Influenza virus surveillance in Pakistan during 2008-2011

Knowledge, Attitude, Practice and Barriers Associated with Influenza Vaccination among Health Care Professionals Working at Tertiary Care Hospitals in Lahore, Pakistan: A Multicenter Analytical Cross-Sectional Study

Health Care Professionals (HCPs), including doctors, nurses, pharmacists, and paramedics, are a high-risk group for influenza infection due to their continuous exposure to patients having a known or unknown history of influenza-like illnesses. Influenza vaccination is the most effective method of primary prevention. This study was conducted to assess knowledge, attitude, practice, and barriers associated with influenza vaccination among HCPs at tertiary care hospitals in Lahore, Pakistan. A multicenter analytical cross-sectional study was conducted among HCPs. Data were collected using a structured questionnaire. All statistical analyses were conducted in R software. A total of 400 HCPs were enrolled, and among these, 67% had a high level of knowledge and 65.5% had a positive attitude towards influenza vaccination. About 51% of HCPs adopted good practices leading to influenza vaccination. Results identified major barriers for influenza vaccinations, including unfamiliarity with vaccine availability (RII = 0.760), insufficient staff for administering the vaccine (RII = 0.649), lack of proper storage (RII = 0.625), safety concerns (RII = 0.613), and cost of vaccine (RII = 0.602). More than half of the HCPs showed a high level of knowledge, a positive attitude, and good practice against influenza vaccination. Despite the positive Knowledge, Attitude, and Practice (KAP) scores and published guidelines, a very low percentage of HCPs were vaccinated against influenza. Many hindering factors were associated with influenza vaccination.

Epidemiology of Community-Acquired Respiratory Tract Infections in Patients Admitted at the Emergency Departments

Objectives: Community-acquired respiratory infections (CARTIs) are responsible for serious morbidities worldwide. Identifying the aetiology can decrease the use of unnecessary antimicrobial therapy. In this study, we intend to determine the pathogenic agents responsible for respiratory infections in patients presenting to the emergency department of several Lebanese hospitals. Methods: A total of 100 patients presenting to the emergency departments of four Lebanese hospitals and identified as having CARTIs between September 2017 and September 2018 were recruited. Specimens of upper and lower respiratory tract samples were collected. Pathogens were detected by a multiplex polymerase chain reaction respiratory panel. Results: Of 100 specimens, 84 contained at least one pathogen. Many patients were detected with ≥2 pathogens. The total number of pathogens from these 84 patients was 163. Of these pathogens, 36 (22%) were human rhinovirus, 28 (17%) were Streptococcus pneumoniae, 16 (10%) were metapneumovirus, 16 (10%) were influenza A virus, and other pathogens were detected with lower percentages. As expected, the highest occurrence of pathogens was observed between December and March. Respiratory syncytial virus accounted for 2% of the cases and only correlated to paediatric patients. Conclusion: CARTI epidemiology is important and understudied in Lebanon. This study offers the first Lebanese data about CARTI pathogens. Viruses were the most common aetiologies of CARTIs. Thus, a different approach must be used for the empirical management of CARTI. Rapid testing might be useful in identifying patients who need antibiotic therapy.

Longitudinal surveillance of influenza in Japan, 2006-2016

We analysed 2006–2016 national influenza surveillance data in Japan with regards to age-, sex-, and predominant virus-related epidemic patterns and the prevalence of serum influenza virus antibodies. We found a significant increase in influenza prevalence in both children (≤ 19 years old) and adults (≥ 20 years old) over time. The influenza prevalence was higher in children (0.33 [95% CI 0.26–0.40]) than in adults (0.09 [95% CI 0.07–0.11]). Additionally, the mean prevalence of antibodies for A(H1N1)pdm09 and A(H3N2) was significantly higher in children than in adults, whereas the mean prevalence of antibodies for B lineages was relatively low in both children and adults. There was a biennial cycle of the epidemic peak in children, which was associated with a relatively higher prevalence of B lineages. The female-to-male ratios of the influenza prevalence were significantly different in children (≤ 19 years old; 1.10 [95% CI:1.08–1.13]), adults (20–59 years old; 0.79 [95% CI 0.75–0.82]), and older adults (≥ 60 years old; 1.01 [95% CI 0.97–1.04]). The significant increase in influenza prevalence throughout the study period suggests a change of immunity to influenza infection. Long-term surveillance is important for developing a strategy to monitor, prevent and control for influenza epidemics.

