title: Influenza risk management: lessons learned from an A(H1N1) pdm09 outbreak investigation in an operational military setting.
abstract: BACKGROUND
  At the onset of an influenza pandemic, when the severity of a novel strain is still undetermined and there is a threat of introduction into a new environment, e.g., via the deployment of military troops, sensitive screening criteria and conservative isolation practices are generally recommended.
  
  
  OBJECTIVE
  In response to elevated rates of influenza-like illness among U.S. military base camps in Kuwait, U.S. Naval Medical Research Unit No. 3 partnered with local U.S. Army medical units to conduct an A(H1N1) pdm09 outbreak investigation.
  
  
  METHODS
  Initial clinical data and nasal specimens were collected via the existent passive surveillance system and active surveillance was conducted using a modified version of the World Health Organization/U.S. Centers for Disease Control and Prevention influenza-like illness case definition [fever (T > 100.5˚F/38˚C) in addition to cough and/or sore throat in the previous 72 hours] as the screening criteria. Samples were tested via real-time reverse-transcription PCR and sequenced for comparison to global A(H1N1) pdm09 viruses from the same time period.
  
  
  RESULTS
  The screening criteria used in Kuwait proved insensitive, capturing only 16% of A(H1N1) pdm09-positive individuals. While still not ideal, using cough as the sole screening criteria would have increased sensitivity to 73%.
  
  
  CONCLUSIONS
  The results of and lessons learned from this outbreak investigation suggest that pandemic influenza risk management should be a dynamic process (as information becomes available regarding true attack rates and associated mortality, screening and isolation criteria should be re-evaluated and revised as appropriate), and that military operational environments present unique challenges to influenza surveillance.
authors.affiliation: Global Disease Detection and Response Program, United States of America. Naval Medical Research Unit No, Cairo, Egypt.
authors.forename: Margaret
authors.initials: M
authors.lastname: Farrell
authors.forename: Peter
authors.initials: P
authors.lastname: Sebeny
authors.forename: John D
authors.initials: JD
authors.lastname: Klena
authors.forename: Cecilia
authors.initials: C
authors.lastname: Demattos
authors.forename: Guillermo
authors.initials: G
authors.lastname: Pimentel
authors.forename: Mark
authors.initials: M
authors.lastname: Turner
authors.forename: Antony
authors.initials: A
authors.lastname: Joseph
authors.forename: Jennifer
authors.initials: J
authors.lastname: Espiritu
authors.forename: John
authors.initials: J
authors.lastname: Zumwalt
authors.forename: Erica
authors.initials: E
authors.lastname: Dueger
mesh_terms: D003371:Cough / Q000175:diagnosis / Q000453:epidemiology; D004279:DNA, Viral / Q000032:analysis; D004196:Disease Outbreaks / Q000517:prevention & control*; D005334:Fever / Q000175:diagnosis / Q000453:epidemiology; D006801:Humans; D053118:Influenza A Virus, H1N1 Subtype / Q000235:genetics / Q000302:isolation & purification; D007251:Influenza, Human / Q000175:diagnosis* / Q000453:epidemiology* / Q000821:virology; D007730:Kuwait / Q000453:epidemiology; D008403:Mass Screening / Q000379:methods; D008889:Military Personnel / Q000706:statistics & numerical data; D010612:Pharyngitis / Q000175:diagnosis / Q000453:epidemiology; D010802:Phylogeny; D060888:Real-Time Polymerase Chain Reaction; D012308:Risk Management; D014481:United States
chemical_list: D004279:DNA, Viral