title: Transmission of the First Influenza A(H1N1)pdm09 Pandemic Wave in Australia Was Driven by Undetected Infections: Pandemic Response Implications.
abstract: BACKGROUND
  During the first wave of influenza A(H1N1)pdm09 in Victoria, Australia the rapid increase in notified cases and the high proportion with relatively mild symptoms suggested that community transmission was established before cases were identified. This lead to the hypothesis that those with low-level infections were the main drivers of the pandemic.
  
  
  METHODS
  A deterministic susceptible-infected-recovered model was constructed to describe the first pandemic wave in a population structured by disease severity levels of asymptomatic, low-level symptoms, moderate symptoms and severe symptoms requiring hospitalisation. The model incorporated mixing, infectivity and duration of infectiousness parameters to calculate subgroup-specific reproduction numbers for each severity level.
  
  
  RESULTS
  With stratum-specific effective reproduction numbers of 1.82 and 1.32 respectively, those with low-level symptoms, and those with asymptomatic infections were responsible for most of the transmission. The effective reproduction numbers for infections resulting in moderate symptoms and hospitalisation were less than one. Sensitivity analyses confirmed the importance of parameters relating to asymptomatic individuals and those with low-level symptoms.
  
  
  CONCLUSIONS
  Transmission of influenza A(H1N1)pdm09 was largely driven by those invisible to the health system. This has implications for control measures--such as distribution of antivirals to cases and contacts and quarantine/isolation--that rely on detection of infected cases. Pandemic plans need to incorporate milder scenarios, with a graded approach to implementation of control measures.
authors.affiliation: Victorian Infectious Diseases Reference Laboratory, North Melbourne, Victoria, Australia.|National Centre for Epidemiology and Population Health, The Australian National University, Canberra, Australian Capital Territory, Australia.|Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia.
authors.forename: James E
authors.initials: JE
authors.lastname: Fielding
authors.affiliation: Victorian Infectious Diseases Reference Laboratory, North Melbourne, Victoria, Australia.|National Centre for Epidemiology and Population Health, The Australian National University, Canberra, Australian Capital Territory, Australia.
authors.forename: Heath A
authors.initials: HA
authors.lastname: Kelly
authors.affiliation: National Centre for Epidemiology and Population Health, The Australian National University, Canberra, Australian Capital Territory, Australia.
authors.forename: Kathryn
authors.initials: K
authors.lastname: Glass
mesh_terms: D005260:Female; D049673:History, 20th Century; D006801:Humans; D053118:Influenza A Virus, H1N1 Subtype; D064149:Influenza Pandemic, 1918-1919; D007251:Influenza, Human / Q000453:epidemiology* / Q000266:history / Q000635:transmission*; D008297:Male; D008954:Models, Biological; D014739:Victoria