of Pediatrics, Tribhuvan University Institute of Medicine, Nepal
| | - Tor A Strand
- Research Department, Innlandet Hospital Trust, Lillehammer, Norway
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, United States of America
| | | | - Marcela Echavarria
- Clinical Virology Unit, Centro de Educación Médica e Investigaciones Clínicas, Mar del Plata, Argentina
| | | | - Nitya Wadhwa
- Translational Health Science and Technology Institute, Faridabad, India
| | - Rakesh Lodha
- All India Institute of Medical Sciences, New Delhi, India
| | - Satinder Aneja
- School of Medical Sciences & Research, Sharda University, Greater Noida, India
| | - Angela Gentile
- Department of Epidemiology, "R. Gutiérrez" Children's Hospital, Buenos Aires, Argentina
| | - Mandeep Chadha
- Former Scientist G, ICMR National Institute of Virology, Pune, India
| | | | - Kerry-Ann F O'Grady
- Australian Centre for Health Services Innovation, Queensland University of Technology, Kelvin Grove, Australia
| | - Alexey W Clara
- Centers for Disease Control, Central American Region, Guatemala City, Guatemala
| | - Chris A Rees
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, United States of America
| | - Harry Campbell
- Centre for Global Health, Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Harish Nair
- Centre for Global Health, Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Jennifer Falconer
- Centre for Global Health, Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Linda J Williams
- Centre for Global Health, Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Margaret Horne
- Centre for Global Health, Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Shamim A Qazi
- Department of Maternal, Newborn, Child, and Adolescent Health (Retired), World Health Organization, Geneva, Switzerland
| | - Yasir Bin Nisar
- Department of Maternal, Newborn, Child, and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland.
| | | |
Collapse
|
2
|
Frimpong JA, Ampofo WK, Nyarko KM, Duque J, Aboagye J, Koram K, Widdowson M. Effect of antipyretics on performance of influenza surveillance in Ghana. Influenza Other Respir Viruses 2022; 17:e13068. [PMID: 36370028 PMCID: PMC9835404 DOI: 10.1111/irv.13068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 10/25/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The World Health Organization's case definition for influenza-like illness (ILI) includes a measured temperature of ≥38°C. We conducted this study to assess the effect of antipyretics on performance of ILI surveillance in Ghana. METHODS A cross-sectional study was conducted in two districts of Ghana from September 2013 to May 2014. We collected epidemiological data and respiratory specimens from an expanded ILI case definition, which included patients presenting to health facilities with measured temperature ≥38°C or reported fever (but afebrile at the time of evaluation), and cough, with onset in the last 10 days. Specimens were tested for influenza viruses by real time reverse-transcription polymerase chain reaction. RESULTS Of 321 participants who met our expanded ILI case definition, 236 presented with temperature of <38°C but reported subjective fever. Of these, 17% (39/236) were positive for influenza virus; Of those with fever ≤38°C who took antipyretics, 21%(16/77) were positive for influenza, compared with 14%(23/159) of those who did not take antipyretics. The addition of subjective fever to the standard ILI case definition captured approximately an additional 57% influenza cases but also required testing of approximately four times as many patients. However, including those without fever on presentation that had taken antipyretics found an additional 23% of Influenza cases and only two times as much testing. CONCLUSION Depending on the goals of surveillance (monitoring virus circulation or determining disease burden) and available resources, a more sensitive case definition including subjective fever and history of use of antipyretics may be warranted.
Collapse
Affiliation(s)
| | | | - Kofi Mensah Nyarko
- Department of Environmental and Public HealthUniversity of Environmental and Sustainable DevelopmentSomanyaGhana
| | | | - James Aboagye
- Noguchi Memorial Institute for Medical ResearchUniversity of GhanaAccraGhana
| | - Kwadwo Koram
- Noguchi Memorial Institute for Medical ResearchUniversity of GhanaAccraGhana
| | | |
Collapse
|
3
|
Khamphaphongphane B, Chiew M, Mott JA, Khamphanoulath S, Khanthamaly V, Vilivong K, Sisouk T, Bell L, Dueger E, Sullivan S, Iuliano AD, Tsuyuoka R, Keosavanh O. Estimating the national burden of hospitalizations for influenza-associated severe acute respiratory infection in the Lao People's Democratic Republic, 2016. Western Pac Surveill Response J 2021; 12:19-27. [PMID: 34540308 DOI: 10.5365/wpsar.2020.11.2.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Objective Estimates of the burden of influenza are needed to inform prevention and control activities for seasonal influenza, including to support the development of appropriate vaccination policies. We used sentinel surveillance data on severe acute respiratory infection (SARI) to estimate the burden of influenza-associated hospitalizations in the Lao People's Democratic Republic. Methods Using methods developed by the World Health Organization, we combined data from hospital logbook reviews with epidemiological and virological data from influenza surveillance from 1 January to 31 December 2016 in defined catchment areas for two sentinel sites (Champasack and Luang Prabang provincial hospitals) to derive population-based estimates of influenza-associated SARI hospitalization rates. Hospitalization rates by age group were then applied to national age-specific population estimates using 2015 census data. Results We estimated the overall influenza-associated SARI hospitalization rate to be 48/100 000 population (95% confidence interval [CI]: 44–51) or 3097 admissions (95% CI: 2881–3313). SARI hospitalization rates were estimated to be as low as 40/100 000 population (95% CI: 37–43) and as high as 92/100 000 population (95% CI: 87–98) after accounting for SARI patient underascertainment in hospital logbooks. Influenza-associated SARI hospitalization rates were highest in children aged < 5 years (219; 95% CI: 198–241) and persons aged 3 65 years (106; 95% CI: 91–121). Discussion Our findings have identified age groups at higher risk for influenza-associated SARI hospitalization, which will support policy decisions for influenza prevention and control strategies, including for vaccination. Further work is needed to estimate the burdens of outpatient influenza and influenza in specific high-risk subpopulations.
Collapse
|
4
|
Nambafu J, Achakolong M, Mwendwa F, Bwika J, Riunga F, Gitau S, Patel H, Adam RD. A prospective observational study of community acquired pneumonia in Kenya: the role of viral pathogens. BMC Infect Dis 2021; 21:703. [PMID: 34301184 PMCID: PMC8300991 DOI: 10.1186/s12879-021-06388-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 07/02/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Lower respiratory tract infections continue to contribute significantly to morbidity and mortality across all age groups globally. In sub-Saharan Africa, many studies of community acquired pneumonia in adults have focused on HIV-infected patients and little attention has been given to risk factors and etiologic agents in an urban area with a more moderate HIV prevalence. METHODS We prospectively enrolled 77 patients admitted to a 280 bed teaching hospital in Kenya with radiographically confirmed community acquired pneumonia from May 2019 to March 2020. The patients were followed for etiology and clinical outcomes. Viral PCR testing was performed using the FTD respiratory pathogen-21 multiplex kit on nasopharyngeal or lower respiratory samples. Additional microbiologic workup was performed as determined by the treating physicians. RESULTS A potential etiologic agent(s) was identified in 57% including 43% viral, 5% combined viral and bacterial, 5% bacterial and 4% Pneumocystis. The most common etiologic agent was Influenza A which was associated with severe clinical disease. The most common underlying conditions were cardiovascular disease, diabetes and lung disease, while HIV infection was identified in only 13% of patients. Critical care admission was required for 24, and 31% had acute kidney injury, sometimes in combination with acute respiratory distress or sepsis. CONCLUSION Viruses, especially influenza, were commonly found in patients with CAP. In contrast to other studies from sub-Saharan Africa, the underlying conditions were similar to those reported in high resource areas and point to the growing concern of the double burden of infectious and noncommunicable diseases.
Collapse
Affiliation(s)
- Jamila Nambafu
- Department of Medicine, Aga Khan University, Third Parklands Rd, Nairobi, Kenya
| | - Mary Achakolong
- Department of Pathology, Aga Khan University, Third Parklands Rd, Nairobi, Kenya
| | - Fridah Mwendwa
- Department of Pathology, Aga Khan University, Third Parklands Rd, Nairobi, Kenya
| | - Jumaa Bwika
- Department of Medicine, Aga Khan University, Third Parklands Rd, Nairobi, Kenya
| | - Felix Riunga
- Department of Medicine, Aga Khan University, Third Parklands Rd, Nairobi, Kenya
| | - Samuel Gitau
- Department of Radiology, Aga Khan University, Nairobi, Kenya
| | - Hanika Patel
- Department of Radiology, Aga Khan University, Nairobi, Kenya
| | - Rodney D. Adam
- Department of Medicine, Aga Khan University, Third Parklands Rd, Nairobi, Kenya
- Department of Pathology, Aga Khan University, Third Parklands Rd, Nairobi, Kenya
| |
Collapse
|
5
|
Smith ER, Fry AM, Hicks LA, Fleming-Dutra KE, Flannery B, Ferdinands J, Rolfes MA, Martin ET, Monto AS, Zimmerman RK, Nowalk MP, Jackson ML, McLean HQ, Olson SC, Gaglani M, Patel MM. Reducing Antibiotic Use in Ambulatory Care Through Influenza Vaccination. Clin Infect Dis 2021; 71:e726-e734. [PMID: 32322875 DOI: 10.1093/cid/ciaa464] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 04/20/2020] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Improving appropriate antibiotic use is crucial for combating antibiotic resistance and unnecessary adverse drug reactions. Acute respiratory illness (ARI) commonly causes outpatient visits and accounts for ~41% of antibiotics used in the United States. We examined the influence of influenza vaccination on reducing antibiotic prescriptions among outpatients with ARI. METHODS We enrolled outpatients aged ≥6 months with ARI from 50-60 US clinics during 5 winters (2013-2018) and tested for influenza with RT-PCR; results were unavailable for clinical decision making and clinical influenza testing was infrequent. We collected antibiotic prescriptions and diagnosis codes for ARI syndromes. We calculated vaccine effectiveness (VE) by comparing vaccination odds among influenza-positive cases with test-negative controls. We estimated ARI visits and antibiotic prescriptions averted by influenza vaccination using estimates of VE, coverage, and prevalence of antibiotic prescriptions and influenza. RESULTS Among 37 487 ARI outpatients, 9659 (26%) were influenza positive. Overall, 36% of ARI and 26% of influenza-positive patients were prescribed antibiotics. The top 3 prevalent ARI syndromes included: viral upper respiratory tract infection (47%), pharyngitis (18%), and allergy or asthma (11%). Among patients testing positive for influenza, 77% did not receive an ICD-CM diagnostic code for influenza. Overall, VE against influenza-associated ARI was 35% (95% CI, 32-39%). Vaccination prevented 5.6% of all ARI syndromes, ranging from 2.8% (sinusitis) to 11% (clinical influenza). Influenza vaccination averted 1 in 25 (3.8%; 95% CI, 3.6-4.1%) antibiotic prescriptions among ARI outpatients during influenza seasons. CONCLUSIONS Vaccination and accurate influenza diagnosis may curb unnecessary antibiotic use and reduce the global threat of antibiotic resistance.