Sentinel surveillance for influenza A viruses in Lahore District Pakistan in flu season 2015-2016

Background

Influenza A virus (IAV) remains an important global public health threat with limited epidemiological information available from low-and-middle-income countries. The major objective of this study was to describe the proportions, temporal and spatial distribution, and demographic and clinical characteristics of IAV positive patients with influenza like illness (ILI) and severe acute respiratory illness (SARI) in Lahore, Pakistan.

Methods

Prospective surveillance was established in a sentinel hospital from October 2015 to May 2016. All eligible outpatients and inpatients with ILI or SARI were enrolled in the study. Nasal and/or throat swabs were collected along with clinico-epidemiological data. Samples were tested by real-time RT-PCR (rRT-PCR) to identify IAV and subtype. The descriptive analysis of data was done in R software.

Results

Out of 311 enrolled patients, 284 (91.3%) were ILI and 27 (8.7%) were SARI cases. A distinct peak of ILI and SARI activity was observed in February. Fifty individuals (16%) were positive for IAV with peak positivity observed in December. Of 50 IAV, 15 were seasonal H3N2, 14 were H1N1pdm09 and 21 were unable to be typed. The majority of IAV positive cases (98%) presented with current or history of fever, 88% reported cough and 82% reported sore throat. The most common comorbidities in IAV positive cases were hepatitis C (4%), obesity (4%) and tuberculosis (6%). The highest incidence of patients reporting to the hospital was seen three days post symptoms onset (66/311) with 14 of these (14/66) positive for IAV.

Conclusion

Distinct trends of ILI, SARI and IAV positive cases were observed which can be used to inform public health interventions (vaccinations, hand and respiratory hygiene) at appropriate times among high-risk groups. We suggest sampling from both ILI and SARI patients in routine surveillance as recommended by WHO.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-07021-7.

Risk Factors of Influenza-Associated Respiratory Illnesses Reported to a Sentinel Hospital of Lahore, Pakistan: 2015-2016

Epidemiological data about determinants of influenza A virus (IAV) in the Pakistani population is scarce. We aimed to conduct a prospective hospital-based active surveillance study from October 2015 to May 2016 to identify potential risk factors associated with IAV infection among patients with influenza-like illness (ILI) and severe acute respiratory illness (SARI). Surveillance was conducted in Lahore General Hospital, selected as a sentinel site in Lahore District, Pakistan. Nasal/throat samples were collected along with epidemiological and clinical data from enrolled patients. Real-time reverse-transcription polymerase chain reaction (rRT-PCR) was performed to identify IAV and its subtypes (H1N1pdm09, H3N2). Data were analyzed to determine risk factors and risk markers associated with IAV infections. A total of 311 suspected ILI and SARI cases were enrolled in the study, and among these 50 were IAV-positive. Of these 50 confirmed cases of IAV, 14 were subtyped as H1N1pdm09 and 15 were H3N2; the remaining 21 were untyped. A final multivariable model identified four independent risk factors/markers for IAV infection: exposure history to ILI patients within last 7 days and gender being male were identified as risk factors of IAV infection, while use of antibiotics prior to hospital consultation and presence of fever were identified as risk markers. We concluded that adopting nonpharmaceutical interventions like hand hygiene, masks, social distancing, and where possible, avoiding identified risk factors could decrease the risk of IAV infection and may prevent imminent outbreaks of IAV in the community.

Epidemiology of Influenza among patients with influenza-like illness and severe acute respiratory illness in Pakistan: A 10-year surveillance study 2008-17

In Pakistan, the burden of influenza was largely unknown, as no formal surveillance system was in place. In 2008, an influenza surveillance system was set up in eight sentinel sites. This study describes the epidemiology of influenza virus using a 10-year surveillance data from 2008 to 2017. Nasopharyngeal/throat swabs were collected from patients with influenza-like illness (ILI) and severe acute respiratory illness (SARI) along with relevant epidemiological information. The samples were tested using real-time reverse transcriptase-polymerase chain reaction for the detection and characterization of influenza viruses. A total of 17 209 samples were tested for influenza, out of which 3552 (20.6%) were positive; 2151/11 239 (19.1%) were patients with ILI, whereas 1401/5970 (23.5%) were patients with SARI. Influenza A/H1N1pdm09 was the predominant strain with 40.6% (n = 1442) followed by influenza B (936, 26.4%). Influenza A/H1N1pdm09 was predominant among the children (5-14 years) and adults (15-64 years). Influenza B strain was predominantly found in the elderly age group (≥ 65 years) accounting for 48% of cases followed by children (2-4 years) accounting for 37% of cases. This 10-year surveillance data provides evidence of influenza activity in the country throughout the year with seasonal winter peaks. The results could be used to strengthen the epidemic preparedness and response plan.

