Ahead of Print - Unchanged Severity of Influenza A(H1N1)pdm09 Infection in Children during First Postpandemic Season - Vol. 18 No. 11 - November 2012 - Emerging Infectious Disease journal - CDC

Ahead of Print - Unchanged Severity of Influenza A(H1N1)pdm09 Infection in Children during First Postpandemic Season - Vol. 18 No. 11 - November 2012 - Emerging Infectious Disease journal - CDC

Volume 18, Number 11—November 2012

Research

Unchanged Severity of Influenza A(H1N1)pdm09 Infection in Children during First Postpandemic Season

Article Contents

• Methods
• Results
• Discussion
• Conclusions
• Acknowledgments
• References
• Figure 1
• Figure 2
• Figure 3
• Figure 4
• Table 1
• Table 2
• Table 3
• Suggested Citation

Mathias Altmann , Lena Fiebig, Silke Buda, Rüdiger von Kries, Manuel Dehnert, and Walter Haas

Author affiliations: Robert Koch Institute, Berlin, Germany (M. Altmann, L. Fiebig, S. Buda, M. Dehnert, W. Haas); and Ludwig-Maximilians-Universität, München, Germany (R. von Kries)

Suggested citation for this article

Abstract

We conducted a nationwide hospital-based prospective study in Germany of influenza A(H1N1)pdm09 cases among children <15 112="112" 14="14" 156="156" 17="17" 2009="2009" 2010="2010" 3.2="3.2" 44="44" 5.3="5.3" a="a" accounted="accounted" admitted="admitted" affected.="affected." age="age" although="although" and="and" between="between" care="care" case-patients="case-patients" cases.="cases." challenge="challenge" children.="children." children="children" death="death" deaths="deaths" died="died" difference="difference" during="during" eligible="eligible" especially="especially" factor="factor" findings="findings" for="for" hospital-acquired="hospital-acquired" identified="identified" immunosuppressed="immunosuppressed" immunosuppression="immunosuppression" in="in" infants="infants" infection="infection" infections="infections" influenza="influenza" intensive="intensive" median="median" most="most" myocarditis="myocarditis" need="need" nosocomial="nosocomial" not="not" occurred="occurred" of="of" our="our" p="p" pandemic="pandemic" patients:="patients:" patients="patients" pediatric="pediatric" postpandemic="postpandemic" predictive="predictive" prevent="prevent" preventing="preventing" related="related" remained="remained" risk="risk" seasons.="seasons." seasons="seasons" severe="severe" shift="shift" significant="significant" stress="stress" the="the" to="to" transmission="transmission" underlying="underlying" units="units" virus="virus" vs.="vs." was="was" we="we" which="which" year="year" years="years" younger="younger">

In Germany during the influenza A(H1N1)pdm09 pandemic, there were ≈1,070,000 influenza-related medical consultations and ≈1,800 hospitalizations for children 0–14 years of age during October 12, 2009–January 15, 2010, as determined using data provided by the German syndromic surveillance system for acute respiratory infections (1). Moreover, 29 laboratory-confirmed A(H1N1)pdm09 infection–related deaths in children were notified through the mandatory German surveillance system for infectious diseases (2). The highest number of notified hospitalizations and deaths were among children 10–14 years of age (3,4). In a nationwide hospital-based observational study investigating severely ill children who had been admitted to pediatric intensive care units (PICUs) or had died with laboratory-confirmed A(H1N1)pdm09, we reported a high proportion (75%) of case-patients with underlying risk factors, of which neurodevelopmental disorders were most prevalent (5). In addition, we found that in 10% of the cases, children had acquired their infection while hospitalized and that few had been vaccinated, revealing a need for improving preventive measures to reduce severe disease and adverse outcomes (5).
On August 10, 2010, the general director of the World Health Organization declared the world was no longer in phase 6 of influenza pandemic alert; we were moving into the postpandemic phase (6). Experience from past pandemics suggested that the pandemic virus would gradually take on the behavior of a seasonal influenza virus and circulate for several years. However, in view of the potential for transformation of the virus into a more virulent form (7), as suggested by higher rates of mortality during second pandemic waves in Copenhagen (1918), the United States (1957), and Eurasia (1968–1970) (8,9), the World Health Organization acknowledged the unpredictability of pandemic viruses; recommended continued vigilance; and issued advice on surveillance, vaccination, and prompt clinical management of cases during the postpandemic phase (6).
Little is known about the severity of A(H1N1)pdm09 in children during the first postpandemic season (10). To obtain information on critically ill A(H1N1)pdm09-infected children and to compare risk factors and disease course, outcome, and severity for patients during the pandemic and first postpandemic season, we prospectively and continuously performed a nationwide study in Germany during August 3, 2009–July 29, 2011.

Methods

Study Design

We conducted a nationwide prospective observational study in Germany by using the German Survey Center for Rare Pediatric Diseases (ESPED; an established children’s hospitals network comprising all 375 pediatric hospitals in Germany) to identify children <15 10="10" 2009="2009" 2010="2010" 2011="2011" 29="29" 3="3" 9="9" a="a" admitted="admitted" age="age" all="all" and="and" august="august" by="by" case="case" cases="cases" confirmed="confirmed" deaths.="deaths." deaths="deaths" definition="definition" during="during" form.="form." in="in" included="included" infection="infection" infections.="infections." influenza="influenza" of="of" only="only" p="p" pandemic="pandemic" pdm09="pdm09" picus="picus" postpandemic="postpandemic" related="related" reported="reported" season="season" standardized="standardized" the="the" to="to" ugust="ugust" uly="uly" using="using" virus="virus" were="were" with="with" years="years">

Data Collection

Figure 1

Figure 1. . . Overview of study participation and participant groups among severe pediatric cases with A(H1N1)pdm09, Germany, 2009–2011. PCIU, pediatric intensive care unit.