Collapse
Affiliation(s)
- Emily R Smith
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Alicia M Fry
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Lauri A Hicks
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Brendan Flannery
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jill Ferdinands
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Melissa A Rolfes
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | | | | | | | - Michael L Jackson
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Huong Q McLean
- Marshfield Clinic Research Institute, Marshfield, Wisconsin, USA
| | - Scott C Olson
- Marshfield Clinic Research Institute, Marshfield, Wisconsin, USA
| | - Manjusha Gaglani
- Baylor Scott & White Health, Texas A&M University, Temple, Texas, USA
| | - Manish M Patel
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| |
Collapse
|
6
|
Barry MA, Arinal F, Talla C, Hedible BG, Sarr FD, Ba IO, Diop B, Dia N, Vray M. Performance of case definitions and clinical predictors for influenza surveillance among patients followed in a rural cohort in Senegal. BMC Infect Dis 2021; 21:31. [PMID: 33413174 PMCID: PMC7790019 DOI: 10.1186/s12879-020-05724-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 12/18/2020] [Indexed: 11/18/2022] Open
Abstract
Background Influenza is a major cause of morbidity and mortality in Africa. However, a lack of epidemiological data remains for this pathology, and the performances of the influenza-like illness (ILI) case definitions used for sentinel surveillance have never been evaluated in Senegal. This study aimed to i) assess the performance of three different ILI case definitions, adopted by the WHO, USA-CDC (CDC) and European-CDC (ECDC) and ii) identify clinical factors associated with a positive diagnosis for Influenza in order to develop an algorithm fitted for the Senegalese context. Methods All 657 patients with a febrile pathological episode (FPE) between January 2013 and December 2016 were followed in a cohort study in two rural villages in Senegal, accounting for 1653 FPE observations with nasopharyngeal sampling and influenza virus screening by rRT-PCR. For each FPE, general characteristics and clinical signs presented by patients were collected. Sensitivity, Specificity, Positive Predictive Value (PPV) and Negative Predictive Value (NPV) for the three ILI case definitions were assessed using PCR result as the reference test. Associations between clinical signs and influenza infection were analyzed using logistic regression with generalized estimating equations. Sore throat, arthralgia or myalgia were missing for children under 5 years. Results WHO, CDC and ECDC case definitions had similar sensitivity (81.0%; 95%CI: 77.0–85.0) and NPV (91.0%; 95%CI: 89.0–93.1) while the WHO and CDC ILI case definitions had the highest specificity (52.0%; 95%CI: 49.1–54.5) and PPV (32.0%; 95%CI: 30.0–35.0). These performances varied by age groups. In children < 5 years, the significant predictors of influenza virus infection were cough and nasal discharge. In patients from 5 years, cough, nasal discharge, sore throat and asthenia grade 3 best predicted influenza infection. The addition of “nasal discharge” as a symptom to the WHO case definition decreased sensitivity but increased specificity, particularly in the pediatric population. Conclusion In summary, all three definitions studies (WHO, ECDC & CDC) have similar performance, even by age group. The revised WHO ILI definition could be chosen for surveillance purposes for its simplicity. Symptomatic predictors of influenza virus infection vary according the age group. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-020-05724-x.
Collapse
Affiliation(s)
- Mamadou Aliou Barry
- Institut Pasteur de Dakar, Unité d'Epidémiologie des maladies infectieuses, 36, Avenue Pasteur, Dakar, Sénégal.
| | - Florent Arinal
- Institut Pasteur de Dakar, Unité d'Epidémiologie des maladies infectieuses, 36, Avenue Pasteur, Dakar, Sénégal
| | - Cheikh Talla
- Institut Pasteur de Dakar, Unité d'Epidémiologie des maladies infectieuses, 36, Avenue Pasteur, Dakar, Sénégal
| | - Boris Gildas Hedible
- Institut Pasteur de Dakar, Unité d'Epidémiologie des maladies infectieuses, 36, Avenue Pasteur, Dakar, Sénégal
| | - Fatoumata Diene Sarr
- Institut Pasteur de Dakar, Unité d'Epidémiologie des maladies infectieuses, 36, Avenue Pasteur, Dakar, Sénégal
| | | | - Boly Diop
- Ministère de la Santé et de l'Action Sociale, Direction de la Prévention, Dakar, Sénégal
| | - Ndongo Dia
- Institut Pasteur de Dakar, Pôle de Virologie, Dakar, Sénégal
| | - Muriel Vray
- Institut Pasteur de Dakar, Unité d'Epidémiologie des maladies infectieuses, 36, Avenue Pasteur, Dakar, Sénégal
| |
Collapse
|
7
|
Uyeki TM, Bernstein HH, Bradley JS, Englund JA, File TM, Fry AM, Gravenstein S, Hayden FG, Harper SA, Hirshon JM, Ison MG, Johnston BL, Knight SL, McGeer A, Riley LE, Wolfe CR, Alexander PE, Pavia AT. Clinical Practice Guidelines by the Infectious Diseases Society of America: 2018 Update on Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management of Seasonal Influenzaa. Clin Infect Dis 2020; 68:e1-e47. [PMID: 30566567 DOI: 10.1093/cid/ciy866] [Citation(s) in RCA: 325] [Impact Index Per Article: 81.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 10/05/2018] [Indexed: 12/19/2022] Open
Abstract
These clinical practice guidelines are an update of the guidelines published by the Infectious Diseases Society of America (IDSA) in 2009, prior to the 2009 H1N1 influenza pandemic. This document addresses new information regarding diagnostic testing, treatment and chemoprophylaxis with antiviral medications, and issues related to institutional outbreak management for seasonal influenza. It is intended for use by primary care clinicians, obstetricians, emergency medicine providers, hospitalists, laboratorians, and infectious disease specialists, as well as other clinicians managing patients with suspected or laboratory-confirmed influenza. The guidelines consider the care of children and adults, including special populations such as pregnant and postpartum women and immunocompromised patients.
Collapse
Affiliation(s)
- Timothy M Uyeki
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Henry H Bernstein
- Division of General Pediatrics, Cohen Children's Medical Center, New Hyde Park, New York
| | - John S Bradley
- Division of Infectious Diseases, Rady Children's Hospital.,University of California, San Diego
| | - Janet A Englund
- Department of Pediatrics, University of Washington, Seattle Children's Hospital
| | - Thomas M File
- Division of Infectious Diseases Summa Health, Northeast Ohio Medical University, Rootstown
| | - Alicia M Fry
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Stefan Gravenstein
- Providence Veterans Affairs Medical Center and Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island
| | - Frederick G Hayden
- Division of Infectious Diseases and International Health, University of Virginia Health System, Charlottesville
| | - Scott A Harper
- Office of Public Health Preparedness and Response, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jon Mark Hirshon
- Department of Emergency Medicine, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Michael G Ison
- Divisions of Infectious Diseases and Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - B Lynn Johnston
- Department of Medicine, Dalhousie University, Nova Scotia Health Authority, Halifax, Canada
| | - Shandra L Knight
- Library and Knowledge Services, National Jewish Health, Denver, Colorado
| | - Allison McGeer
- Division of Infection Prevention and Control, Sinai Health System, University of Toronto, Ontario, Canada
| | - Laura E Riley
- Department of Maternal-Fetal Medicine, Massachusetts General Hospital, Boston
| | - Cameron R Wolfe
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Paul E Alexander
- McMaster University, Hamilton, Ontario, Canada.,Infectious Diseases Society of America, Arlington, Virginia
| | - Andrew T Pavia
- Division of Pediatric Infectious Diseases, University of Utah, Salt Lake City
| |
Collapse
|
8
|
Klink T, Rankin DA, Piya B, Spieker AJ, Faouri S, Shehabi A, Williams JV, Khuri-Bulos N, Halasa NB. Evaluating the diagnostic accuracy of the WHO Severe Acute Respiratory Infection (SARI) criteria in Middle Eastern children under two years over three respiratory seasons. PLoS One 2020; 15:e0232188. [PMID: 32353012 PMCID: PMC7192447 DOI: 10.1371/journal.pone.0232188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 04/08/2020] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE The World Health Organization created the Severe Acute Respiratory Infection (SARI) criteria in 2011 to monitor influenza (flu)-related hospitalization. Many studies have since used the SARI case definition as inclusion criteria for surveillance studies. We sought to determine the sensitivity, specificity, positive predictive value, and negative predictive value of the SARI criteria for detecting ten different respiratory viruses in a Middle Eastern pediatric cohort. MATERIALS AND METHODS The data for this study comes from a prospective acute respiratory surveillance study of hospitalized children <2 years in Amman, Jordan from March 16, 2010 to March 31, 2013. Participants were recruited if they had a fever and/or respiratory symptoms. Nasal and throat swabs were obtained and tested by real-time RT-PCR for eleven viruses. Subjects meeting SARI criteria were determined post-hoc. Sensitivity, specificity, positive predictive value, and negative predictive value of the SARI case definition for detecting ten different viruses were calculated and results were stratified by age. RESULTS Of the 3,175 patients enrolled, 3,164 were eligible for this study, with a median age of 3.5 months, 60.4% male, and 82% virus-positive (44% RSV and 3.8% flu). The sensitivity and specificity of the SARI criteria for detecting virus-positive patients were 44% and 77.9%, respectively. Sensitivity of SARI criteria for any virus was lowest in children <3 months at 22.4%. Removing fever as a criterion improved the sensitivity by 65.3% for detecting RSV in children <3 months; whereas when cough was removed, the sensitivity improved by 45.5% for detecting flu in same age group. CONCLUSIONS The SARI criteria have poor sensitivity for detecting RSV, flu, and other respiratory viruses-particularly in children <3 months. Researchers and policy makers should use caution if using the criteria to estimate burden of disease in children.