Awareness of H1N1 influenza among Pakistani pharmacy students

Aim — This study was aimed to investigate knowledge and attitudes of H1N1 influenza among pharmacy students. Material and Methods — A cross-sectional study was carried out among undergraduate and postgraduate students of the Punjab University College of Pharmacy, University of the Punjab, Lahore from February-May 2018. A self-administered questionnaire was used to evaluate knowledge and attitudes of H1N1 influenza. All data were analyzed using SPSS 22. Results — The median age of study participants (N=420) was 20 years, with majority of females (72.4%), undergraduate students (96.7%) belonging to middle economic class (89.8%). The median knowledge score was 18, with 38.1% having poor, 55.7% moderate and 6.2% excellent knowledge score (score <17, 17-25, and 26-34, respectively). The median attitude score was 47 (9); around 52% of the participants were found to have positive attitudes. Initially, there was a significant difference of knowledge score, not attitude, among age categories. However, in post hoc analysis, after Bonferroni adjustment (P<0.017), individuals > 26 years of age had better knowledge scores than 21-25 years (p=0.015) and ≤20 years (p=0.005) age categories. Gender had no significant influence on the knowledge as well as attitude score. Futhermore, postgraduate students had signifcanlty better knowledge scores, not attitude, than undergraduates (p=0.002). Conclusions — Our findings highlight the need to equip pharmacy students with comprehensive knowledge of H1N1 influenza so that in future they can help increase the public awareness at community pharmacies, hospitals or the communities they reside.

Outcome of upper respiratory tract infections in healthy children: Antibiotic stewardship in treatment of acute upper respiratory tract infections

Objective

The objective of the study was to assess the outcome of upper respiratory tract infections (URTI) in healthy children.

Methods

This descriptive study was conducted on 314 children aged 3-36 months in the paediatric outpatient clinic and emergency department with symptoms of URTI (fever, cough, rhinorrhoea) for ≤5 days. Patient's demographics, clinical features, laboratory data and outcome were recorded. Follow up phone calls were made to parents on day 7 (response 93.6%) and day 14 (response 94.6%) to record outcome.

Results

A total of 314 children with URTIs were included. Majority (57.6%) were males and <1year of age (40%). Common manifestations of URTI were fever (89%), cough (79%), rhinorrhoea (62%), pharyngitis (79%) and conjunctivitis (46%). More than half (53%) had history of contact with URTI in a family member. Mean duration of symptoms was 2.7±1.3 days. Majority (93%) of children were given supportive treatment and only 6.7% received antibiotics initially. Most of children (76%) recovered within one week and 91.8% within two weeks with supportive care only. Only 4% children were hospitalized and 12% required follow up visit of which 16% needed oral antibiotics. Complications or deaths did not occur.

Conclusions

Majority of URTIs in healthy children resolved with supportive treatment and do not require antibiotics. Antibiotic stewardship in simple URTIs should be practiced using awareness and advocacy campaigns.

Seasonality of influenza and its association with meteorological parameters in two cities of Pakistan: A time series analysis

Background

Influenza is known to have a specific pattern of seasonality the reasons for which are yet to be fully ascertained. Temperate zones show influenza epidemic during the winter months. The tropical and subtropical regions show more diverse influenza outbreak patterns. This study explores the seasonality of influenza activity and predicts influenza peak based on historical surveillance time series data in Islamabad and Multan, Pakistan.

Methods

This is a descriptive study of routinely collected monthly influenza sentinel surveillance data and meteorological data from 2012–16 in two sentinel sites of Pakistan: Islamabad (North) and Multan (Central).

Results

Mean number of cases of influenza and levels of precipitation were higher in Islamabad compared to Multan. Mean temperature and humidity levels were similar in both the cities. The number of influenza cases rose with decrease in precipitation and temperature in Islamabad during 2012–16, although the same cannot be said about humidity. The relationship between meteorological parameters and influenza incidence was not pronounced in case of Multan. The forecasted values in both the cities showed a significant peak during the month of January.