On notification by treating physicians of patients with A(H1N1)pdm09 infection, the ESPED study center distributed and subsequently collected a structured questionnaire, which had been adapted by the authors from an earlier study on seasonal influenza (11). Of 284 distributed questionnaires requested by 186 hospitals, 95% (271/284) were returned to the study center (Figure 1). After excluding 3 questionnaires that had been notified twice and 101 questionnaires for patients who did not meet the case definition, 62% (167/271) of the questionnaires from 83 hospitals remained. Reasons for not meeting the case definition included patient age >15 years and patient not admitted to PICU. In accordance with the case definition, only cases of A(H1N1)pdm09 infection were reported during the pandemic season (2009–10), and 9 cases of influenza A (not further subtyped) and 2 cases of influenza B infection were reported in the postpandemic season (2010–11). Therefore, further analyses were restricted to A(H1N1)pdm09 cases.
The structured questionnaire covered anonymous patient information and information regarding the hospital stay, clinical signs and symptoms, clinical and laboratory findings, specific treatments, status of influenza vaccination, disease complications, and underlying chronic medical conditions (chronic respiratory diseases; cardiac diseases; immunodeficiency; and neurodevelopmental disorders, including developmental delay, cerebral palsy, epilepsy, and other cognitive disorders). Answer categories were predetermined, but free space was designated for respondents to provide information about other diagnoses and coexisting illnesses/medical conditions. Hospital-acquired infection was defined by a date of symptom onset being >2 days after the date of hospital admission; 2 days corresponds with the median incubation time for A(H1N1)pdm09 according to Cao et al. (12). Data were double entered by using EpiData 3.1 software (www.epidata.dk/) in an electronic database.

Data Analysis

Reported values are those for children with available information. Descriptive statistics comprised the calculation of median and interquartile ranges (IQRs) for continuous variables and absolute numbers and proportions (together with 95% binomial exact CIs, when appropriate) for categorical variables. Comparative analyses were based on the Wilcoxon rank-sum test for continuous variables and Fisher exact test for categorical variables. Odds ratios (ORs) and 95% CIs were calculated. Multivariable analysis was performed by using a logistic regression with a stepwise approach to compare cases of hospital-acquired infection with cases of community-acquired infection and survivors with nonsurvivors in PICUs. In doing so, risk factors with a p value <0 .2=".2" 0.05="0.05" 11.0="11.0" 2-sided="2-sided" age="age" all="all" analyses="analyses" analysis="analysis" and="and" are="are" by="by" college="college" considered="considered" exception="exception" for="for" in="in" included="included" lp="lp" models.="models." multivariable="multivariable" of="of" p="p" performed="performed" reported="reported" season="season" sex="sex" significant.="significant." stata="stata" station="station" statistical="statistical" tatacorp="tatacorp" the="the" tx="tx" usa="usa" using="using" values="values" was="was" were="were" which="which" with="with">

Data Protection and Ethics Clearance

Adherence to national data protection laws was approved by the Federal Commissioner for Data Protection and Freedom of Information of Germany. Ethical approval was granted by the Ethics Committee, Charité-Universitätsmedizin, Berlin, Germany.

Results

Comparison of 2009–10 and 2010–11 Seasons

Figure 2

Figure 2. . . Distribution of 136 critically ill children with confirmed A(H1N1)pdm09, by date of disease onset, September 21, 2009–February 22, 2011, Germany. Only cases with available date of symptom onset are...

We identified 156 critically ill children with confirmed A(H1N1)pdm09 infection: 112 in 2009–10 and 44 in 2010–11 (Figure 1). Dates of symptom onset ranged from September 21, 2009, to March 20, 2010, for 2009–10 and from December 20, 2010, to February 22, 2011, for 2010–11 (Figure 2). Cases were reported from 15 of the 16 federal states in Germany during 2009–10 and from 10 during 2010–11.

Figure 3

Figure 3. . . Proportion of critically ill children with A(H1N1)pdm09 by age group and season, Germany.

Figure 4

Figure 4. . . Age distribution of the 156 critically ill children with confirmed A(H1N1)pdm09, by season, Germany.

The proportion of boys among case-patients was higher in 2009–10 than 2010–11 (59% vs. 37%, p = 0.02) (Table 1). The median age of case-patients was 5.3 and 3.2 years in 2009–10 and 2010–11, respectively, and differed statistically (p = 0.007) between the 2 seasons. The age distribution in 2010–11 compared with that in 2009–10 was characterized by a markedly higher proportion of children < 2 years of age and a lower proportion of children 10–14 years of age (Figure 3). In both seasons, infants <1 a="a" age="age" cases="cases" group="group" highest="highest" href="http://wwwnc.cdc.gov/eid/article/18/11/12-0719_article.htm#tnF4" number="number" of="of" represented="represented" the="the" title="Figure 4" with="with" year="year">Figure 4