Collapse
Affiliation(s)
- Thomas Klink
- Medicine and Pediatric Residency Program, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Danielle A. Rankin
- Vanderbilt Epidemiology PhD Program, Vanderbilt University School of Medicine, Vanderbilt University, Nashville, Tennessee, United States of America
- Department of Pediatrics, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Bhinnata Piya
- Vanderbilt Institute for Clinical and Translational Research, Nashville, Tennessee, United States of America
| | - Andrew J. Spieker
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Samir Faouri
- Department of Pediatrics, Al Bashir Hospital, Amman, Jordan
| | - Asem Shehabi
- Department of Pediatrics, Jordan University, Amman, Jordan
| | - John V. Williams
- Department of Pediatrics, University of Pittsburgh School of Medicine, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States of America
| | | | - Natasha B. Halasa
- Department of Pediatrics, Vanderbilt University, Nashville, Tennessee, United States of America
| |
Collapse
|
9
|
Patil R, Roy S, Ingole V, Bhattacharjee T, Chaudhary B, Lele P, Hirve S, Juvekar S. Profile: Vadu Health and Demographic Surveillance System Pune, India. J Glob Health 2020; 9:010202. [PMID: 31263545 PMCID: PMC6594669 DOI: 10.7189/jogh.09.010202] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Rutuja Patil
- KEM Hospital Research Centre Pune (KEMHRC), Vadu Rural Health Program, India.,Usher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh UK
| | - Sudipto Roy
- KEM Hospital Research Centre Pune (KEMHRC), Vadu Rural Health Program, India.,Usher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh UK
| | - Vijendra Ingole
- KEM Hospital Research Centre Pune (KEMHRC), Vadu Rural Health Program, India.,ISGlobal, Barcelona, Spain
| | - Tathagata Bhattacharjee
- KEM Hospital Research Centre Pune (KEMHRC), Vadu Rural Health Program, India.,INDEPTH Network, Accra, Ghana
| | - Bharat Chaudhary
- KEM Hospital Research Centre Pune (KEMHRC), Vadu Rural Health Program, India
| | - Pallavi Lele
- KEM Hospital Research Centre Pune (KEMHRC), Vadu Rural Health Program, India.,INDEPTH Network, Accra, Ghana
| | - Siddhivinayak Hirve
- KEM Hospital Research Centre Pune (KEMHRC), Vadu Rural Health Program, India
| | - Sanjay Juvekar
- KEM Hospital Research Centre Pune (KEMHRC), Vadu Rural Health Program, India.,INDEPTH Network, Accra, Ghana
| | | |
Collapse
|
10
|
Ngobeni H, Tempia S, Cohen AL, Walaza S, Kuonza L, Musekiwa A, von Gottberg A, Hellferscee O, Wolter N, Treurnicht FK, Moyes J, Naby F, Mekgoe O, Cohen C. The performance of different case definitions for severe influenza surveillance among HIV-infected and HIV-uninfected children aged <5 years in South Africa, 2011-2015. PLoS One 2019; 14:e0222294. [PMID: 31536552 PMCID: PMC6752836 DOI: 10.1371/journal.pone.0222294] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 08/26/2019] [Indexed: 11/18/2022] Open
Abstract
In 2014, the World Health Organization (WHO) proposed a new severe influenza surveillance case definition, which has not been evaluated in a high human immunodeficiency virus (HIV) prevalence setting. Our study aimed to assess the performance of this proposed case definition in identifying influenza among HIV-uninfected and HIV-infected children aged <5 years in South Africa. We prospectively enrolled children aged <5 years hospitalised with physician-diagnosed lower respiratory tract infection (LRTI) at two surveillance sites from January 2011 to December 2015. Epidemiologic and clinical data were collected. We tested nasopharyngeal aspirates for influenza using reverse transcription polymerase chain reaction. We used logistic regression to assess factors associated with influenza positivity among HIV-infected and HIV-uninfected children. We calculated sensitivity and specificity for different signs and symptoms and combinations of these for laboratory-confirmed influenza. We enrolled 2,582 children <5 years of age with LRTI of whom 87% (2,257) had influenza and HIV results, of these 14% (318) were HIV-infected. The influenza detection rate was 5% (104/1,939) in HIV-uninfected and 5% (16/318) in HIV-infected children. Children with measured fever (≥38°C) were two times more likely to test positive for influenza than those without measured fever among the HIV-uninfected (OR 2.2, 95% Confidence Interval (CI) 1.5-3.4; p<0.001). No significant association was observed between fever and influenza infection among HIV-infected children. Cough alone had sensitivity of 95% (95% CI 89-98%) in HIV-uninfected and of 100% (95% CI 79-100%) in HIV-infected children but low specificity: 7% (95% CI 6-8%) and 6% (95% CI 3-9%) in HIV-uninfected and HIV-infected children, respectively. The WHO post-2014 case definition for severe acute respiratory illness (SARI-an acute respiratory infection with history of fever or measured fever of ≥ 38°C and cough; with onset within the last ten days and requires hospitalization), had a sensitivity of 66% (95% CI 56-76%) and specificity of 46% (95% CI 44-48%) among HIV-uninfected and a sensitivity of 63% (95% CI 35-84%) and a specificity of 42% (95% CI 36-48%) among HIV-infected children. The sensitivity and specificity of the WHO post-2014 case definition for SARI were similar among HIV-uninfected and HIV-infected children. Our findings support the adoption of the 2014 WHO case definition for children aged <5 years irrespective of HIV infection status.
Collapse
Affiliation(s)
- Hetani Ngobeni
- South African Field Epidemiology Training Programme, Johannesburg, South Africa
- School of Health Systems and Public Health, University of Pretoria, Pretoria, South Africa
| | - Stefano Tempia
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- Influenza Program, Centers for Disease Control and Prevention, Pretoria, South Africa
- MassGenics, Duluth, Georgia, United States of America
| | - Adam L. Cohen
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- Global Immunization Monitoring and Surveillance Team, Vaccines and Biologicals, World Health Organisation, Geneva, Switzerland
| | - Sibongile Walaza
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
| | - Lazarus Kuonza
- South African Field Epidemiology Training Programme, Johannesburg, South Africa
- School of Health Systems and Public Health, University of Pretoria, Pretoria, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Alfred Musekiwa
- School of Health Systems and Public Health, University of Pretoria, Pretoria, South Africa
| | - Anne von Gottberg
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
- School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Orienka Hellferscee
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
| | - Nicole Wolter
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
- School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Florette K. Treurnicht
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
| | - Jocelyn Moyes
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Fathima Naby
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
| | - Omphile Mekgoe
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
| | - Cheryl Cohen
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| |
Collapse
|
11
|
Uyeki TM, Bernstein HH, Bradley JS, Englund JA, File TM, Fry AM, Gravenstein S, Hayden FG, Harper SA, Hirshon JM, Ison MG, Johnston BL, Knight SL, McGeer A, Riley LE, Wolfe CR, Alexander PE, Pavia AT. Clinical Practice Guidelines by the Infectious Diseases Society of America: 2018 Update on Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management of Seasonal Influenzaa. Clin Infect Dis 2019; 68. [PMID: 30566567 PMCID: PMC6653685 DOI: 10.1093/cid/ciy866 10.1093/cid/ciz044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023] Open
Abstract
These clinical practice guidelines are an update of the guidelines published by the Infectious Diseases Society of America (IDSA) in 2009, prior to the 2009 H1N1 influenza pandemic. This document addresses new information regarding diagnostic testing, treatment and chemoprophylaxis with antiviral medications, and issues related to institutional outbreak management for seasonal influenza. It is intended for use by primary care clinicians, obstetricians, emergency medicine providers, hospitalists, laboratorians, and infectious disease specialists, as well as other clinicians managing patients with suspected or laboratory-confirmed influenza. The guidelines consider the care of children and adults, including special populations such as pregnant and postpartum women and immunocompromised patients.