Conclusion

The influenza surveillance system gave a better understanding of the disease trend and could accurately forecast influenza activity in Pakistan.

Etiology of acute viral respiratory infections common in Pakistan: A review

Respiratory infections, especially those of the lower respiratory tract, remain a foremost cause of mortality and morbidity of children greater than 5 years in developing countries including Pakistan. Ignoring these acute-level infections may lead to complications. Particularly in Pakistan, respiratory infections account for 20% to 30% of all deaths of children. Even though these infections are common, insufficiency of accessible data hinders development of a comprehensive summary of the problem. The purpose of this study was to determine the prevalence rate in various regions of Pakistan and also to recognize the existing viral strains responsible for viral respiratory infections through published data. Respiratory viruses are detected more frequently among rural dwellers in Pakistan. Lower tract infections are found to be more lethal. The associated pathogens comprise respiratory syncytial virus (RSV), human metapneumovirus (HMPV), coronavirus, enterovirus/rhinovirus, influenza virus, parainfluenza virus, adenovirus, and human bocavirus. RSV is more dominant and can be subtyped as RSV-A and RSV-B (BA-9, BA-10, and BA-13). Influenza A (H1N1, H5N1, H3N2, and H1N1pdm09) and Influenza B are common among the Pakistani population. Generally, these strains are detected in a seasonal pattern with a high incidence during spring and winter time. The data presented include pneumonia, bronchiolitis, and influenza. This paper aims to emphasise the need for standard methods to record the incidence and etiology of associated pathogens in order to provide effective treatment against viral infections of the respiratory tract and to reduce death rates.

Universal influenza virus vaccines and therapeutics: where do we stand with influenza B virus?

The development of a broadly protective or universal influenza virus vaccine is currently a public health priority worldwide. The vast majority of these efforts is exclusively focused on influenza A viruses. While influenza A viruses cause the majority of all influenza cases worldwide, influenza B viruses should not be ignored. Approximately 25% of all influenza cases are caused by influenza B viruses which circulate as two distinct B/Victoria/2/87-like and B/Yamagata/16/88-like lineages. In contrast to popular belief, influenza B cases frequently cause significant morbidity and mortality, especially in children. Similar to influenza A viruses, influenza B viruses drift antigenically and the influenza B components of current vaccines have to be reformulated almost on an annual basis. A broadly protective vaccine against influenza B viruses is therefore urgently needed. Here we review both broadly protective anti-influenza B antibodies as well as the sparse attempts to create a universal influenza B virus vaccine.

Epidemiological Features and Forecast Model Analysis for the Morbidity of Influenza in Ningbo, China, 2006-2014

This study aimed to identify circulating influenza virus strains and vulnerable population groups and investigate the distribution and seasonality of influenza viruses in Ningbo, China. Then, an autoregressive integrated moving average (ARIMA) model for prediction was established. Influenza surveillance data for 2006–2014 were obtained for cases of influenza-like illness (ILI) (n = 129,528) from the municipal Centers for Disease Control and virus surveillance systems of Ningbo, China. The ARIMA model was proposed to predict the expected morbidity cases from January 2015 to December 2015. Of the 13,294 specimens, influenza virus was detected in 1148 (8.64%) samples, including 951 (82.84%) influenza type A and 197 (17.16%) influenza type B viruses; the influenza virus isolation rate was strongly correlated with the rate of ILI during the overall study period (r = 0.20, p < 0.05). The ARIMA (1, 1, 1) (1, 1, 0)₁₂ model could be used to predict the ILI incidence in Ningbo. The seasonal pattern of influenza activity in Ningbo tended to peak during the rainy season and winter. Given those results, the model we established could effectively predict the trend of influenza-related morbidity, providing a methodological basis for future influenza monitoring and control strategies in the study area.