). Of the 146 children with available information, 114 (78%) had >1 chronic underlying medical condition; the difference between seasons for these conditions was not statistically significant (Table 1). In both seasons, neurodevelopmental disorders were the most prevalent underlying medical condition. Of the 156 critically ill case-patients, 130 were >6 months age and thus eligible for vaccination against A(H1N1)pdm09 virus; however, for children with available information on vaccination status, only 5 (7%) of 67 vaccine-eligible case-patients had been vaccinated in the 2009–10 season, and none had been vaccinated in the 2010–11 season. Of the 69 total children in both seasons with underlying chronic medical conditions, 64 (93%) had not been vaccinated against A(H1N1)pdm09 virus.
More cases of sepsis were reported during the postpandemic season than during the pandemic season (21% vs. 8%; p = 0.048) (Table 1). Treatment with oseltamivir was used equally (in ≈62% of children) during both seasons. The time to oseltamivir administration after symptom onset (median 4 days) was similar throughout both seasons. The use of catecholamine and mechanical ventilation was more frequent in 2010–11 than in 2009–10, but the difference was not statistically different.

Hospital-acquired Infections

Hospital-acquired infections accounted for 11% (11 of 101) of the cases in 2009–10 and for 23% (8/35) in 2010–11 (p = 0.0931) (Table 1). Of the total study cohort, 14% (19/136) of the patients (9 in a general ward and 10 in a PICU) most likely had hospital-acquired infection. For these case-patients, the median time from hospital admission to symptom onset was 29 days (IQR 12–73 days). The median age for patients with hospital-acquired infection was 1.1 years, and 56% (10/18) were boys (difference not statistically significant between seasons).
The overall case-fatality ratios were 26% (5/19) among patients with hospital-acquired infection and 20% (23/117) among those with community-acquired infection (p = 0.543). Compared with patients with community-acquired infection, those with hospital-acquired infection had more complications, including acute respiratory distress syndrome (ARDS) (OR 2.7, p = 0.054) and sepsis (OR 3.1, p = 0.064), but the differences were not statistically significant (Table 2). In the multivariable model, immunodeficiency (OR 5.9, 95% CI 1.5–23.9; p = 0.013) and mechanical ventilation (OR 8.9, 95% CI 1.1–74.7; p = 0.043) were significantly associated with hospital-acquired infection after adjusting for age, sex, and season.

Case Fatalities Ratios

The case fatality ratio in PICUs did not differ between seasons: 15% (16/106) and 21% (9/44) of PICU case-patients died in 2009–10 and 2010–11, respectively (p = 0.473) (Table 1). For the 2 seasons, 25 of 150 PICU case-patients died, corresponding to a case-fatality ratio of 17% (95% CI 11%–24%). On hospital discharge, 26% (27/104) of the survivors were reported to have possible sequelae or worsening of a pre-existing medical condition.
No statistical differences were found between survivors and nonsurvivors in underlying chronic medical conditions and vaccination status. ARDS (OR 3.2, 95% CI 1.1–9.2, p = 0.029), myocarditis (OR 30.9, 95% CI 2.6–360.7,; p = 0.006), and mechanical ventilation (OR 18.3; 95% CI 1.3–251.6, p = 0.030) were independently associated with a fatal outcome in the multivariable model after adjusting for age, sex, and season (Table 3).
Compared with survivors, nonsurvivors more frequently required mechanical ventilation (p = 0.001) and treatment with catecholamine (p = 0.002); no differences were found in oseltamivir administration (65% vs. 62%, p = 0.8185). Time from symptom onset to oseltamivir uptake did not differ between survivors (median 4 days, IQR 1–6 days) and nonsurvivors (median 4 days, IQR 2–8 days).

Discussion

During the first postpandemic season, fewer cases of A(H1N1) pdm09 infection were reported, but the severity and outcome of cases did not differ between the pandemic and postpandemic seasons. We further analyzed data from the 2 seasons as 2 outbreak waves of 1 virus and identified a high number of hospital-acquired infections and ARDS and myocarditis as 2 predictors for a fatal outcome.
Compared with the 2009–10 pandemic season, the 2010–11 postpandemic season started later in the winter and had less than half the number of cases. High disease awareness during the pandemic season may have enhanced testing and reporting during 2009–10; thus the reduced case number for 2010–11 should be interpreted with caution. However in the United States, where reporting of influenza-related deaths in children is mandatory, a similar decline in the number of fatal A(H1N1)pdm09-associated cases was noted between the 2009–10 and 2010–11 influenza seasons (282 and 71 deaths among children, respectively) (13). Before the 2009–10 pandemic and similar to the postpandemic season, an average of 82 (range 46–153) children in the United States died each year from seasonal influenza–related illnesses (14). However, in the postpandemic 2010–11 season, different proportions of all circulating influenza subtypes might have led to different numbers of persons exposed to A(H1N1)pdm09, which makes comparisons between seasons and across countries difficult.
For the 2010–11 season, we assumed a more limited number of susceptible persons because exposure to influenza virus during the pandemic might have provided immunologic protection (15–17). This hypothesis is supported by our results showing a shift toward infection in younger age groups in 2010–11. A similar finding was reported in a prospective study of children with A(H1N1)pdm09 infection in a Spanish hospital (median age 7.0 and 0.8 years in 2009–10 and 2010–11, respectively) (10). During both seasons, children <1 16="16" 2009="2009" 2010="2010" 2="2" 65="65" a="a" affected="affected" age="age" although="although" always="always" and="and" been="been" between="between" boys="boys" could="could" difference="difference" distribution="distribution" group="group" groups="groups" had="had" has="has" have="have" href="http://wwwnc.cdc.gov/eid/article/18/11/12-0719_article.htm#r18" immunologically="immunologically" in="in" infected="infected" infection="infection" influenced="influenced" influenza="influenza" it="it" might="might" more="more" naive="naive" numbers="numbers" of="of" other="other" pandemic-like="pandemic-like" pdm09="pdm09" reflect="reflect" remains="remains" seasons="seasons" serious="serious" sex="sex" similar="similar" situation.="situation." suggested="suggested" than="than" that="that" the="the" therefore="therefore" this="this" those="those" title="18" unexplained="unexplained" were="were" why="why" year="year">18