Collapse
Affiliation(s)
- Timothy M Uyeki
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Henry H Bernstein
- Division of General Pediatrics, Cohen Children's Medical Center, New Hyde Park, New York
| | - John S Bradley
- Division of Infectious Diseases, Rady Children's Hospital
- University of California, San Diego
| | - Janet A Englund
- Department of Pediatrics, University of Washington, Seattle Children's Hospital
| | - Thomas M File
- Division of Infectious Diseases Summa Health, Northeast Ohio Medical University, Rootstown
| | - Alicia M Fry
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Stefan Gravenstein
- Providence Veterans Affairs Medical Center and Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island
| | - Frederick G Hayden
- Division of Infectious Diseases and International Health, University of Virginia Health System, Charlottesville
| | - Scott A Harper
- Office of Public Health Preparedness and Response, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jon Mark Hirshon
- Department of Emergency Medicine, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Michael G Ison
- Divisions of Infectious Diseases and Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - B Lynn Johnston
- Department of Medicine, Dalhousie University, Nova Scotia Health Authority, Halifax, Canada
| | - Shandra L Knight
- Library and Knowledge Services, National Jewish Health, Denver, Colorado
| | - Allison McGeer
- Division of Infection Prevention and Control, Sinai Health System, University of Toronto, Ontario, Canada
| | - Laura E Riley
- Department of Maternal-Fetal Medicine, Massachusetts General Hospital, Boston
| | - Cameron R Wolfe
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Paul E Alexander
- McMaster University, Hamilton, Ontario, Canada
- Infectious Diseases Society of America, Arlington, Virginia
| | - Andrew T Pavia
- Division of Pediatric Infectious Diseases, University of Utah, Salt Lake City
| |
Collapse
|
12
|
Ram Purakayastha D, Vishnubhatla S, Rai SK, Broor S, Krishnan A. Estimation of Burden of Influenza among under-Five Children in India: A Meta-Analysis. J Trop Pediatr 2018; 64:441-453. [PMID: 29112737 DOI: 10.1093/tropej/fmx087] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND We estimated the burden of influenza-related acute respiratory tract infection (ARI) among under-fives in India through meta-analysis. METHODOLOGY We estimated pooled incidence and proportional positivity of laboratory-diagnosed influenza among under-fives using data from observational studies published from 1 January 1961 to 31 December 2016. Death due to influenza was estimated using a multiplier model. RESULTS Influenza-associated ARI incidence was estimated as 132 per 1000 child-years (115-149). The patients positive for influenza among ARI in outpatients and inpatients were estimated to be 11.2% (8.8-13.6) and 7.1% (5.5-8.8), respectively. We estimated total influenza cases during 2016 as 16 009 207 (13 942 916-18 082 769) in India. Influenza accounted for 10 913 476 (9 504 666-12 362 310) outpatient visits and 109 431 (83 882-134 980) hospitalizations. A total of 27 825 (21 382-34 408) influenza-associated under-five deaths were estimated in India in 2016. CONCLUSION Influenza imposes a substantial burden among under-fives in India. Public health approach for its prevention and control needs to be explored.
Collapse
Affiliation(s)
- Debjani Ram Purakayastha
- Centre for Community Medicine, All India Institute of Medical Sciences, AIIMS Campus, Ansari Nagar East, New Delhi, India
| | - Sreenivas Vishnubhatla
- Department of Biostatistics, All India Institute of Medical Sciences, AIIMS Campus, Ansari Nagar East, New Delhi, India
| | - Sanjay Kumar Rai
- Centre for Community Medicine, All India Institute of Medical Sciences, AIIMS Campus, Ansari Nagar East, New Delhi, India
| | - Sobha Broor
- Department of Microbiology, Faculty of Medicine and health Sciences, SGT University, Chandu-Budhera, Gurugram-Badli Road, Gurgaon, Haryana, India
| | - Anand Krishnan
- Centre for Community Medicine, All India Institute of Medical Sciences, AIIMS Campus, Ansari Nagar East, New Delhi, India
| |
Collapse
|
13
|
Fitzner J, Qasmieh S, Mounts AW, Alexander B, Besselaar T, Briand S, Brown C, Clark S, Dueger E, Gross D, Hauge S, Hirve S, Jorgensen P, Katz MA, Mafi A, Malik M, McCarron M, Meerhoff T, Mori Y, Mott J, Olivera MTDC, Ortiz JR, Palekar R, Rebelo-de-Andrade H, Soetens L, Yahaya AA, Zhang W, Vandemaele K. Revision of clinical case definitions: influenza-like illness and severe acute respiratory infection. Bull World Health Organ 2017; 96:122-128. [PMID: 29403115 PMCID: PMC5791775 DOI: 10.2471/blt.17.194514] [Citation(s) in RCA: 171] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 10/30/2017] [Accepted: 10/30/2017] [Indexed: 12/24/2022] Open
Abstract
The formulation of accurate clinical case definitions is an integral part of an effective process of public health surveillance. Although such definitions should, ideally, be based on a standardized and fixed collection of defining criteria, they often require revision to reflect new knowledge of the condition involved and improvements in diagnostic testing. Optimal case definitions also need to have a balance of sensitivity and specificity that reflects their intended use. After the 2009-2010 H1N1 influenza pandemic, the World Health Organization (WHO) initiated a technical consultation on global influenza surveillance. This prompted improvements in the sensitivity and specificity of the case definition for influenza - i.e. a respiratory disease that lacks uniquely defining symptomology. The revision process not only modified the definition of influenza-like illness, to include a simplified list of the criteria shown to be most predictive of influenza infection, but also clarified the language used for the definition, to enhance interpretability. To capture severe cases of influenza that required hospitalization, a new case definition was also developed for severe acute respiratory infection in all age groups. The new definitions have been found to capture more cases without compromising specificity. Despite the challenge still posed in the clinical separation of influenza from other respiratory infections, the global use of the new WHO case definitions should help determine global trends in the characteristics and transmission of influenza viruses and the associated disease burden.
Collapse
Affiliation(s)
- Julia Fitzner
- Infectious Hazard Management, World Health Organization, avenue Appia 20, 1211 Geneva 27, Switzerland
| | - Saba Qasmieh
- Infectious Hazard Management, World Health Organization, avenue Appia 20, 1211 Geneva 27, Switzerland
| | - Anthony Wayne Mounts
- Infectious Hazard Management, World Health Organization, avenue Appia 20, 1211 Geneva 27, Switzerland
| | - Burmaa Alexander
- National Centre for Communicable Diseases, Ulaanbataar, Mongolia
| | - Terry Besselaar
- Infectious Hazard Management, World Health Organization, avenue Appia 20, 1211 Geneva 27, Switzerland
| | - Sylvie Briand
- Infectious Hazard Management, World Health Organization, avenue Appia 20, 1211 Geneva 27, Switzerland
| | - Caroline Brown
- Regional Office for Europe, World Health Organization, Copenhagen, Denmark
| | - Seth Clark
- Infectious Hazard Management, World Health Organization, avenue Appia 20, 1211 Geneva 27, Switzerland
| | - Erica Dueger
- Western Pacific Regional Office, World Health Organization, Manila, Philippines
| | - Diane Gross
- Regional Office for Europe, World Health Organization, Copenhagen, Denmark
| | - Siri Hauge
- Department of Infectious Disease Epidemiology, Norwegian Institute of Public Health, Oslo, Norway
| | - Siddhivinayak Hirve
- Infectious Hazard Management, World Health Organization, avenue Appia 20, 1211 Geneva 27, Switzerland
| | - Pernille Jorgensen
- Regional Office for Europe, World Health Organization, Copenhagen, Denmark
| | - Mark A Katz
- Centers for Disease Control and Prevention, Atlanta, United States of America (USA)
| | - Ali Mafi
- Eastern Mediterranean Regional Office, World Health Organization, Cairo, Egypt
| | - Mamunur Malik
- Eastern Mediterranean Regional Office, World Health Organization, Cairo, Egypt
| | - Margaret McCarron
- Centers for Disease Control and Prevention, Atlanta, United States of America (USA)
| | - Tamara Meerhoff
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, Netherlands
| | - Yuichiro Mori
- Infectious Hazard Management, World Health Organization, avenue Appia 20, 1211 Geneva 27, Switzerland
| | - Joshua Mott
- United States Centers for Disease Control and Prevention Kenya Office, Nairobi, Kenya
| | | | - Justin R Ortiz
- Infectious Hazard Management, World Health Organization, avenue Appia 20, 1211 Geneva 27, Switzerland
| | - Rakhee Palekar
- Pan American Health Organization, World Health Organization, Washington, USA
| | | | - Loes Soetens
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, Netherlands
| | - Ali Ahmed Yahaya
- Regional Office for Africa, World Health Organization, Brazzaville, Congo
| | - Wenqing Zhang
- Infectious Hazard Management, World Health Organization, avenue Appia 20, 1211 Geneva 27, Switzerland
| | - Katelijn Vandemaele
- Infectious Hazard Management, World Health Organization, avenue Appia 20, 1211 Geneva 27, Switzerland
| |
Collapse
|
14
|
Tinoco YO, Azziz-Baumgartner E, Uyeki TM, Rázuri HR, Kasper MR, Romero C, Silva ME, Simons MP, Soto GM, Widdowson MA, Gilman RH, Bausch DG, Montgomery JM. Burden of Influenza in 4 Ecologically Distinct Regions of Peru: Household Active Surveillance of a Community Cohort, 2009-2015. Clin Infect Dis 2017; 65:1532-1541. [PMID: 29020267 PMCID: PMC5850002 DOI: 10.1093/cid/cix565] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 06/22/2017] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND There are limited data on the burden of disease posed by influenza in low- and middle-income countries. Furthermore, most estimates of influenza disease burden worldwide rely on passive sentinel surveillance at health clinics and hospitals that lack accurate population denominators. METHODS We documented influenza incidence, seasonality, health-system utilization with influenza illness, and vaccination coverage through active community-based surveillance in 4 ecologically distinct regions of Peru over 6 years. Approximately 7200 people in 1500 randomly selected households were visited 3 times per week. Naso- and oropharyngeal swabs were collected from persons with influenza-like illness and tested for influenza virus by real-time reverse-transcription polymerase chain reaction. RESULTS We followed participants for 35353 person-years (PY). The overall incidence of influenza was 100 per 1000 PY (95% confidence interval [CI], 97-104) and was highest in children aged 2-4 years (256/1000 PY [95% CI, 236-277]). Seasonal incidence trends were similar across sites, with 61% of annual influenza cases occurring during the austral winter (May-September). Of all participants, 44 per 1000 PY (95% CI, 42-46) sought medical care, 0.7 per 1000 PY (95% CI, 0.4-1.0) were hospitalized, and 1 person died (2.8/100000 PY). Influenza vaccine coverage was 27% among children aged 6-23 months and 26% among persons aged ≥65 years. CONCLUSIONS Our results indicate that 1 in 10 persons develops influenza each year in Peru, with the highest incidence in young children. Active community-based surveillance allows for a better understanding of the true burden and seasonality of disease that is essential to plan the optimal target groups, timing, and cost of national influenza vaccination programs.
