MISMS South Asia Influenza

Meeting and Technical Workshop

Selected Abstracts

August 9-13, 2011

Dwarikas Hotel, Kathmandu, Nepal

MISMS South Asia Influenza Meeting and Training Workshop

August 9-13, 2011 Dwarikas Hotel Kathmandu, Nepal
Table of Contents
Session II: Etiology of respiratory infections and clinical issues in South Asia3-4
Asad Ali, Role of influenza A in pediatric hospitalizations due to acute respiratory illnesses in Karachi,
Pakistan.3
Ram Chandyo, Virus etiology in community acquired pneumonia in Bhaktapur, Nepalcross-sectional and
case-control study ....4
Session IV: Influenza surveillance in Asia and the Pacific .5-9
Geeta Shakya, An experience with influenza surveillance in Nepal, 2010...5
Sanjaya Shrestha, Sentinel human surveillance of influenza in Nepal.6
Dibesh Karmacharya, Building molecular diagnostic capacity in resource-strapped countries for viral
detection, surveillance, and monitoring- our experience in Nepal..7
Kedar Baral, Epidemiological and virological surveillance of influenza like illness in Patan Academy of
Health Sciences, Nepal ....8
Paul White, New approaches for old diseases: Sentinel and syndromic influenza surveillance in New
Zealand 9
Session V: Etiology of respiratory infections and clinical issues in South Asia II10-12
Siddhivinayak Hirve, Estimating age-specific global infection rates for the 2009 influenza pandemic
influenza: a meta-analysis of H1N1pdm serological studies.10
Nusrat Homaira, Incidence of influenza-associated mortality in Bangladesh: 2009.11
Rajesh Chudasama, Clinico-epidemiological features of the hospitalized patients with 2009 pandemic
influenza A (H1N1) virus infection in Saurashtra region, India (September 2009 to February 2010).12
Session VI: Issues in vaccination and health policy 13-16
Mark Steinhoff, Influenza immunization in pregnancy and newborn outcomes 13
Abdullah Mamun, Effectiveness of 2009 pandemic influenza A (H1N1) vaccine in Bangladesh, 2010: a
program evaluation .....14
Mejbah U Bhuiyan, Costs associated with hospitalizations with respiratory viral infections in Bangladesh
..15
Paul White, The science and art of coordinated national response to pandemics: Lessons learned during the
influenza A (H1N1) 2009 outbreaks in New Zealand..16

Asad Ali, MBBS, MPH

Assistant Professor, Aga Khan University, Pakistan
Role of Influenza A in pediatric hospitalizations due to acute respiratory illnesses in Karachi, Pakistan.
Ali A, Akhtar N, Aziz F.
Background: Acute respiratory illnesses (ARI) are the second leading cause of childhood mortality in Pakistan.
The contribution of influenza A virus in the ARI burden in Pakistan is not known. We conducted a prospective
surveillance study to define the seasonality, frequency clinical features of ARI associated with influenza A in
children hospitalized at the Aga Khan University.
Methods: After informed consent, children < 5 year old, hospitalized with fever or any respiratory illness at the
Aga Khan University from August 2009 till March 2011 were enrolled. Baseline information and clinical
features were captured using standardized questionnaires and throat swab was obtained for detection of
influenza A virus using real time RT PCR. After the discharge of the child, medical records were reviewed to
record hospital course and outcome.
Results: Six hundred and fifty children meeting eligibility criteria were enrolled in the study and influenza A
was detected in 34 (5.2%) of these children. Influenza A was detected in children primarily during November
and February. Children with influenza A were older (median 12.2 months) compared to children negative for
influenza A (median 9.7 months) (p=0.02). The presenting symptoms of children positive for influenza A were
similar to children testing negative for influenza A. Children with influenza A were 3.78 times more likely to be
transferred to the ICU (12.1% vs. 3.2%, p=0.02), four times more likely to be intubated (12.1% vs. 3.0%,
p=0.02) and 13 times more likely to die (9% vs. 0.7%, p=0.004) as compared to children negative for influenza
A.
Conclusion: Influenza A circulates mainly during November to February in Karachi. Children with influenza A
are at high risk of complications and death. This data support the argument in favor of influenza vaccination in
children in Karachi.