). Our results show that case-fatality ratios for the 2 seasons were similar. In Greece (19) and New-Zealand (20), according to the respective national surveillance systems in intensive care unit settings, case-fatality ratios among all age groups were also similar for the 2 seasons. This result is reassuring, in view of concerns of a possible transformation of the strain into a more severe form (7), and is in agreement with the antigenic and genetic homogeneity of the virus since its emergence (21).
In both seasons, we identified a large number of probable hospital-acquired A(H1N1)pdm09 infections. Immunodeficiency, most often reported as acute lymphoblastic leukemia, was associated with hospital-acquired infection, and this underlying chronic medical condition, has also been identified as a risk factor for community-acquired A(H1N1)pdm09 (22,23). Findings from a retrospective hospital-based study investigating the prevalence of respiratory virus infections among children with cancer or HIV infection reported that 40% of the respiratory infections were acquired during the hospital stay, and influenza A virus was the second most prevalent respiratory infection (24). In our study, patients with hospital-acquired infection had more complications, including ARDS and sepsis, than patients with community-acquired infections. However, a significant association between hospital-acquired infection and death was not found, possibly because of the small number of cases, as found by Spaeder et al. (25) in a retrospective cohort study in PICU setting. In this study, hospital acquisition of viral respiratory infection was shown to be associated with an increased risk for death, even after adjusting for chronic medical conditions that predispose to an increased risk for complications from viral illness. Our findings emphasize the need for isolation of and preventive measures for children with immunodeficiency, as reported (26). Preventive measures should include the vaccination of health care workers. Indeed, a survey in Germany showed that only 35% (n = 3,900) of the health care workers in a university hospital setting were vaccinated during the 2010–11 influenza season (27). Studies in earlier seasons showed even lower influenza vaccination rates among health care workers (28).
We identified 25 A(H1N1)pdm09-associated deaths among children admitted to PICUs during the pandemic and postpandemic seasons. ARDS was the most prevalent complication among case-patients who died (60% of cases) and was highly associated with death. Myocarditis was also highly associated with death in children; this finding supports those among adults (29,30) and other findings among A(H1N1)pdm09-infected children (31).
During both seasons, 62% of the children received oseltamivir treatment. This proportion is lower than described in other studies in PICU settings, e.g., 81% in an inception-cohort study in Australia and New Zealand (32), 88% in a US cohort (31), 96% in a retrospective observational multicenter study in Turkey (33), and 100% of children in a retrospective Dutch cohort (34). Observational and random clinical trials have shown the potential of oseltamivir to reduce the length of hospitalization when started <24 hours of illness onset (35,36). The Infectious Diseases Society of America recommends that any person with confirmed or suspected influenza who requires hospitalization receive influenza antiviral therapy, even if the patient enters care >48 hours after illness onset (37). The German Society for Pediatric Infectious Diseases recommends that immunocompetent children without underlying chronic medical conditions should not receive influenza antiviral therapy >48 hours after onset of influenza symptoms (38). Most A(H1N1)pdm09 virus isolates tested worldwide remain sensitive to oseltamivir; thus, strategies to optimize the use of oseltamivir should be considered, and additional evidence should be collected with respect to reduction of nosocomial spread of A(H1N1)pdm09 virus and to potential benefits from late treatment in severely ill children.
We showed that 93% of the children with underlying chronic medical conditions who were eligible for vaccination had not been vaccinated. This finding highlights a need to improve vaccine coverage among this population, for which influenza vaccination is recommended in Germany (39). Children who did not survive received more intensive treatment (mechanical ventilation and catecholamine) than those who survived, and nearly all influenza A viruses tested continue to be antigenically similar to those found in the current trivalent vaccine (40); thus, enhanced prevention in children through vaccination, especially among those with underlying chronic medical conditions, remains a high priority.
Our study is subject to several limitations. Factors such as physicians’ awareness, diagnostic testing, and reporting behavior, which may have had different influences in the 2 seasons, were not assessed. Only children hospitalized in pediatric hospitals were included in the study; however, it can be assumed that critically ill children hospitalized in general hospitals were transferred to pediatric hospitals covered by the ESPED network. In addition, our knowledge of the clinical features of patients was based only on information provided in the structured questionnaires. Ascertainment of underlying chronic medical conditions was not standardized and, thus, may have differed among treating physicians.

Conclusions

During the first postpandemic A(H1N1)pdm09 season, the situation for children with severe A(H1N1)pdm09 disease did not differ from that for children with severe disease during the pandemic. Signs of pulmonary failure or suspected myocarditis in such children should alert health care providers to immediately initiate maximum care, and prevention of nosocomial transmission of influenza virus should be reinforced, especially in immunosuppressed children. The unchanged severity of influenza A(H1N1)pdm09 virus infections in the first postpandemic season (2010–11) and the constant high proportion of possibly hospital-acquired infections stress the challenge of preventing severe cases in children beyond the pandemic situation.