Collapse
Affiliation(s)
- Yeny O Tinoco
- US Naval Medical Research Unit No. 6, Bellavista, Peru
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | - Timothy M Uyeki
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Hugo R Rázuri
- US Naval Medical Research Unit No. 6, Bellavista, Peru
| | | | | | - Maria E Silva
- US Naval Medical Research Unit No. 6, Bellavista, Peru
| | - Mark P Simons
- US Naval Medical Research Unit No. 6, Bellavista, Peru
| | | | - Marc-Alain Widdowson
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Robert H Gilman
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Daniel G Bausch
- US Naval Medical Research Unit No. 6, Bellavista, Peru
- Tulane School of Public Health and Tropical Medicine, New Orleans, Louisiana; and
| | - Joel M Montgomery
- US Naval Medical Research Unit No. 6, Bellavista, Peru
- Division of Global Health Protection, Centers for Disease Control and Prevention, Atlanta, Georgia
| |
Collapse
|
15
|
Amini R, Gilca R, Douville-Fradet M, Boulianne N, De Serres G. Evaluation of the New World Health Organization Case Definition of Severe Acute Respiratory Infection for Influenza Surveillance During the Peak Weeks of Two Influenza Seasons in Quebec, Canada. J Pediatric Infect Dis Soc 2017; 6:297-300. [PMID: 27496537 DOI: 10.1093/jpids/piw044] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 07/11/2016] [Indexed: 12/21/2022]
Abstract
During the peak of the 2012-2013 and 2014-2015 influenza seasons in Quebec, Canada, the sensitivity of the new World Health Organization (WHO) case definition of severe acute respiratory infection (SARI) in <5-year-old children was 65% for polymerase chain reaction-confirmed influenza and 79% for other respiratory viruses (ORVs), whereas its specificity and positive predictive value were approximately 2- and 4-fold lower for influenza than ORVs (25% vs 40% and 18% vs 76%, respectively). The use of the WHO SARI definition for influenza surveillance in children should be interpreted with caution according to the specific surveillance goals.
Collapse
Affiliation(s)
- R Amini
- Institut National de Santé Publique du Québec
| | - R Gilca
- Institut National de Santé Publique du Québec.,Centre Hospitalier Universitaire de Quebec.,Laval University, Quebec, Quebec City, Canada
| | - M Douville-Fradet
- Institut National de Santé Publique du Québec.,Centre Hospitalier Universitaire de Quebec
| | - N Boulianne
- Institut National de Santé Publique du Québec.,Centre Hospitalier Universitaire de Quebec
| | - G De Serres
- Institut National de Santé Publique du Québec.,Centre Hospitalier Universitaire de Quebec.,Laval University, Quebec, Quebec City, Canada
| |
Collapse
|
16
|
Abstract
BACKGROUND There are limited data regarding testing and treatment patterns for children presenting to the emergency department (ED) with a febrile respiratory illness. OBJECTIVES The aims of the study were to evaluate the rates of diagnostic testing, antibiotic use, and pneumonia diagnosis among children presenting to an ED with a febrile respiratory illness and to evaluate whether differences exist on the basis of care at a pediatric versus a general ED. METHODS Cross-sectional study of children presenting to an ED with a febrile respiratory illness from 2001 to 2010 used the National Hospital Ambulatory Medical Care Survey. Using extrapolated estimates from the weighted population sample, rates of laboratory and radiographic testing, antibiotic use, and pneumonia diagnosis were ascertained. Comparisons were made between children treated at a general versus pediatric ED. A subpopulation of children undergoing chest radiograph was identified to target those with concern for radiographic pneumonia. RESULTS Fifteen percent of the 12 million visits for febrile respiratory illness occurred in a pediatric ED. Thirteen percent (95% confidence interval [CI], 11-15) of patients had a complete blood count, 4% (95% CI, 3-5) had a blood culture, and 33% (95% CI, 30-35) had a chest radiograph obtained; no differences were observed on the basis of ED type. Despite similar rates of pneumonia diagnosis, antibiotics were prescribed less often for children cared for in a pediatric (35% [95% CI, 30-41]) versus general ED (50% [95% CI, 47-53]). Similar findings were observed among the subgroup of children with febrile respiratory illness undergoing chest radiograph. CONCLUSIONS High rates of diagnostic testing were observed among children with febrile respiratory illnesses, despite low rates of pneumonia diagnosis. Antibiotic use was higher among children cared for at a general ED compared with pediatric ED.
Collapse
|
17
|
Makokha C, Mott J, Njuguna HN, Khagayi S, Verani JR, Nyawanda B, Otieno N, Katz MA. Comparison of severe acute respiratory illness (sari) and clinical pneumonia case definitions for the detection of influenza virus infections among hospitalized patients, western Kenya, 2009-2013. Influenza Other Respir Viruses 2016; 10:333-9. [PMID: 27219455 PMCID: PMC4910169 DOI: 10.1111/irv.12382] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2016] [Indexed: 12/13/2022] Open
Abstract
Although the severe acute respiratory illness (SARI) case definition is increasingly used for inpatient influenza surveillance, pneumonia is a more familiar term to clinicians and policymakers. We evaluated WHO case definitions for severe acute respiratory illness (SARI) and pneumonia (Integrated Management of Childhood Illnesses (IMCI) for children aged <5 years and Integrated Management of Adolescent and Adult Illnesses (IMAI) for patients aged ≥13 years) for detecting laboratory-confirmed influenza among hospitalized ARI patients. Sensitivities were 84% for SARI and 69% for IMCI pneumonia in children aged <5 years and 60% for SARI and 57% for IMAI pneumonia in patients aged ≥13 years. Clinical pneumonia case definitions may be a useful complement to SARI for inpatient influenza surveillance.
Collapse
Affiliation(s)
| | - Joshua Mott
- Centers for Disease Control and PreventionNairobiKenya
- Centers for Disease Control and Prevention (CDC)AtlantaGAUSA
| | | | | | - Jennifer R. Verani
- Centers for Disease Control and PreventionNairobiKenya
- Centers for Disease Control and Prevention (CDC)AtlantaGAUSA
| | | | - Nancy Otieno
- Kenya Medical Research Institute (KEMRI)KisumuKenya
| | - Mark A. Katz
- Centers for Disease Control and Prevention (CDC)AtlantaGAUSA
| |
Collapse
|
18
|
Oliveira CR, Costa GSR, Paploski IAD, Kikuti M, Kasper AM, Silva MMO, Tavares AS, Cruz JS, Queiroz TL, Lima HCAV, Calcagno J, Reis MG, Weinberger DM, Shapiro ED, Ko AI, Ribeiro GS. Influenza-like illness in an urban community of Salvador, Brazil: incidence, seasonality and risk factors. BMC Infect Dis 2016; 16:125. [PMID: 26975185 PMCID: PMC4791800 DOI: 10.1186/s12879-016-1456-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Accepted: 03/07/2016] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Our understanding of the epidemiology of influenza is limited in tropical regions, which in turn has hampered identifying optimal region-specific policy to diminish disease burden. Influenza-like illness (ILI) is a clinical diagnosis that can be used as a surrogate for influenza. This study aimed to define the incidence and seasonality of ILI and to assess its association with climatic variables and school calendar in an urban community in the tropical region of Salvador, Brazil. METHODS Between 2009 and 2013, we conducted enhanced community-based surveillance for acute febrile illnesses (AFI) among patients ≥ 5 years of age in a slum community emergency unit in Salvador, Brazil. ILI was defined as a measured temperature of ≥ 37.8 °C or reported fever in a patient with cough or sore throat for ≤ 7 days, and negative test results for dengue and leptospirosis. Seasonality was analyzed with a harmonic regression model. Negative binomial regression models were used to correlate ILI incidence with rainfall, temperature, relative humidity and the number of days per month that schools were in session while controlling for seasonality. RESULTS There were 2,651 (45.6% of 5,817 AFI patients) ILI cases with a mean annual incidence of 60 cases/1,000 population (95% CI 58-62). Risk of ILI was highest among 5-9 year olds with an annual incidence of 105 cases/1,000 population in 2009. ILI had a clear seasonal pattern with peaks between the 35-40th week of the year. ILI peaks were higher and earlier in 5-9 year olds compared with > 19 year olds. No association was seen between ILI and precipitation, relative humidity or temperature. There was a significant association between the incidence of ILI in children 5-9 years of age and number of scheduled school days per month. CONCLUSIONS We identified a significant burden of ILI with distinct seasonality in the Brazilian tropics and highest rates among young school-age children. Seasonal peaks of ILI in children 5-9 years of age were positively associated with the number of school days, indicating that children may play a role in the timing of seasonal influenza transmission.
