Validity of clinical case definitions for influenza surveillance among hospitalized patients: results from a rural community in North India.
OBJECTIVE
Clinical case definitions used for influenza surveillance among hospitalized patients vary and need systematic evaluation. DESIGN, SETTING AND SAMPLE: During July 2009-August 2011, we collected clinical data and specimens (nasal and throat swabs) from rural patients hospitalized for acute medical illnesses. Specimens were tested by rRT-PCR for influenza viruses.


METHODS
Case definitions evaluated the following: influenza-like illness (ILI: measured fever plus cough or sore throat); severe acute respiratory illness (SARI: ILI with difficulty breathing in ≥5 years, Integrated Management of Childhood Illness-defined pneumonia or severe pneumonia, or physician diagnosed lower respiratory infection in <5 years); acute respiratory infection (ARI: ≥1 of cough, nasal discharge, difficulty breathing or sore throat); febrile acute respiratory illness (FARI: fever plus either cough, sore throat, runny nose, difficulty breathing, or earache). Variants that included "reported fever" and additional sign-symptom combinations were also evaluated.


RESULTS
We enrolled 1043 hospitalized patients, including 257 children <5 years of age (range 1 day-86 years). Seventy-four patients tested influenza virus positive (including 28 A(H1N1)pdm09). Sensitivity(95% CI) and specificity (95% CI) for influenza infection were 78% (67-87) and 60% (57-63) for ILI (measured/reported fever); 37% (26-49) and 78% (75-80) for SARI (measured/reported fever); 82% (72-90) and 57% (54-60) for FARI (measured/reported fever); 88% (78-94) and 45% (42-49) for ARI; and 74% (63-84) and 61% (58-64) for measured/reported fever plus cough. Case definitions including only measured fever had lower sensitivity.


CONCLUSIONS
ILI and FARI with measured/reported fever provided good balance between sensitivity and specificity among hospitalized patients. The simpler case definition of measured/reported fever plus cough is suited for field surveillance.
AIIMS-INCLEN collaborative influenza projects, The INCLEN Trust International, New Delhi, India.
Vivek
V
Gupta
Fatimah S
FS
Dawood
Sanjay K
SK
Rai
Shobha
S
Broor
Rajan
R
Wigh
Akhilesh C
AC
Mishra
Kathryn
K
Lafond
Joshua A
JA
Mott
Marc-Alain
MA
Widdowson
Renu B
RB
Lal
Anand
A
Krishnan
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D005260:Female; D006760:Hospitalization; D006801:Humans; D007194:India / Q000453:epidemiology; D007223:Infant; D007251:Influenza, Human / Q000453:epidemiology* / Q000628:therapy / Q000821:virology; D008297:Male; D008875:Middle Aged; D009975:Orthomyxoviridae / Q000145:classification / Q000235:genetics / Q000302:isolation & purification*; D012424:Rural Population; D018571:Sentinel Surveillance; D055815:Young Adult