title: Influenza-like illness in a Vietnamese province: epidemiology in correlation with weather factors and determinants from the surveillance system.
abstract: BACKGROUND
  Seasonal influenza affects from 5 to 15% of the world's population annually and causes an estimated 250,000-500,000 deaths worldwide. The World Health Organization (WHO) recommends 'sentinel surveillance' for influenza-like illness (ILI) because it is simple and calls for standardized methods at a relatively low cost that can be implemented throughout the world. In Vietnam, ILI is a key priority for public health also because of its annually recurring temporal pattern. Two major factors, on which the spread of influenza depends, are the strain of the virus and its rate of mutation, since flu strains constantly mutate as they compete with host immune systems. In the context of global climate change, the role of climatic factors has been discussed, as they may significantly contribute to the cause of large outbreaks of ILI.
  
  
  OBJECTIVE
  1) To describe the epidemiology of ILI in Ha Nam province, Vietnam; 2) to seek scientific evidence on the association of ILI occurrence with weather factors in Ha Nam province; and 3) to analyze factors from the Ha Nam ILI surveillance system that contribute to explaining the correlation between the ILI and the weather factors.
  
  
  METHODS
  A data set of 89,270 monthly reported ILI cases from 2008 to 2012 in Ha Nam was used to describe ILI epidemiological characteristics. Spearman correlation analyses between ILI cases and weather factors were conducted to identify which preceding period of months and weather patterns influenced the occurrence of ILI cases. Ten in-depth interviews with health workers in charge of recording and reporting ILI cases at different levels of the ILI surveillance system were conducted to gain a deeper understanding of factors contributing to explaining the relation between the ILI and the weather factors.
  
  
  RESULTS
  The results indicated that the ILI occurred annually in all districts of the Ha Nam province in the five studied years. An epidemic occurred in 2009 with the number of cases three times higher than the average threshold. There was a relation between the ILI cases in the previous 1 month with ILI cases of the following month. A seasonal cycle of ILI and correlation between weather elements were not clearly detected. A qualitative study showed that the number of ILI cases reported by the Provincial Preventive Medicine Centre (PPMC) in Ha Nam might not have reflected the accurate number of seasonal ILI occurring in this area. This was due to three gaps in the ILI surveillance system that initially were detected through key in-depth interviews in the Duy Tien and Binh Luc districts. They reported inconsistent ways of recording and reporting ILI cases among communes, lack of ILI survey forms, and irregular and delayed feedback from the PPMC.
  
  
  CONCLUSIONS
  There were no clear patterns of association between weather factors and ILI cases detected from the five studied years. The number of ILI cases reported by the PPMC in Ha Nam may not reflect adequately the actual number of seasonal ILI occurring in this area due to three weak points in the ILI surveillance system initially detected through the case of the Duy Tien and Binh Luc districts. These three weak points of the system should be examined by a study conducted in the remaining districts in Ha Nam.
authors.affiliation: Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam; daothiminhan@yahoo.com.
authors.forename: Dao Thi
authors.initials: DT
authors.lastname: Minh An
authors.affiliation: Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam.
authors.forename: Nguyen Thi Bich
authors.initials: NT
authors.lastname: Ngoc
authors.affiliation: Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.
authors.forename: Maria
authors.initials: M
authors.lastname: Nilsson
mesh_terms: D057231:Climate Change; D003430:Cross-Sectional Studies; D004196:Disease Outbreaks / Q000706:statistics & numerical data; D006801:Humans; D009980:Influenza A virus / Q000302:isolation & purification*; D007251:Influenza, Human / Q000453:epidemiology* / Q000209:etiology; D062486:Public Health Surveillance / Q000379:methods*; D036301:Qualitative Research; D018571:Sentinel Surveillance; D014744:Vietnam / Q000453:epidemiology; D014887:Weather
keywords: ILI; ILI surveillance system; climate; epidemiology; influenza; time series analysis; weather