Collapse
Affiliation(s)
- Carlos R. Oliveira
- Department of Pediatrics, School of Medicine, Yale University, New Haven, USA
| | - Gisela S. R. Costa
- Centro de Pesquisas Gonçalo Moniz, Fundação Oswaldo Cruz, Ministério da Saúde, Rua Waldemar Falcão, 121, Candeal, 40296-710 Salvador, Brazil
| | - Igor A. D. Paploski
- Centro de Pesquisas Gonçalo Moniz, Fundação Oswaldo Cruz, Ministério da Saúde, Rua Waldemar Falcão, 121, Candeal, 40296-710 Salvador, Brazil
- Instituto de Saúde Coletiva, Universidade Federal da Bahia, Salvador, Brazil
| | - Mariana Kikuti
- Centro de Pesquisas Gonçalo Moniz, Fundação Oswaldo Cruz, Ministério da Saúde, Rua Waldemar Falcão, 121, Candeal, 40296-710 Salvador, Brazil
- Instituto de Saúde Coletiva, Universidade Federal da Bahia, Salvador, Brazil
| | - Amelia M. Kasper
- Centro de Pesquisas Gonçalo Moniz, Fundação Oswaldo Cruz, Ministério da Saúde, Rua Waldemar Falcão, 121, Candeal, 40296-710 Salvador, Brazil
| | - Monaise M. O. Silva
- Centro de Pesquisas Gonçalo Moniz, Fundação Oswaldo Cruz, Ministério da Saúde, Rua Waldemar Falcão, 121, Candeal, 40296-710 Salvador, Brazil
| | - Aline S. Tavares
- Centro de Pesquisas Gonçalo Moniz, Fundação Oswaldo Cruz, Ministério da Saúde, Rua Waldemar Falcão, 121, Candeal, 40296-710 Salvador, Brazil
| | - Jaqueline S. Cruz
- Centro de Pesquisas Gonçalo Moniz, Fundação Oswaldo Cruz, Ministério da Saúde, Rua Waldemar Falcão, 121, Candeal, 40296-710 Salvador, Brazil
| | - Tássia L. Queiroz
- Instituto de Saúde Coletiva, Universidade Federal da Bahia, Salvador, Brazil
| | - Helena C. A. V. Lima
- Centro de Pesquisas Gonçalo Moniz, Fundação Oswaldo Cruz, Ministério da Saúde, Rua Waldemar Falcão, 121, Candeal, 40296-710 Salvador, Brazil
| | - Juan Calcagno
- Centro de Pesquisas Gonçalo Moniz, Fundação Oswaldo Cruz, Ministério da Saúde, Rua Waldemar Falcão, 121, Candeal, 40296-710 Salvador, Brazil
| | - Mitermayer G. Reis
- Centro de Pesquisas Gonçalo Moniz, Fundação Oswaldo Cruz, Ministério da Saúde, Rua Waldemar Falcão, 121, Candeal, 40296-710 Salvador, Brazil
- Department of Epidemiology of Microbial Diseases, School of Public Health, Yale University, New Haven, USA
- Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Brazil
| | - Daniel M. Weinberger
- Department of Epidemiology of Microbial Diseases, School of Public Health, Yale University, New Haven, USA
| | - Eugene D. Shapiro
- Department of Pediatrics, School of Medicine, Yale University, New Haven, USA
- Department of Epidemiology of Microbial Diseases, School of Public Health, Yale University, New Haven, USA
- Department of Investigative Medicine, School of Medicine, Yale University, New Haven, USA
| | - Albert I. Ko
- Centro de Pesquisas Gonçalo Moniz, Fundação Oswaldo Cruz, Ministério da Saúde, Rua Waldemar Falcão, 121, Candeal, 40296-710 Salvador, Brazil
- Department of Epidemiology of Microbial Diseases, School of Public Health, Yale University, New Haven, USA
| | - Guilherme S. Ribeiro
- Centro de Pesquisas Gonçalo Moniz, Fundação Oswaldo Cruz, Ministério da Saúde, Rua Waldemar Falcão, 121, Candeal, 40296-710 Salvador, Brazil
- Instituto de Saúde Coletiva, Universidade Federal da Bahia, Salvador, Brazil
- Department of Epidemiology of Microbial Diseases, School of Public Health, Yale University, New Haven, USA
| |
Collapse
|
19
|
Thomas R. The case for ILI surveillance. Vaccine 2015; 33:6515-6. [PMID: 26482063 PMCID: PMC7130647 DOI: 10.1016/j.vaccine.2015.09.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Indexed: 11/26/2022]
|
20
|
Hardelid P, Rait G, Gilbert R, Petersen I. Recording of Influenza-Like Illness in UK Primary Care 1995-2013: Cohort Study. PLoS One 2015; 10:e0138659. [PMID: 26390295 PMCID: PMC4577110 DOI: 10.1371/journal.pone.0138659] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 09/02/2015] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND There is a lack of recent studies examining recording of influenza-like illness (ILI) in primary care in the UK over time and according to population characteristics. Our aim was to determine time trends and socio-demographic patterns of ILI recorded consultations in primary care. METHODS We used The Health Improvement Network (THIN) UK primary care database and extracted data on all ILI consultations between 1995 and 2013. We estimated ILI recorded consultation rates per 100,000 person-weeks (pw) by age, gender, deprivation and winter season. Negative binomial regression models were used to examine time trends and the effect of socio-demographic characteristics. Trends in ILI recorded consultations were compared to trends in consultations with less specific symptoms (cough or fever) recorded. RESULTS The study involved 7,682,908 individuals in 542 general practices. The ILI consultation rate decreased from 32.5/100,000 pw (95% confidence interval (CI) 32.1, 32.9) in 1995-98 to 15.5/100,000 pw (95% CI 15.4, 15.7) by 2010-13. The decrease occurred prior to 2002/3, and rates have remained largely stable since then. Declines were evident in all age groups. In comparison, cough or fever consultation rates increased from 169.4/100,000 pw (95% CI 168.6, 170.3) in 1995-98 to 237.7/100,000 pw (95% CI 237.2, 238.2) in 2010-13. ILI consultation rates were highest among individuals aged 15-44 years, higher in women than men, and in individuals from deprived areas. CONCLUSION There is substantial variation in ILI recorded consultations over time and by population socio-demographic characteristics, most likely reflecting changing recording behaviour by GPs. These results highlight the difficulties in using coded information from electronic primary care records to measure the severity of influenza epidemics across time and assess the relative burden of ILI in different population subgroups.
Collapse
Affiliation(s)
- Pia Hardelid
- Population, Policy and Practice Programme, University College London Institute of Child Health, London, United Kingdom
- Research Department of Primary Care and Population Health, University College London, London, United Kingdom
| | - Greta Rait
- PRIMENT Clinical Trials Unit, Research Department of Primary Care and Population Health, University College London, London, United Kingdom
| | - Ruth Gilbert
- Population, Policy and Practice Programme, University College London Institute of Child Health, London, United Kingdom
| | - Irene Petersen
- Research Department of Primary Care and Population Health, University College London, London, United Kingdom
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
| |
Collapse
|
21
|
Abstract
Influenza-like illness (ILI) case definitions, such as those from the European Centre for Disease Control and Prevention, World Health Organization (WHO) and United States Centers for Disease Control and Prevention, are commonly used for influenza surveillance. We assessed how various case definitions performed during the initial wave of influenza A(H1N1) pdm09 infections in Singapore on a cohort of 727 patients with two to three blood samples and whose symptoms were reviewed fortnightly from June to October 2009. Using seroconversion (≥ 4-fold rise) to A/California/7/2009 (H1N1), we identified 36 presumptive influenza A(H1N1)pdm09 episodes and 664 episodes unrelated to influenza A(H1N1)pdm09. Cough, fever and headache occurred more commonly in presumptive influenza A(H1N1)pdm09. Although the sensitivity was low (36%), the recently revised WHO ILI case definition gave a higher positive predictive value (42%) and positive likelihood ratio (13.3) than the other case definitions. Results including only episodes with primary care consultations were similar. Individuals who worked or had episodes with fever, cough or sore throat were more likely to consult a physician, while episodes with Saturday onset were less likely, with some consultations skipped or postponed. Our analysis supports the use of the revised WHO ILI case definition, which includes only cough in the presence of fever defined as body temperature ≥ 38 °C for influenza surveillance.