This work has been funded by a Fogarty GRIP grant 5R01TW008126-02, PI Syed Asad Ali titled "Burden of
RSV and Influenza Virus in Children in Pakistan". This abstract has not been presented or published before.

Ram Chandyo, MD
Co-investigator, Institute of Medicine/MAL-ED, Nepal
Virus etiology in community acquired pneumonia in Bhaktapur, Nepal- cross-sectional and case control
study. Mathisen M, Strand TA, Sharma BN, Chandyo RK, Valentiner-Branth P, Basnet S, Adhikari RK,
Hvidsten D, Shrestha PS, Sommerfelt H.
Background: Pneumonia remains the leading cause of illness and death in children less than 5 years of age in
low-and-middle-income countries. Both bacteria and viruses are major causes of pneumonia in children. The
disease burden attributed to the different respiratory pathogens varies with season and between regions.
Knowledge of the relative importance of each agent is essential for adequate case management as well as
prevention strategies, such as development of vaccines.
Objectives: The aims of this study were to obtain information on the frequency of seven common respiratory
RNA viruses and their seasonal distribution over a three-year period. In a case-control study, we also wanted to
measure the degree to which the individual viruses were associated with WHO/IMCI-defined pneumonia.
Methods: We examined nasopharyngeal aspirates (NPA) from 2220 community-acquired pneumonia in two to
35 month old children in Bhaktapur, Nepal, from July 2004 to June 2007. The specimens were examined for
respiratory syncytial virus (RSV), influenza virus type A (InfA) and B (InfB), parainfluenza virus type 1, 2 and
3 (PIV1, PIV2, and PIV3), and human metapneumovirus (hMPV) using a multiplex reverse transcriptase PCR
assay. For the case-control study, we enrolled 680 pneumonia cases and 680 age-matched controls.
Results: We identified 920 virus isolates in 888 (40.0%) of the 2220 specimens, of which 335 (15.1%) yielded
RSV, 164 (7.4%) InfA, 129 (5.8%) PIV3, 98 (4.4%) PIV1, 93 (4.2%) hMPV; 84 (3.8%) InfB, and 17 (0.8%)
PIV2. At least one virus was detected in NPA in 248 (36.5%) cases and 48 (7.1%) controls. The matched odds
ratio (MOR) for detection of the individual viruses from a case compared to a control varied from 2.0 to 13.0;
the highest associations were observed for PIV type 3 (MOR 13.0; 95% CI 6.0, 28.0), RSV (10.7; CI 4.6, 24.6)
and influenza A (6.3; CI 1.9, 21.4).
Conclusions: Our findings indicate that these seven RNA viruses are important causes of pneumonia in young
children in Bhaktapur. Although influenza A and PIV type 3, like RSV, were among the most common viruses
and were strongly associated with pneumonia, RSV was by far the most frequently detected virus over the threeyear period.
Previously published in:
Pediatr Infect Dis J. 2010 Jan; 29(1): e1-6.
The Pediatric Infectious Disease Journal. 2010 Aug; 29(8): 731-5.
http://www.biomedcentral.com/content/pdf/1741-7015-7-35.pdf