Dr Altmann is epidemiologist at the Robert Koch Institute. His research interests include infectious disease epidemiology and international health.

Acknowledgments

We are grateful to the German Pediatric Surveillance Unit (ESPED), in particular Beate Heinrich for managing the study centers. We acknowledge all contributing medical doctors and clinics for their valuable information and time.
This project was funded by the Robert Koch Institute.

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36. Heinonen S, Silvennoinen H, Lehtinen P, Vainionpaa R, Vahlberg T, Ziegler T, Early oseltamivir treatment of influenza in children 1–3 years of age: a randomized controlled trial. Clin Infect Dis. 2010;51:887–94. DOIPubMed
37. Harper SA, Bradley JS, Englund JA, File TM, Gravenstein S, Hayden FG, Seasonal influenza in adults and children–diagnosis, treatment, chemoprophylaxis, and institutional outbreak management: clinical practice guidelines of the Infectious Diseases Society of America. Clin Infect Dis. 2009;48:1003–32. DOIPubMed
38. German Society for Pediatric Infectious Diseases. Aktualisierte Empfehlung der DGPI zur Diagnostik, Therapie und Prophylaxe der Infektion mit dem Neuen Influenza A/H1N1v-Virus bei Kindern und Jugendlichen. 2009 [cited 2012 May 2]. http://www.dgpi.de/pdf/InflA%20_H1N1v_DGPI-Empfehlungen_09Nov2009.pdf 
39. German Standing Vaccination Committee (STIKO). Epidemiological Bulletin—vaccination against new Influenza A (H1N1) 2009 [in German] [cited 2012 Aug 15]. http://www.rki.de/DE/Content/Infekt/EpidBull/Archiv/2009/Ausgaben/41_09.pdf?__blob=publicationFile
40. World Health Organization. Influenza update–06 May 2011 [cited 2011 May 13]. http://www.who.int/influenza/surveillance_monitoring/updates/2011_05_06_GIP_surveillance/en/index.html

Figures

• Figure 1. . . Overview of study participation and participant groups among severe pediatric cases with A(H1N1)pdm09, Germany, 2009–2011. PCIU, pediatric intensive care unit.
• Figure 2. . . Distribution of 136 critically ill children with confirmed A(H1N1)pdm09, by date of disease onset, September 21, 2009–February 22, 2011, Germany. Only cases with available date of symptom...
• Figure 3. . . Proportion of critically ill children with A(H1N1)pdm09 by age group and season, Germany.
• Figure 4. . . Age distribution of the 156 critically ill children with confirmed A(H1N1)pdm09, by season, Germany.

Tables

• Table 1.  Comparison of severe cases of influenza A(H1N1)pdm09 virus infection in children during the pandemic and the first postpandemic seasons, Germany, 2009–2011
• Table 2.  Comparison of hospital- and community-acquired cases of severe influenza A(H1N1)pdm09 infection in children during the pandemic and first postpandemic influenza seasons, Germany, 2009–2011
• Table 3.  Comparison of severe cases of influenza A(H1N1)pdm09 infection among children in PICUs during the pandemic and first postpandemic influenza seasons, Germany, 2009–2011

Suggested citation for this article: Altmann M, Fiebig L, Buda S, von Kries R, Dehnert M, Haas W. Unchanged severity of influenza A(H1N1)pdm09 infection in children during first postpandemic season. Emerg Infect Dis [Internet]. 2012 Nov [date cited]. http://dx.doi.org/10.3201/eid1811.120719

DOI: 10.3201/eid1811.120719

Ahead of Print - Seroprevalence of Influenza A(H1N1)pdm09 Virus Antibody, England, 2010 and 2011 - Vol. 18 No. 11 - November 2012 - Emerging Infectious Disease journal - CDC

Ahead of Print - Seroprevalence of Influenza A(H1N1)pdm09 Virus Antibody, England, 2010 and 2011 - Vol. 18 No. 11 - November 2012 - Emerging Infectious Disease journal - CDC

Volume 18, Number 11—November 2012

Dispatch

Seroprevalence of Influenza A(H1N1)pdm09 Virus Antibody, England, 2010 and 2011

Article Contents

• The Study
• Conclusions
• Acknowledgments
• References
• Figure 1
• Figure 2
• Table 1
• Table 2
• Technical Appendix  [155 KB - 3 pages]
• Suggested Citation

Katja Hoschler , Catherine Thompson, Nick Andrews, Monica Galiano, Richard Pebody, Joanna Ellis, Elaine Stanford, Marc Baguelin, Elizabeth Miller, and Maria Zambon

Author affiliations: Health Protection Agency, London, UK (K. Hoschler, C. Thompson, N. Andrews, M. Galiano, R. Pebody; J. Ellis, M. Baguelin, E Miller, M. Zambon); and Health Protection Agency, Manchester, UK (E. Stanford)

Suggested citation for this article

Abstract

The intense influenza activity in England during the 2010–11 winter resulted from a combination of factors. Population-based seroepidemiology confirms that the third wave of influenza A(H1N1)pdm09 virus circulation was associated with a shift in age groups affected, with the highest rate of infection in young adults.

Seroepidemiologic data collected in England during the first 2 influenza pandemic waves suggested that another wave of infection with influenza A(H1N1)pdm09 virus was unlikely during 2010–11 (1). However, a substantial third wave occurred that affected persons in older age groups (2). Severity indicators suggested a higher level of illness and death, with increased cases in critical care and deaths. We conducted further seroepidemiologic study in England during 2010–11 to identify possible reasons for these observations.