Collapse
Affiliation(s)
- L Jiang
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | | | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Brousseau N, Green HK, Andrews N, Pryse R, Baguelin M, Sunderland A, Ellis J, Pebody R. Impact of influenza vaccination on respiratory illness rates in children attending private boarding schools in England, 2013-2014: a cohort study. Epidemiol Infect 2015; 143:3405-15. [PMID: 25876454 DOI: 10.1017/S0950268815000667] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Several private boarding schools in England have established universal influenza vaccination programmes for their pupils. We evaluated the impact of these programmes on the burden of respiratory illnesses in boarders. Between November 2013 and May 2014, age-specific respiratory disease incidence rates in boarders were compared between schools offering and not offering influenza vaccine to healthy boarders. We adjusted for age, sex, school size and week using negative binomial regression. Forty-three schools comprising 14 776 boarders participated. Almost all boarders (99%) were aged 11-17 years. Nineteen (44%) schools vaccinated healthy boarders against influenza, with a mean uptake of 48·5% (range 14·2-88·5%). Over the study period, 1468 respiratory illnesses were reported in boarders (5·66/1000 boarder-weeks); of these, 33 were influenza-like illnesses (ILIs, 0·26/1000 boarder-weeks) in vaccinating schools and 95 were ILIs (0·74/1000 boarder-weeks) in non-vaccinating schools. The impact of vaccinating healthy boarders was a 54% reduction in ILI in all boarders [rate ratio (RR) 0·46, 95% confidence interval (CI) 0·28-0·76]. Disease rates were also reduced for upper respiratory tract infections (RR 0·72, 95% CI 0·61-0·85) and chest infections (RR 0·18, 95% CI 0·09-0·36). These findings demonstrate a significant impact of influenza vaccination on ILI and other clinical endpoints in secondary-school boarders. Additional research is needed to investigate the impact of influenza vaccination in non-boarding secondary-school settings.
Collapse
|
23
|
Budgell E, Cohen AL, McAnerney J, Walaza S, Madhi SA, Blumberg L, Dawood H, Kahn K, Tempia S, Venter M, Cohen C. Evaluation of two influenza surveillance systems in South Africa. PLoS One 2015; 10:e0120226. [PMID: 25822719 PMCID: PMC4379032 DOI: 10.1371/journal.pone.0120226] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 01/20/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The World Health Organisation recommends outpatient influenza-like illness (ILI) and inpatient severe acute respiratory illness (SARI) surveillance. We evaluated two influenza surveillance systems in South Africa: one for ILI and another for SARI. METHODOLOGY The Viral Watch (VW) programme has collected virological influenza surveillance data voluntarily from patients with ILI since 1984 in private and public clinics in all 9 South African provinces. The SARI surveillance programme has collected epidemiological and virological influenza surveillance data since 2009 in public hospitals in 4 provinces by dedicated personnel. We compared nine surveillance system attributes from 2009-2012. RESULTS We analysed data from 18,293 SARI patients and 9,104 ILI patients. The annual proportion of samples testing positive for influenza was higher for VW (mean 41%) than SARI (mean 8%) and generally exceeded the seasonal threshold from May to September (VW: weeks 21-40; SARI: weeks 23-39). Data quality was a major strength of SARI (most data completion measures >90%; adherence to definitions: 88-89%) and a relative weakness of the VW programme (62% of forms complete, with limited epidemiologic data collected; adherence to definitions: 65-82%). Timeliness was a relative strength of both systems (e.g. both collected >93% of all respiratory specimens within 7 days of symptom onset). ILI surveillance was more nationally representative, financially sustainable and expandable than the SARI system. Though the SARI programme is not nationally representative, the high quality and detail of SARI data collection sheds light on the local burden and epidemiology of severe influenza-associated disease. CONCLUSIONS To best monitor influenza in South Africa, we propose that both ILI and SARI should be under surveillance. Improving ILI surveillance will require better quality and more systematic data collection, and SARI surveillance should be expanded to be more nationally representative, even if this requires scaling back on information gathered.
Collapse
Affiliation(s)
- Eric Budgell
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Services, Johannesburg, South Africa
| | - Adam L. Cohen
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, United States and Influenza Program, Centers for Disease Control and Prevention—South Africa, Pretoria, South Africa
| | - Jo McAnerney
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Services, Johannesburg, South Africa
| | - Sibongile Walaza
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Services, Johannesburg, South Africa
| | - Shabir A. Madhi
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Services, Johannesburg, South Africa
- Department of Science and Technology/National Research Foundation: Vaccine-Preventable Diseases, University of the Witwatersrand, Johannesburg, South Africa
| | - Lucille Blumberg
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Services, Johannesburg, South Africa
| | - Halima Dawood
- Department of Medicine, Pietermaritzburg Metropolitan Hospital Complex and University of KwaZulu Natal, South Africa
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Stefano Tempia
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, United States and Influenza Program, Centers for Disease Control and Prevention—South Africa, Pretoria, South Africa
- CTS Global, Inc., Los Angeles, United States of America
| | - Marietjie Venter
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Services, Johannesburg, South Africa
- Zoonoses Research Unit, Department of Medical Virology, University of Pretoria, Pretoria, South Africa
| | - Cheryl Cohen
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Services, Johannesburg, South Africa
- Schools of Public Health and Pathology, University of the Witwatersrand, Johannesburg, South Africa
| |
Collapse
|
24
|
Radin JM, Hawksworth AW, Kammerer PE, Balansay M, Raman R, Lindsay SP, Brice GT. Epidemiology of pathogen-specific respiratory infections among three US populations. PLoS One 2014; 9:e114871. [PMID: 25549089 PMCID: PMC4280218 DOI: 10.1371/journal.pone.0114871] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 11/14/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Diagnostic tests for respiratory infections can be costly and time-consuming. Improved characterization of specific respiratory pathogens by identifying frequent signs, symptoms and demographic characteristics, along with improving our understanding of coinfection rates and seasonality, may improve treatment and prevention measures. METHODS Febrile respiratory illness (FRI) and severe acute respiratory infection (SARI) surveillance was conducted from October 2011 through March 2013 among three US populations: civilians near the US-Mexico border, Department of Defense (DoD) beneficiaries, and military recruits. Clinical and demographic questionnaire data and respiratory swabs were collected from participants, tested by PCR for nine different respiratory pathogens and summarized. Age stratified characteristics of civilians positive for influenza and recruits positive for rhinovirus were compared to other and no/unknown pathogen. Seasonality and coinfection rates were also described. RESULTS A total of 1444 patients met the FRI or SARI case definition and were enrolled in this study. Influenza signs and symptoms varied across age groups of civilians. Recruits with rhinovirus had higher percentages of pneumonia, cough, shortness of breath, congestion, cough, less fever and longer time to seeking care and were more likely to be male compared to those in the no/unknown pathogen group. Coinfections were found in 6% of all FRI/SARI cases tested and were most frequently seen among children and with rhinovirus infections. Clear seasonal trends were identified for influenza, rhinovirus, and respiratory syncytial virus. CONCLUSIONS The age-stratified clinical characteristics associated with influenza suggest that age-specific case definitions may improve influenza surveillance and identification. Improving identification of rhinoviruses, the most frequent respiratory infection among recruits, may be useful for separating out contagious individuals, especially when larger outbreaks occur. Overall, describing the epidemiology of pathogen specific respiratory diseases can help improve clinical diagnoses, establish baselines of infection, identify outbreaks, and help prioritize the development of new vaccines and treatments.
Collapse
Affiliation(s)
- Jennifer M. Radin
- Operational Infectious Diseases Department, Naval Health Research Center San Diego, San Diego, California, United States of America
- Joint Doctoral Program in Public Health (Epidemiology), San Diego State University/University of California San Diego, San Diego, California, United States of America
| | - Anthony W. Hawksworth
- Operational Infectious Diseases Department, Naval Health Research Center San Diego, San Diego, California, United States of America
| | - Peter E. Kammerer
- Operational Infectious Diseases Department, Naval Health Research Center San Diego, San Diego, California, United States of America
| | - Melinda Balansay
- Operational Infectious Diseases Department, Naval Health Research Center San Diego, San Diego, California, United States of America
| | - Rema Raman
- Department of Family and Preventive Medicine, University of California San Diego, La Jolla, California, United States of America
| | - Suzanne P. Lindsay
- Graduate School of Public Health, San Diego State University, San Diego, California, United States of America
| | - Gary T. Brice
- Operational Infectious Diseases Department, Naval Health Research Center San Diego, San Diego, California, United States of America
| |
Collapse
|
25
|
Hirve S, Krishnan A, Dawood FS, Lele P, Saha S, Rai S, Gupta V, Lafond KE, Juvekar S, Potdar V, Broor S, Lal RB, Chadha M. Incidence of influenza-associated hospitalization in rural communities in western and northern India, 2010-2012: a multi-site population-based study. J Infect 2014; 70:160-70. [PMID: 25218056 DOI: 10.1016/j.jinf.2014.08.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 08/02/2014] [Accepted: 08/05/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND The global burden of influenza is increasingly recognized, but data from India remain sparse. We conducted a multi-site population-based surveillance study to estimate and compare rates of influenza-associated hospitalization at two rural Indian health and demographic surveillance system (HDSS) sites at Ballabgarh and Vadu during 2010-2012. METHODS Prospective facility-based surveillance for all hospitalizations (excluding those for trauma, elective surgery and obstetric, ophthalmic or psychiatric reasons) was conducted at 72 health facilities. After collection of clinical details, patients had nasopharyngeal swabs taken and tested by reverse transcription polymerase chain reaction for influenza viruses. Annual healthcare utilization surveys (HUS) were conducted in HDSS households to identify proportion of hospitalizations occurring at non-study facilities to adjust for hospitalizations missed through facility-based surveillance. RESULTS HUS showed that 69% and 67% of hospitalizations occurred at study facilities at Ballabgarh and Vadu, respectively. Overall, 6004 patients hospitalized with acute medical illness at participating facilities were enrolled (1717 from Ballabgarh; 4287 from Vadu). The proportion of patients with influenza was higher at Vadu than Ballabgarh annually (2010: 21% vs. 5%, p < 0.05; 2011: 18% vs. 5%, p < 0.05; 2012: 23% vs. 5%, p < 0.05). Annual adjusted influenza-associated hospitalization rates were 5-11 fold higher in Vadu (20.3-51.6 per 10,000) vs Ballabgarh (4.4-6.3 per 10,000). At both sites, influenza A/H1N1pdm09 and B predominated during 2010, A/H3N2 and B during 2011, and A/H1N1pdm09 and B during 2012. CONCLUSION The markedly different influenza hospitalization rates by season and across communities in India highlight the need for sustained multi-site surveillance system for estimating national influenza disease burden. That would be the first step for initiating discussions around Influenza prevention and control strategies in the country.