Geeta Shakya, MP, PATH

Director, National Public Health Laboratory, Nepal
An experience with influenza surveillance in Nepal, 2010. Shakya G, Shrestha AK, Sedai D, Shrestha SK,
Baral K, Aung L, Schulter WW.
Background: Influenza, as a part of global public health challenge, has emerged and reemerged in Nepal in the
past several decades, notably in zoonotic, seasonal epidemic, and pandemic forms. However, the lack of
surveillance mechanisms rendered the estimate of disease burden and severity of influenza guess-work.
Method: With the introduction of Influenza Surveillance Program, in late 2006, by Walter Reed's AFRIMS Unit
Nepal for human surveillance of influenza by isolation and characterization of influenza viruses circulating
within the human population and with the establishment of Avian Influenza Control Project (AICP) for both
human and animal components in 2007, valuable data started accumulating. The concern of AICP was focused
on Highly Pathogenic Avian Influenza, H5N1, resulting to severe acute respiratory tract infection.
Subsequently, reporting was initiated on pneumonia cases exposed to H5N1 or having a history of contact with
sick or well poultry from 408 health facilities of all 75 districts. Data compilation was supported by
Surveillance Medical Officers of WHO, IPD. However, the pandemic situation of 2009 due to pandemic
Influenza A H1N1 was surveyed and managed by AICP through event-based surveillance. Molecular tests for
virological diagnosis were done at the National Public Health Laboratory (NPHL). In April 2010, NPHL was
designated and subsequently recognized by WHO as the National Influenza Center (NIC) of Nepal. The
mandate was to isolate and characterize influenza viruses circulating within the country through samples
collected from the ten sentinel sites of the National Influenza Surveillance Network and sharing information
with the Global Influenza Surveillance Network. The NPHL coordinated with other influenza programs to
collect information on influenza cases tested by molecular analysis from both human and veterinary sources and
developed a combined report that included influenza samples tested at the NIC. Continuity in the surveillance
work would be strengthened through the Influenza Pandemic Preparedness and Response Project, an
undertaking of Patan Academy of Health Sciences, located in Kathmandu, Nepal.
Results: Of total 1010 cases tested, 530 tested positive for influenza virus infection, of which 58% (304 cases)
were positive for influenza B. The remaining cases tested positive for influenza A, a total consisting of 175
cases of pandemic H1N1 (77.4%), 50 cases of influenza A/unsubtyped (22.2%), and one case of flu A/H3
(0.4%). 10,484 cases were diagnosed as aggregate pneumonia (due to all etiologies) during the surveillance
period, with a mortality of 101 cases (0.096%). Avian outbreaks (eight episodes) due to HPAI virus infection in
the poultry were reported from seven districts in the country. Two clade types of HPAI virus (2.3.2 and 2.2)
were isolated from an outbreak in Kaski district, whereas only one clade type (2.3.2) was isolated from
outbreaks in six districts. 1114 cases of natural death occurred in poultry, whereas 28,037 foul were culled and
destroyed.
Conclusion: The predominant influenza type circulated in year 2010 was influenza B, followed by pandemic
influenza A/H1N1 and then other influenza A subtypes. HPAI virus, clade 2.3.2, normally found in wild birds,
was isolated from poultry without evidence for mode of transmission.

Sanjaya Shrestha, MD
Director, Walter Reed/ AFRIMS Research Unit, Nepal
Sentinel Human Surveillance of Influenza in Nepal. Shrestha SK, Jarman RG, Meyers MS, Shrestha B,
Rayamajhi BB, Shrestha J, Gibbons RV.
The Walter Reed/AFRIMS Research Unit Nepal (WARUN) initiated a surveillance study of human influenza in
Nepal in November 2006 to identify and characterize locally-circulating influenza viruses. The study included
nine centers in Kathmandu, Bharatpur, and Pokhara. Beside these centers, the study also received samples and
provided diagnostic support to the Epidemiology and Disease Control Division (EDCD) and National Public
Health Laboratory (NPHL).
Patients presenting with influenza-like illness (fever 38C with cough and/or sore throat within 72 hours of
onset) at these centers were briefed and were requested to participate in this surveillance program. A case-report
form was completed and a respiratory sample was obtained in a viral transport medium on all consenting
participants. A rapid diagnostic test was offered at the site to aid patient management. A refrigerator/ 2-8 C
icepack, ultra-low freezers, and liquid nitrogen were used to maintain cold chains at centers and to transfer
samples to WARUN. A communication system was established to transfer samples appropriately. These
samples were tested by real time reverse transcriptase polymerase chain reaction (RT-PCR) at WARUN for
seasonal influenza B and subtypes of influenza A (H1, H3, 2009/H1, and H5). Further, RT-PCR, virus isolation,
characterization, and sequencing are performed on selective samples at the Armed Forces Research Institute of
Medical Sciences (AFRIMS) in Thailand, along with other advanced laboratories.
From January 2009 to December 2010, WARUN received 3219 samples from its surveillance centers and
NPHL. There were 58.5% male participants with a quarter (26.1%) less than or equal to five years of age and
38.1% above 15 years of age. Rapid diagnostic test was performed on 87% samples. In 2009, the RT-PCR result
tested 0.8% positive for influenza B and 63.5% tested positive for influenza A (1.1% for H1, 39.8% for H3,
21.7% for 2009H1, and 1.1% for un-subtype) among all tested samples. In 2010, RT-PCR tested 29.8%
influenza B and 22.4% influenza A (0.1% for H3, 17.3% for 2009H1, 5% for un-subtype) among all tested
samples. A total of 2.3% of samples could not be subtyped for influenza A by RT-PCR in these two years.
The result of RT-PCR test indicated that influenza A/H3 as predominant influenza during April to September
2009 and A/2009 H1 predominated October 2009 to January 2010. A/2009 H1 reemerged in July 2010 and
circulated until September 2010. Influenza B started co-circulating with influenza A from January 2010 and
was observed in higher proportion from August 2010 to November 2010.