Comparison of Influenza Epidemiological and Virological Characteristics between Outpatients and Inpatients in Zhejiang Province, China, March 2011-June 2015

Given the rapid rate of global spread and consequently healthcare costs related to influenza, surveillance plays an important role in monitoring the emerging pandemics in China. However, the characteristics of influenza in Southeast of China haven’t been fully studied. Our study use the surveillance data collected from 16 sentinel hospitals across Zhejiang Province during March 2011 through June 2015, including the demographic information and respiratory specimens from influenza-like illness (ILI) patients and severe acute respiratory illness (SARI) patients. As analysis results, most SARI and ILI patients were in the age group of 0–4 years old (62.38% of ILI and 71.54% of SARI). The respiratory specimens have statistically significantly higher positive rate for influenza among ILI patients than that among SARI patients (p < 0.001). The comparison between ILI patients and SARI patients shows no statistically significantly difference in detecting influenza virus type and influenza A virus subtype. The SARI and ILI patients were found to be positively correlated for overall positive rate (r = 0.63, p < 0.001), the weekly percentage of A(H1N1)pdm09 (r = 0.51, p < 0.001), influenza B virus (r = 0.17, p = 0.013), and A/H3N2 (r = 0.43, p < 0.001) among all the positive numbers. Our study demonstrated that the activities of influenza virus, including its subtypes, had a similar temporal pattern between ILI and SARI cases.

Barriers and strategies to improve influenza vaccination in Pakistan

Influenza vaccination is strongly recommended by World Health Organisation on a yearly basis. The rate of immunization in Pakistan is suboptimal. High cost, traditional norms, customs and low levels of education in Pakistan are preventing people from getting vaccinated. It is timely to include influenza vaccination in the expanded programme on immunization (EPI), which is a disease prevention programme aiming to eradicate preventable diseases through subsidized or free immunization. The Ministry of National Health Services, Regulation and Coordination, Government of Pakistan should launch a national influenza vaccine policy in view of this current situation and oversee its implementation. Healthcare professionals should promote influenza vaccination and focus on high risk groups such as the elderly, pregnant women and children. Convincing and educating family members regarding immunization of pregnant women and follow-up with parents regarding a second influenza shot for their children will further improve vaccination rates in Pakistan.

Pandemic Influenza

This chapter will describe pandemic threats and the steps necessary to reduce morbidity and mortality. An explanation is provided on genetic mutations leading to the emergence of novel influenza strains. Medical countermeasures include vaccination and antiviral medications. Public messaging is also important to promote flu shots, reinforce basic hygiene measures, and instruct those who may be ill to limit contacts. The World Health Organization (WHO) tracks seasonal influenza for anomalies indicating an emerging pandemic influenza strain. WHO updated the international pandemic alert system after the 2009–2010 H1N1 pandemic. With each declaration, temporary recommendations are provided, and added regulatory actions are taken by WHO member states. In addition, the Centers for Disease Control and Prevention (CDC) updated the U.S. framework for pandemic influenza preparedness and response. Each pandemic interval is accompanied by specific recommendations for state and local public health authorities. Effective influenza control includes both pharmaceutical and nonpharmaceutical recommendations. Other severe viral pandemic respiratory threats, including the “Middle East Respiratory Syndrome Coronavirus” (MERS-CoV), require similar resources and infrastructure to manage.

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Differentiate between seasonal and pandemic influenza.

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Identify proteins that change during genetic mutation of influenza viruses.

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Describe pharmaceutical options available to prevent influenza or reduce severity of disease.

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List the World Health Organization (WHO) phases of pandemic response.

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Explain the difference between the WHO pandemic phases and the US pandemic intervals.

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Describe how an outbreak peak curve can be compressed and what benefits are derived from compressing it.

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List what individuals can do to reduce the risk of influenza.

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Define nonpharmaceutical interventions and give examples.

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Summarize the types of activities local public health agencies should consider for each of the US pandemic intervals.

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Describe the limitations of a government response to a pandemic.

An Epidemiological Analysis of Summer Influenza Epidemics in Okinawa

Objective This study evaluates the difference between winter influenza and summer influenza in Okinawa. Methods From January 2007 to June 2014, weekly rapid antigen test (RAT) results performed in four acute care hospitals were collected for the surveillance of regional influenza prevalence in the Naha region of the Okinawa Islands. Results An antigenic data analysis revealed that multiple H1N1 and H3N2 viruses consistently co-circulate in Okinawa, creating synchronized seasonal patterns and a high genetic diversity of influenza A. Additionally, influenza B viruses play a significant role in summer epidemics, almost every year. To further understand influenza epidemics during the summer in Okinawa, we evaluated the full genome sequences of some representative human influenza A and influenza B viruses isolated in Okinawa. Phylogenetic data analysis also revealed that multiple H1N1 and H3N2 viruses consistently co-circulate in Okinawa. Conclusion This surveillance revealed a distinct epidemic pattern of seasonal and pandemic influenza in this subtropical region.