Collapse
Affiliation(s)
- Siddhivinayak Hirve
- Vadu Rural Health Program, King Edward Memorial Hospital Research Center, Pune, India
| | - Anand Krishnan
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Fatimah S Dawood
- Influenza Division, National Center for Immunization and Respiratory Disease, Centers for Disease Control and Prevention, Atlanta, USA
| | - Pallavi Lele
- Vadu Rural Health Program, King Edward Memorial Hospital Research Center, Pune, India
| | - Siddhartha Saha
- Influenza Division, National Center for Immunization and Respiratory Disease, Centers for Disease Control and Prevention, Atlanta, USA
| | - Sanjay Rai
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Vivek Gupta
- National Institute of Mental Health and Allied Sciences, Bangalore, India
| | - Kathryn E Lafond
- Influenza Division, National Center for Immunization and Respiratory Disease, Centers for Disease Control and Prevention, Atlanta, USA
| | - Sanjay Juvekar
- Vadu Rural Health Program, King Edward Memorial Hospital Research Center, Pune, India
| | - Varsha Potdar
- National Institute of Virology, Indian Council of Medical Research, 20-A, Dr Ambedkar Road, Pune 411001, India
| | | | - Renu B Lal
- Influenza Division, National Center for Immunization and Respiratory Disease, Centers for Disease Control and Prevention, Atlanta, USA
| | - Mandeep Chadha
- National Institute of Virology, Indian Council of Medical Research, 20-A, Dr Ambedkar Road, Pune 411001, India.
| |
Collapse
|
26
|
Abstract
The substantial economic impact of influenza on society results primarily from lost work time and reduced productivity of patients and caregivers and increased use of medical resources. Additionally, since the 1980s, aging of the US population has meant rising influenza-related morbidity and mortality. According to the most current published data on this topic, in 2003 the total economic burden of influenza epidemics in the USA across all age groups was US$87.1 billion. As of February 2013, overall vaccine effectiveness for the 2012/2013 season was estimated to be 56 %. The Centers for Disease Control and Prevention's National Center for Immunization and Respiratory Diseases has concluded that more effective vaccines and vaccination strategies are needed. Moderate efficacy of the influenza vaccine, continued questions regarding the value of treatment with antivirals, and a growing self-care movement have led to increased use of over-the-counter (OTC) medicines, which play a vital role in managing symptoms associated with mild to moderate influenza and provide an estimated US$102 billion in annual savings for the US healthcare system. A primary benefit to society of using OTC medicines to manage influenza is decreased use of the healthcare system, thereby mitigating the socioeconomic burden of influenza. Considering the stresses placed on the US healthcare system and the substantial productivity losses resulting from seasonal influenza as well as the growing self-care movement, OTC medicines will play an important role in the course of future influenza epidemics.
Collapse
Affiliation(s)
- Michael E Klepser
- Ferris State University College of Pharmacy, PHR 105, 220 Ferris Drive, Big Rapids, MI, 49307, USA,
| |
Collapse
|
27
|
Thomas RE. Is influenza-like illness a useful concept and an appropriate test of influenza vaccine effectiveness? Vaccine 2014; 32:2143-9. [PMID: 24582634 PMCID: PMC7127078 DOI: 10.1016/j.vaccine.2014.02.059] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Revised: 02/07/2014] [Accepted: 02/12/2014] [Indexed: 11/23/2022]
Abstract
PURPOSE To assess the utility of "influenza-like illness" (ILI) and whether it appropriately tests influenza vaccine effectiveness. PRINCIPAL RESULTS The WHO and CDC definitions of "influenza-like illness" are similar. However many studies use other definitions, some not specifying a temperature and requiring specific respiratory and/or systemic symptoms, making many samples non-comparable. Most ILI studies find less than 25% of cases are RT-PCR-positive, those which test for other viruses and bacteria usually find multiple other pathogens, and most identify no pathogen in about 50% of cases. ILI symptom and symptom combinations do not have high sensitivity or specificity in identifying PCR-positive influenza cases. Rapid influenza diagnostic tests are increasingly used to screen ILI cases and they have low sensitivity and high specificity when compared to RT-PCR in identifying influenza. MAIN CONCLUSIONS The working diagnosis of ILI presumes influenza may be involved until proven otherwise. Health care workers would benefit by renaming the WHO and CDC ILI symptoms and signs as "acute respiratory illness" and also using the WHO acute severe respiratory illness definition if the illness is severe and meets this criterion. This renaming would shift attention to identify the viral and bacterial pathogens in cases and epidemics, identify new pathogens, implement vaccination plans appropriate to the identified pathogens, and estimate workload during the viral season. Randomised controlled trials testing the effectiveness of influenza vaccine require all participants to be assessed by a gold standard (RT-PCR). ILI has no role in measuring influenza vaccine effectiveness. ILI is well established in the literature and in the operational definition of many surveillance databases and its imprecise definition may be inhibiting progress in research and treatment. The current ILI definition could with benefit be renamed "acute respiratory illness," with additional definitions for "severe acute respiratory illness" (SARI) with RT-PCR testing for pathogens to facilitate prevention and treatment.
Collapse
Affiliation(s)
- Roger E Thomas
- Department of Family Medicine, Faculty of Medicine, University of Calgary, G012, Health Sciences Centre, 3330 Hospital Drive NW, Calgary, Alberta, Canada T2N 4N1.
| |
Collapse
|
28
|
Flick H, Drescher M, Prattes J, Tovilo K, Kessler H, Vander K, Seeber K, Palfner M, Raggam R, Avian A, Krause R, Hoenigl M. Predictors of H1N1 influenza in the emergency department: proposition for a modified H1N1 case definition. Clin Microbiol Infect 2014; 20:O105-8. [DOI: 10.1111/1469-0691.12352] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2013] [Revised: 06/25/2013] [Accepted: 07/31/2013] [Indexed: 11/28/2022]
|
29
|
Hoenigl M, Prattes J, Drescher M, Tovilo K, Seeber K, Kessler HH, Vander K, Palfner M, Meilinger M, Avian A, Valentin T, Zollner-Schwetz I, Strenger V, Krause R, Flick H. Comparison of clinical presentation and laboratory values at admission between PCR-confirmed influenza A H1N1 infection and influenza-like disease, South-East Austria. Infection 2013; 42:317-24. [PMID: 24190398 DOI: 10.1007/s15010-013-0549-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Accepted: 10/24/2013] [Indexed: 11/27/2022]
Abstract
PURPOSE Reliable and rapid diagnosis of influenza A H1N1 is essential to initiate the appropriate antiviral therapy and preventive measures. As PCR assays are time-consuming and rapid antigen tests have a limited sensitivity, official influenza case definitions are used in many clinical settings. These, however, are based exclusively on clinical criteria and have only a moderate potential to differentiate between influenza and other febrile diseases. Only limited data on the differences in clinical and laboratory parameters between influenza and non-influenza febrile diseases are available to date. METHODS This was a retrospective case-negative control series that was conducted in Styria, southeast Austria. We analyzed the differences in clinical presentation and laboratory admission parameters between patients with PCR-confirmed H1N1 influenza infection (n = 199) and those with influenza-like disease and negative influenza PCR results (ILD group; n = 252). RESULTS In the multivariable analysis lower C-reactive protein (CRP) level, lower white blood cell (WBC) count, fever, wheezing, cough, and the absence of nausea or sudden onset remained significant predictors of H1N1 influenza in adult patients (n = 263). Lower CRP level, lower WBC count, and cough remained significant predictors in pediatric patients (<16 years; n = 188). CONCLUSION Lower CRP level, lower WBC count, and cough were significant predictors of H1N1 in both the adult and pediatric patient group. These data may help to develop an improved case definition for suspected H1N1 infection which combines clinical findings and easily available laboratory parameters.
Collapse
Affiliation(s)
- M Hoenigl
- Division of Pulmonology, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria,
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|