The Study

This observational study used anonymized, residual serum samples from routine microbiological testing. Patient age and sex, date of sample collection, and source laboratory information were available (3).

Figure 1

Figure 1. . . Number of influenza A(H1N1)pdm09 virus detections (and percentage positive) detected through a network of Health Protection Agency laboratories (the Respiratory DataMart system) from the start of the pandemic in...

Samples were from patients 0–99 years of age, of whom 53% were female. Samples were grouped according to collection date: pre–first wave (before April 2009 [1,403 samples]) and post–first wave (August–October 2009 [3,091 samples]); post–second wave (January–April 2010 [2,225 samples]); and pre–third wave (June–October 2010 [1,782 samples]) and post–third wave (February–April 2011 [1,257 samples]) (Figure 1). Availability of samples by region and patient age was not consistent. With the objective of measuring age-dependent incidence, we prioritized serum samples by patient age. Samples were spread across 7 age groups (<5 15="15" 25="25" 45="45" 5="5" 65="65" and="and" class="text-underline" span="span">>

75 years) and came from the 9 regions of England (East, East Midlands, London, North East, North West, South East, South West, West Midlands, and Yorkshire and Humber). Viruses were characterized and sequenced as described (4). All samples were tested by hemagglutination-inhibition (HI) assay; samples with sufficient material also were tested by microneutralization assay according to standard methods (1). Samples with titers >32 or >40 by HI or microneutralization assay, respectively, were considered seropositive.
We determined antibody persistence by comparing antibody levels in the post–second wave panel with those of the pre–third wave panel on a subset of samples from 3 regions (North East, North West, and South West) where samples were available for both time points. Results were assessed with 95% confidence intervals. The full analysis of the seroprevalence preceding the 2010–11 season is detailed elsewhere (1).

Figure 2

Figure 2. . . Percentage of samples with hemagglutination-inhibition titer >32 during consecutive waves of influenza activity, England, summer 2009 and 2009-10 and 2010-11 influenza seasons. Data were plotted from all available...

In samples from all persons except those in the youngest age group (<5 2009="2009" 2010="2010" 5="5" age="age" and="and" antibody="antibody" assays="assays" before="before" by="by" class="text-underline" decline="decline" declined="declined" end="end" from="from" hi="hi" in="in" largest="largest" limited="limited" microneutralization="microneutralization" of="of" onset="onset" persons="persons" post="post" pre="pre" reduction="reduction" season="season" second="second" span="span" the="the" third="third" this="this" to="to" was="was" wave="wave" winter="winter" with="with" years="years">>
75-year group (−15% and −20% by HI and microneutralization assays, respectively). In children <5 10="10" a="a" and="and" antibody="antibody" assays="assays" by="by" during="during" hi="hi" href="http://wwwnc.cdc.gov/eid/article/18/11/12-0720-t1.htm" increased="increased" levels="levels" nicroneutralization="nicroneutralization" period="period" respectively="respectively" same="same" the="the" time="time" title="Table 1" years="years">Table 1, Table 2; Figure 2). We assessed changes in antibody levels during the 2010–11 season using data from all 5 available regions (East, North East, North West, South West, and Yorkshire and Humber) (Table 1, Table 2; Technical Appendix Table  [PDF - 155 KB - 3 pages]). For all age groups, HI and microneutralization assays demonstrated similar trends, although the increase by microneutralization assay in elderly persons was lower than by HI assay (48% vs. 28% increase). We found no evidence for association of titer with sex or region.
Children in the 2 youngest groups (<14 years) had the highest titers overall and highest percentage of seropositive samples (Table 1, Table 2; Figure 2; Technical Appendix Table  [PDF - 155 KB - 3 pages]). The highest increases in seroprevalence during the third wave were observed in the oldest age group (>75 years, from 17% to 65% seropositive by HI assay), followed by young adults (15–44 years, from 33% to 66% seropositive by HI assay) (Technical Appendix Figure  [PDF - 155 KB - 3 pages]).

Conclusions

Clinical surveillance data obtained during the course of acute illness (2) and seroepidemiology through population sampling are consistent and together point toward a shift in the age range for infection with A(H1N1)pdm09 in the first season after the 2009 pandemic. This finding is similar to those in earlier pandemics (5) and other countries (6). Historical data, including from 1918, suggest that the initial impact in children is followed by a dramatic shift in age distribution of infected persons, with the probability of infection in adults exceeding those of children until the age distribution returns to the normal seasonal pattern (5,7). This adaptation process may take 3–10 years (7).
The rates of decline in antibody to A(H1N1)pdm09 from the 2009–10 to the 2010–11 winters are similar to historic data (8) and A(H1N1)pdm09 vaccine trials (9,10). The implications of such reduction are uncertain. The seroprevalence data suggested susceptibility in young adults pre–third wave, but not in children who were targeted by an extended vaccination program in the United Kingdom from January 2010. Up to 30% of children <5 a="a" href="http://wwwnc.cdc.gov/eid/article/18/11/12-0720_article.htm#r11" title="11" vaccinated="vaccinated" were="were" years="years">11