Dibesh Karmacharya
International Director, Center for Molecular Dynamics - Nepal
Building molecular diagnostic capacity in resource-strapped countries for viral detection, surveillance,
and monitoring- our experience in Nepal. Karmacharya D.
The challenge of detection, surveillance, and monitoring for viral-borne diseases in resource-strapped countries
like Nepal is exacerbated by the lack of a good molecular diagnostic and immunology laboratory. The Center
for Molecular Dynamics-Nepal, CMDN, has been working with its state-of-the-art molecular diagnostic
laboratory based in Kathmandu, Nepal to work on such areas as early and precise detection of pathogens
utilizing genomic-based assays, conducting molecular epidemiology to track the movement of diseases like HIV
within the country, to study the prevalence and strain variation of HPV in cervical carcinoma, and to profile
possible viral and bacterial pathogens in epidemic diarrhea. This presentation is an effort to highlight some of
the advantages and challenges of building a molecular diagnostic laboratory in low-resource settings like Nepal
and operating it in the context of addressing current and pressing challenges in healthcare in such countries.

Bibliographic citation of where this work has been previously presented and/or accepted for publication:
BIT 1st World Congress of Virus & Infections-2010
Busan, S. Korea

Kedar Baral, MBBS, MPH

Professor, Patan Academy of Health Sciences, Nepal
Epidemiological and virological surveillance of influenza-like illness in Patan Academy of Health
Sciences, Nepal. Prasai P, Paudel S, Pahari DP, Gnawali R, Rajbhandari A, Acharya P, Karki A, Baral KP.
Introduction: Surveillance is a key component in the control of influenza outbreaks. Early detection of rapidlyincreasing numbers of influenza-like illness (ILI) cases and identification of strains (new or seasonal) are the
primary goals of surveillance. Here, we present the epidemiological and virological surveillance data of ILI
cases studied between January and June 2011 at Patan Hospital, a teaching hospital of the Patan Academy of
Health Sciences, Nepal.
Methods: Patan Hospital is implementing a US CDC-founded influenza surveillance program using National
Standard Operating Procedures for case definition, data, and sample collection and testing. All patients who met
ILI case definition in general outpatient clinics (male, female, and under-14 clinics) and emergency departments
were recorded according to epidemiological week. The throat swab of the first ILI cases presenting to the study
clinics on every Mondays and Thursdays were tested using reverse transcriptase polymerase chain reaction (RTPCR). We used CDC-supplied primers and probes for universal influenza A, pandemic influenza A 2009 (H1),
influenza A (H1), influenza A (H3), influenza A (H5) and influenza B.
Results: A total of 737 ILI cases that presented to the four study clinics in Patan hospital from January to June
2011 and corresponding to epidemiological weeks 1 to 26 were recorded. The proportion of ILI cases per 100
OPD patients was 0.6. From these cases, 81 throat swab samples were collected for virological study. The
distribution of ILI samples showed that most of the cases were reported by the under-14 clinic (45.7%),
followed by the female clinic (28.4%), the male clinic (24.7%) and the emergency department (1.2%). The
mean age of the studied population was 20.4 years with 16.4 years (SD), and 54% were males. Molecular
diagnosis of influenza was done on 81 samples. Of the samples tested, only four were found positive, two for A
(pandemic 2009) and two for B. The positive cases were in the 15-25 year age group and presented between 5
to 11 epidemiological weeks.
Conclusion and recommendations: The proportion of ILI cases presenting to OPD of Patan Hospital is low and
may not represent the community-level incidence. One of the possible reasons of underreporting could be that
ILI symptoms were not perceived by the patients to be serious enough to require medical attention, given
relatively easy access to over-the-counter medicine. Hence, to detect community level prevalence of ILI and
identification of circulating viruses, community based surveillance would be critical.

