Severe acute respiratory infections surveillance for early signals in the community.

BACKGROUND: Surveillance of acute respiratory infections (ARI) in the Netherlands and other European countries is based mostly on primary care data, with little insight into the severe spectrum of the disease. We compared time-trends for ARI in secondary care with influenza-like illness (ILI), ARI and pneumonia in primary care, and crude mortality, in order to assess the value of routinely collected data on respiratory infections in hospitals and the added value of severe acute respiratory infections (SARI) surveillance. METHODS: We calculated incidence of ARI in secondary care, ILI, ARI, and pneumonia in primary care, and crude mortality using five historical databases (2008-2016). RESULTS: Over eight years, seasonal incidence peaks of ARI in secondary care occurred earlier than ILI and ARI incidence peaks in primary care, except during the 2009 influenza A(H1N1) pandemic and post-pandemic season. The median time-lag between ARI in secondary care and ILI, ARI and pneumonia in primary care was 6.5 weeks, 7 weeks, and 1 week, respectively. Crude mortality lagged a median 5 weeks behind ARI in secondary care. CONCLUSION: This observational study demonstrates that routinely collected data can be used for describing trends of ARI in secondary care and may be suitable for near real-time SARI surveillance. In most seasons, the incidence peaks for ARI in secondary care preceded the peaks in primary care and crude mortality with a considerable time-lag. It would be of great value to add microbiological test results to the incidence data to better explain the difference in time-lag between these surveillance systems.

European all-cause excess and influenza-attributable mortality in the 2017/18 season: should the burden of influenza B be reconsidered?

OBJECTIVES: Weekly monitoring of European all-cause excess mortality, the EuroMOMO network, observed high excess mortality during the influenza B/Yamagata dominated 2017/18 winter season, especially among elderly. We describe all-cause excess and influenza-attributable mortality during the season 2017/18 in Europe. METHODS: Based on weekly reporting of mortality from 24 European countries or sub-national regions, representing 60% of the European population excluding the Russian and Turkish parts of Europe, we estimated age stratified all-cause excess morality using the EuroMOMO model. In addition, age stratified all-cause influenza-attributable mortality was estimated using the FluMOMO algorithm, incorporating influenza activity based on clinical and virological surveillance data, and adjusting for extreme temperatures. RESULTS: Excess mortality was mainly attributable to influenza activity from December 2017 to April 2018, but also due to exceptionally low temperatures in February-March 2018. The pattern and extent of mortality excess was similar to the previous A(H3N2) dominated seasons, 2014/15 and 2016/17. The 2017/18 overall all-cause influenza-attributable mortality was estimated to be 25.4 (95%CI 25.0-25.8) per 100,000 population; 118.2 (116.4-119.9) for persons aged 65. Extending to the European population this translates into over-all 152,000 deaths. CONCLUSIONS: The high mortality among elderly was unexpected in an influenza B dominated season, which commonly are considered to cause mild illness, mainly among children. Even though A(H3N2) also circulated in the 2017/18 season and may have contributed to the excess mortality among the elderly, the common perception of influenza B only having a modest impact on excess mortality in the older population may need to be reconsidered.

Estimated incidence and number of outpatient visits for seasonal influenza in 2015-2016 in Beijing, China.

Information on morbidity burden of seasonal influenza in China is limited. A multiplier model was used to estimate the incidence and number of outpatient visits for seasonal influenza by age group for the 2015-2016 season in Beijing, the capital of China, based on reported numbers of influenza-like illness consultations and proportions of positive cases from influenza surveillance systems in Beijing, general consultation rates and other parameters from previous studies, surveys and surveillance systems. An estimated total of 1 190 200 (95% confidence interval (CI) 830 400-1 549 900) cases of influenza virus infections occurred in Beijing, 2015-2016 season, with an attack rate of 5·5% (95% CI 3·9-7·2%). These infections resulted in an estimated 468 280 (95% CI 70 700-606 800) outpatient visits, with an attack rate of 2·2% (95% CI 0·3-2·8%). The attack rate of influenza virus infections was highest among children aged 0-4 years (31·9% (95% CI 21·9-41·9%)), followed by children aged 5-14 years (18·7% (95% CI 12·9-24·5%)). Our study demonstrated a substantial influenza-related morbidity in Beijing, China, especially among the preschool- and school-aged children. This suggests that development or modification of seasonal influenza targeted vaccination strategies need to recognize that incidence is highest in children.

Excess mortality among the elderly in European countries, December 2014 to February 2015.

Since December 2014 and up to February 2015, the weekly number of excess deaths from all-causes among individuals ≥ 65 years of age in 14 European countries have been significantly higher than in the four previous winter seasons. The rise in unspecified excess mortality coincides with increased proportion of influenza detection in the European influenza surveillance schemes with a main predominance of influenza A (H3N2) viruses seen throughout Europe in the current season, though cold snaps and other respiratory infections may also have had an effect.

Pooling European all-cause mortality: methodology and findings for the seasons 2008/2009 to 2010/2011.