). During the 2010–11 season, antibody was acquired primarily by young and old adults. The largest increase in antibody levels after the 2010–11 winter occurred in persons >75 years of age. Clinical surveillance data suggests that elderly persons (>65 years of age) were relatively spared from infection with A(H1N1)pdm09 virus (12). We propose that the increase resulted primarily from seasonal influenza vaccination in 2010–11 with vaccine uptake of 72.8% (13). In young adults (15–44 years), we believe that acquisition of antibody occurred as susceptible persons became infected during the winter. Children were relatively spared from infection with A(H1N1)pdm09 during winter 2010–11; their high rate of infection in the 2 previous pandemic waves, together with vaccination, left a limited number of susceptible persons (Figure 2).
Our study design—a retrospective, periodic, cross-sectional collection—has certain limitations. We analyzed similar but not identical groups and persons at different time points. For each sample, only limited information was available. Without information about vaccination status or influenza exposure history during the season, our interpretation of antibody levels and their changes has to be taken with caution. However, in this descriptive analysis we also used supportive evidence from UK influenza surveillance programs and take into account the date of vaccination timing and uptake, which strengthens our interpretation of the serologic data.
The collections for each sample set were distributed over time periods of up to 21 weeks, during which antibody levels would have changed, depending on the combined effects of seroconversion, antibody waning and availability of vaccination. A novel likelihood-based approach, described previously has therefore been developed to overcome some of the limitations of the conventional statistical method (1).
We found no evidence of substantial antigenic drift in circulating viruses that could affect seroepidemiology results (Technical Appendix Table  [PDF - 155 KB - 3 pages]). We conclude that the intense A(H1N1)pdm09 virus activity in the England during the 2010–11 winter must have resulted from a combination of factors.
The change in age distribution of infection is likely to have caused increased severity, resulting from a larger number of patients with underlying concurrent conditions (12) or from age-dependent changes in pathology. Defining antibody correlates of protection becomes more complex with rising patient age as other immune mechanisms increasingly contribute to protection, e.g., CD4+ T cells, as demonstrated in human challenge experiments (14). Moreover, a murine model identified the role of age in susceptibility to pathogenesis and transmission of influenza virus infection (15). These observations might help to provide some mechanistic insights for the shift in age distribution of infection and severity in the season after the 2009 pandemic. Genetic drift in circulating virus over time affecting human airway adaptation and varying climatic conditions during different pandemic waves also should be investigated.

Dr Hoschler is Advanced Clinical Scientist at the Respiratory Virus Unit, Microbiology Services–Colindale, Health Protection Agency, UK. Her research is focused on influenza serology, including the investigation of natural and vaccine responses, influenza seroepidemiology and development of new diagnostic serologic assays.

Acknowledgments

We thank the Health Protection Agency Regional Microbiology Network and National Health Service laboratories that collect samples for the Health Protection Agency seroepidemiology program. We are grateful for the technical support provided by Janice Baldevarona, Surita Gangar, Paola Barbero, Dipa Lakhman, Ray Borrow, Kevin Potts, and Sam Tomes.
This study was funded by the National Institute for Health Research Health Technology Assessment Programme and the Department of Health.

References

1. Hardelid P, Andrews NJ, Hoschler K, Stanford E, Baguelin M, Waight PA, Assessment of baseline age-specific antibody prevalence and incidence of infection to novel influenza A/H1N1 2009. Health Technol Assess. 2010;14:115–92.PubMed
2. Presanis AM, Pebody RG, Paterson BJ, Tom BD, Birrell PJ, Charlett A, Changes in severity of 2009 pandemic A/H1N1 influenza in England: a Bayesian evidence synthesis. BMJ. 2011;343:d5408. DOIPubMed
3. Health Protection Agency. Seroepidemiology Programme. London [cited 2012 May 14]. http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/SeroepidemiologyProgramme/
4. Galiano M, Agapow PM, Thompson C, Platt S, Underwood A, Ellis J, Evolutionary pathways of the pandemic influenza A (H1N1) 2009 in the UK. PLoS ONE. 2011;6:e23779. DOIPubMed
5. Simonsen L, Clarke MJ, Schonberger LB, Arden NH, Cox NJ, Fukuda K. Pandemic versus epidemic influenza mortality: a pattern of changing age distribution. J Infect Dis. 1998;178:53–60. DOIPubMed
6. Viasus D, Cordero E, Rodriguez-Bano J, Oteo JA, Fernandez-Navarro A, Ortega L, Changes in epidemiology, clinical features and severity of influenza A (H1N1) 2009 pneumonia in the first post-pandemic influenza season. Clin Microbiol Infect. 2012;18:E55–62. DOIPubMed
7. Saglanmak N, Andreasen V, Simonsen L, Molbak K, Miller MA, Viboud C. Gradual changes in the age distribution of excess deaths in the years following the 1918 influenza pandemic in Copenhagen: using epidemiological evidence to detect antigenic drift. Vaccine. 2011;29(Suppl 2):B42–8. DOIPubMed
8. Davies JR, Grilli EA, Smith AJ. Infection with influenza A H1N1. 2. The effect of past experience on natural challenge. J Hyg (Lond). 1986;96:345–52. DOIPubMed
9. Nicholson KG, Abrams KR, Batham S, Clark TW, Hoschler K, Lim WS, A randomised, partially observer blind, multicentre, head-to-head comparison of a two-dose regimen of Baxter and GlaxoSmithKline H1N1 pandemic vaccines, administered 21 days apart. Health Technol Assess. 2010;14:193–334.PubMed
10. Walker WT, de Whalley P, Andrews N, Oeser C, Casey M, Michaelis L, H1N1 antibody persistence 1 year after immunization with an adjuvanted or whole-virion pandemic vaccine and immunogenicity and reactogenicity of subsequent seasonal influenza vaccine: a multicenter follow-on study. Clin Infect Dis. 2012;54:661–9. DOIPubMed
11. Health Protection Agency. Pandemic H1N1 (swine) influenza vaccine uptake amongst patient groups in primary care in England 2009/10 [cited 2012 May 14]. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_121014.pdf 
12. Health Protection Agency. Surveillance of influenza and other respiratory viruses in the UK: 2010–2011 report [cited 2012 May 14]. http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1296687414154
13. Health Protection Agency. Seasonal influenza vaccine uptake amongst GP patient groups in England. Winter season 2010–11 [cited 2012 May 14]. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_129856.pdf 
14. Wilkinson TM, Li CK, Chui CS, Huang AK, Perkins M, Liebner JC, Preexisting influenza-specific CD4(+) T cells correlate with disease protection against influenza challenge in humans. Nat Med. 2012;18:274–80. DOIPubMed
15. Sun S, Zhao G, Xiao W, Hu J, Guo Y, Yu H, Age-related sensitivity and pathological differences in infections by 2009 pandemic influenza A (H1N1) virus. Virol J. 2011;8:52. DOIPubMed

