Research Article: Monitoring the Impact of Influenza by Age: Emergency Department Fever and Respiratory Complaint Surveillance in New York City

Date Published: August 7, 2007

Publisher: Public Library of Science

Author(s): Donald R Olson, Richard T Heffernan, Marc Paladini, Kevin Konty, Don Weiss, Farzad Mostashari, Neil M Ferguson

Abstract: BackgroundThe importance of understanding age when estimating the impact of influenza on hospitalizations and deaths has been well described, yet existing surveillance systems have not made adequate use of age-specific data. Monitoring influenza-related morbidity using electronic health data may provide timely and detailed insight into the age-specific course, impact and epidemiology of seasonal drift and reassortment epidemic viruses. The purpose of this study was to evaluate the use of emergency department (ED) chief complaint data for measuring influenza-attributable morbidity by age and by predominant circulating virus.Methods and FindingsWe analyzed electronically reported ED fever and respiratory chief complaint and viral surveillance data in New York City (NYC) during the 2001–2002 through 2005–2006 influenza seasons, and inferred dominant circulating viruses from national surveillance reports. We estimated influenza-attributable impact as observed visits in excess of a model-predicted baseline during influenza periods, and epidemic timing by threshold and cross correlation. We found excess fever and respiratory ED visits occurred predominantly among school-aged children (8.5 excess ED visits per 1,000 children aged 5–17 y) with little or no impact on adults during the early-2002 B/Victoria-lineage epidemic; increased fever and respiratory ED visits among children younger than 5 y during respiratory syncytial virus-predominant periods preceding epidemic influenza; and excess ED visits across all ages during the 2003–2004 (9.2 excess visits per 1,000 population) and 2004–2005 (5.2 excess visits per 1,000 population) A/H3N2 Fujian-lineage epidemics, with the relative impact shifted within and between seasons from younger to older ages. During each influenza epidemic period in the study, ED visits were increased among school-aged children, and each epidemic peaked among school-aged children before other impacted age groups.ConclusionsInfluenza-related morbidity in NYC was highly age- and strain-specific. The impact of reemerging B/Victoria-lineage influenza was focused primarily on school-aged children born since the virus was last widespread in the US, while epidemic A/Fujian-lineage influenza affected all age groups, consistent with a novel antigenic variant. The correspondence between predominant circulating viruses and excess ED visits, hospitalizations, and deaths shows that excess fever and respiratory ED visits provide a reliable surrogate measure of incident influenza-attributable morbidity. The highly age-specific impact of influenza by subtype and strain suggests that greater age detail be incorporated into ongoing surveillance. Influenza morbidity surveillance using electronic data currently available in many jurisdictions can provide timely and representative information about the age-specific epidemiology of circulating influenza viruses.

Partial Text: Throughout the twentieth century, epidemic and pandemic influenza was responsible for causing widespread illness, economic disruption, and considerable loss of life worldwide [1–3]. While the seasonal recurrence of influenza is anticipated each year, it remains difficult to predict the predominant seasonal strains and impossible to know when and where the next human pandemic will emerge. Timely regional monitoring of influenza-related morbidity is a priority for seasonal surveillance and pandemic preparedness [4].

In our analysis of New York City ED data, we found that predominant increases in fever and respiratory visits corresponded in timing and magnitude with laboratory-confirmed influenza, and we suggest that our estimates of excess ED visits provide a reliable surrogate measure of the incident impact attributable to influenza. By applying standard statistical methods to electronic ED chief complaint data, and interpreting results in the context of available information about circulating viruses, we were able to evaluate and track age-specific influenza morbidity in greater detail than was previously possible in NYC. We found the burden of excess ED visits was greatest during peak influenza periods, disproportionately impacted children, often impacted children earliest, generally coincided in timing with P&I hospitalization admission data, and preceded P&I death data by roughly 1–2 wk. The age-specific pattern of excess ED visits varied depending on the predominant circulating viral type, subtype, and strain. We expand on these findings below.



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