Several European countries have timely all-cause mortality monitoring. However, small changes in mortality may not give rise to signals at the national level. Pooling data across countries may overcome this, particularly if changes in mortality occur simultaneously. Additionally, pooling may increase the power of monitoring populations with small numbers of expected deaths, e.g. younger age groups or fertile women. Finally, pooled analyses may reveal patterns of diseases across Europe. We describe a pooled analysis of all-cause mortality across 16 European countries. Two approaches were explored. In the 'summarized' approach, data across countries were summarized and analysed as one overall country. In the 'stratified' approach, heterogeneities between countries were taken into account. Pooling using the 'stratified' approach was the most appropriate as it reflects variations in mortality. Excess mortality was observed in all winter seasons albeit slightly higher in 2008/09 than 2009/10 and 2010/11. In the 2008/09 season, excess mortality was mainly in elderly adults. In 2009/10, when pandemic influenza A(H1N1) dominated, excess mortality was mainly in children. The 2010/11 season reflected a similar pattern, although increased mortality in children came later. These patterns were less clear in analyses based on data from individual countries. We have demonstrated that with stratified pooling we can combine local mortality monitoring systems and enhance monitoring of mortality across Europe.

The estimated disease burden of norovirus in The Netherlands.

Noroviruses are an important cause of acute gastroenteritis in humans. We incorporated new insights gained over the past decade in an updated estimate of the disease burden of (foodborne) norovirus illness in The Netherlands in 2009. The disease outcomes - non-consulting cases, visiting a general practitioner, hospitalization and mortality - and the foodborne proportion were derived from cohort studies, surveillance data and literature. Age-specific incidence estimates were applied to the population age distribution in The Netherlands in 2009. The general population incidence was 3800/100 000 (95% CI 2670­5460), including 0.4 fatal cases/100 000,resulting in 1622 (95% CI 966­2650) disability-adjusted life-years in a population of 16.5 million [corrected].The updated burden of norovirus is over twofold higher than previously estimated, due in particular to the new insights in case-fatality ratios. Results suggest that the burden of norovirus institutional outbreaks is relatively small compared to the burden of community-acquired norovirus infections.

In search of hidden Q-fever outbreaks: linking syndromic hospital clusters to infected goat farms.

Large Q-fever outbreaks were reported in The Netherlands from May 2007 to 2009, with dairy-goat farms as the putative source. Since Q-fever outbreaks at such farms were first reported in 2005, we explored whether there was evidence of human outbreaks before May 2007. Space-time scan statistics were used to look for clusters of lower-respiratory infections (LRIs), hepatitis, and/or endocarditis in hospitalizations, 2005-2007. We assessed whether these were plausibly caused by Q fever, using patients' age, discharge diagnoses, indications for other causes, and overlap with reported Q fever in goats/humans. For seven detected LRI clusters and one hepatitis cluster, we considered Q fever a plausible cause. One of these clusters reflected the recognized May 2007 outbreak. Real-time syndromic surveillance would have detected four of the other clusters in 2007, one in 2006 and two in 2005, which might have resulted in detection of Q-fever outbreaks up to 2 years earlier.

Sudden deaths following influenza vaccination: can this be expected?

BACKGROUND: In November 2006, four Dutch people, aged 53, 58, 80 and 88, died unexpectedly on the day they had received their influenza vaccination. A rapid epidemiological assessment was needed to quantify the risk of a causal association. METHODS: Using routinely available data on age-stratified population size, cardiovascular mortality, and vaccination coverage, a daily rate and daily risk of sudden death per 5-year age-group was calculated. A cumulative probability that at least one person in four specific age-groups would die on the day of vaccination was calculated using a binomial distribution. No assumptions on deaths in other age groups were included. RESULTS: The overall likelihood that at least one person in each of the four age categories 50-54, 55-59, 80-84 and 85-89 would die suddenly on the day of influenza vaccination in the Netherlands was calculated to be 0.016. This was 330 times more likely than nobody dying in each of these categories, and 45 times less likely than the most probable outcome. CONCLUSION: We concluded that there was a small but real chance of the four deaths occurring without a causal link to the vaccination. Policy decisions regarding unexpected deaths following vaccination can benefit from a rapid epidemiological evaluation.

[Syndromic surveillance for the detection of outbreaks of unusual infectious diseases]. / Syndroomsurveillance om uitbraken van ongebruikelijke infectieziekten vroegtijdig te signaleren.

Syndromic surveillance has been developed in order to detect outbreaks of unusual infectious diseases such as severe acute respiratory syndrome (SARS) or anthrax at an early stage. Whereas the usual surveillance systems are based on established diagnoses and emergency department discharge data, syndromic surveillance uses preliminary outcomes and derived data such as absenteeism, prescription medication and requests for laboratory tests. Investigations abroad have indicated the potential ofsyndromic surveillance. In the Netherlands, the National Institute of Public Health and Environment (RIVM) is examining the feasibility of implementing syndromic surveillance.

[The 14th International Aids Conference: 'Knowledge, commitment and action']. / De 14e Internationale Aidsconferentie: 'Kennis, betrokkenheid en actie'.

During the world AIDS conference in Barcelona it became clear that the worst-case scenario of 10 years ago has become a reality: the HIV epidemic is continuing to spread. Also in industrialised countries the incidence of HIV infections among homosexual men is once again increasing. An HIV vaccine is still not available. Although the development of antiretroviral therapy continues, HIV inhibitors do not result in an eradication of HIV. It is still not clear as to when therapy can best be started and what the consequences are of temporarily withdrawing therapy. In countries where HIV inhibitors are widely available, the life expectancy of HIV-infected persons is increasing. The life expectancy of HIV patients will possibly decrease again due to an increased resistance towards the currently available antiretroviral drugs.