Figures

• Figure 1. . . Number of influenza A(H1N1)pdm09 virus detections (and percentage positive) detected through a network of Health Protection Agency laboratories (the Respiratory DataMart system) from the start of the...
• Figure 2. . . Percentage of samples with hemagglutination-inhibition titer >32 during consecutive waves of influenza activity, England, summer 2009 and 2009-10 and 2010-11 influenza seasons. Data were plotted from...

Tables

• Table 1.  Seroprevalence of influenza A(H1N1)pdm09 virus antibody, England, 2010 and 2011
• Table 2. Seroincidence estimates of influenza A(H1N1)pdm09 virus antibody, England, 2010 and 2011

Technical Appendix

• Technical Appendix.    [155 KB - 3 pages]

Suggested citation for this article: Hoschler K, Thompson C, Andrews N, Galiano M, Pebody R, Ellis J, et al. Seroprevalence of influenza A(H1N1)pdm09 virus antibody, England, 2010 and 2011. Emerg Infect Dis [Internet]. 2012 Nov [date cited]. http://dx.doi.org/10.3201/eid1811.120720

DOI: 10.3201/eid1811.120720

U.S. Food & Drug Administration (FDA) FDA-TRACK Update

FDA-TRACK is an agency-wide performance management system that monitors over 100 FDA program offices through key performance measures and projects.  These measures are reported monthly and updated quarterly on the website.
What's New with FDA-TRACK
August 2012 Performance Data Updates
New performance data is available for the dashboards below.
Cross Agency

• July 9, 2012: FDA-TRACK Medical Countermeasures Initiative (MCMi) Quarterly Briefing Summary
• FDA-TRACK Medical Countermeasures Initiative (MCMi) Dashboard – OCET completed its key projects, “Implement Intramural Component of MCM Regulatory Science Program”, “Implement Extramural Component of MCM Regulatory Science Program”, and “MCMi Public Regulatory Science Symposium”. 
• July 17, 2012: FDA-TRACK Advisory Committees Quarterly Briefing Summary
• FDA-TRACK Advisory Committees Dashboard

Center for Biologics Evaluation and Research (CBER)

• FDA-TRACK CBER Cross Management Support Offices Dashboard
• FDA-TRACK CBER Cross Program Support Offices Dashboard
• FDA-TRACK CBER Research and Review Offices Dashboard

Center for Tobacco Products (CTP)

• July 16, 2012: FDA-TRACK CTP Quarterly Briefing Summary
• FDA-TRACK CTP Dashboard – The Office of Health Communication and Education (OHCE) completed both Public Outreach and Health Education key projects.

National Center for Toxicological Research (NCTR)

• July 9, 2012: FDA-TRACK NCTR Quarterly Briefing Summary
• FDA-TRACK NCTR Administrative Offices Dashboard
• FDA-TRACK NCTR Research Divisions Dashboard – DBT completed its “Chemical inactivation of protein toxins on food contact surfaces” program measure. OSC completed its “Toxicology Studies and Research” program measure. Two final reports were completed: Toxicity of Usnea Lichen – Usnic Acid and Toxicity of Glucosamine – Chondroitin Sulfate.

Office of Special Medical Programs (OSMP)

• July 17, 2012: FDA-TRACK OSMP Quarterly Briefing Summary
• FDA-TRACK Office of Special Medical Programs Dashboard

Office of the Commissioner (OC)

• July 9, 2012: FDA-TRACK Office of the Chief Scientist Quarterly Briefing Summary
• FDA-TRACK OC Office of the Chief Scientist (OCS) Dashboard

September 2012 Upcoming Performance Data Updates

The below listed programs are expected to publish performance data updates in September 2012. Updates are posted to each dashboard approximately 30 business days after each quarterly briefing with FDA senior leadership.

• Center for Veterinary Medicine (CVM)

General Program Updates

• Quarterly Briefing Summaries – Visit this page for public summaries of accomplishments discussed at each FDA-TRACK briefing. We post summaries approximately 30 business days after each quarterly briefing, along with updated performance measures and results. This page includes a new summary for Advisory Committees, CTP, MCMi, NCTR, OCS and OSMP.
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• Didn’t find what you were looking for? Please email us at FDATRACK@fda.hhs.gov to suggest performance measures or key projects.