Paul White, PhD

Spatial Epidemiologist, Food & Agriculture Organisation of the United Nations
Emergency Centre for Transboundary Animal Diseases India
New approaches for old diseases: Sentinel and syndromic influenza surveillance in New Zealand. White P.
After the SARS epidemic and global concerns over emerging influenza A(H5N1) Highly Pathogenic Avian
Influenza, the New Zealand (NZ) Ministry of Health (MoH) commissioned a working group to explore potential
approaches for establishing early warning surveillance for existing and emerging influenza-like-illnesses (ILI).
This talk discusses the implementation of three human health approaches: general practitioner (GP) sentinel
surveillance, registered nurse telephone helpline triage syndromic surveillance, and hospital emergency
department admission surveillance.
Over 100 GP practices sentinels were enrolled from across NZ. The GPs were trained to provide a confirmation
flag in their computer practice management system (PMS) whenever a patient presented meeting the ILI case
definition. Weekly on Monday morning, the HealthStat surveillance system network connected to each of the
participating GPs PMS and collected the positive ILI flags from each of the sentinels. The data were verified
and any discrepancies followed up. The data were dispatched to the MoH for analysis and interpretation and
were compiled into a report that was issued across the public health sector of NZ.
The free telephone HealthLine surveillance system used decision tree diagnostic prompts. HealthLine, similar
to GP HealthStat, used an ILI case definition with an ILI flag that was prompted for confirmation whenever a
callers enquiries met the case definition. All positive flags were weekly collated on Monday, data verified, and
passed to the MoH for analysis and compilation into the same report as for HealthStat.
Together with these two national systems, a third regional syndromic surveillance system was established using
Emergency Department (ED) admissions data from Wellington hospital. This system collected flags for two
sets of weekly ED admissions, one for an ILI case definition and the other for a wider respiratory case
definition.
All three surveillance approaches used the same Cumulative Summation (CuSum) analytical approach based on
the CDC Early Aberration Reporting System (EARS). CuSum compares current event counts with previous
counts within a timeframe and flags events that exceed certain thresholds. The CuSum approach demonstrated,
by retrospective analysis of the ED respiratory data the ability to detect a small outbreak that occurred in
Wellington in 2005 in school children. The EARS flagged increasing ED admissions 7 days ahead of school
absenteeism reports reaching public health authorities and 10 days before action was taken (the inference here is
that action could have been taken earlier had this system been live at the time).
The turnaround time of all three systems was quicker than the average 10 day reporting time of laboratory
diagnosis. While not confirmatory, these systems have demonstrated their value in providing early warning of
likely outbreak events. HealthStat and Healthline were the first and currently remain the only year round semiautomated multi-data stream sentinel and syndromic surveillance system collecting data daily and reporting it
weekly in NZ.

Siddhivinayak Hirve, MD, MS, MPH

Consultant, KEM Hospital Research Center, Switzerland
Estimating Age-Specific Global Infection Rates for the 2009 Influenza Pandemic Influenza: a MetaAnalysis of H1N1pdm Serological Studies. Hirve S, Van Kerkhove MD, Koukounari A, MountsAW, for the
H1N1pdm serology working group.
Background: The true global impact of the 2009 influenza pandemic (H1N1pdm) is not well understood.
Estimates of hospitalizations and deaths related to influenza based on clinical and virological information alone
underestimate the true burden of disease. In addition, the proportion of infections due to H1N1pdm that were
mild or asymptomatic is unknown. Serological studies are an important tool to more accurately estimate
infection rates, and coupled with clinical information, they can estimate the clinical attack rate as well as the
proportion of asymptomatic cases in the population.
Aims: Here we estimate age-specific cross-reactive antibodies to H1N1pdm virus and rates of infection of
H1N1pdm during the first year of the pandemic (2009-10) using data from published and unpublished seroepidemiologic studies of H1N1pdm.
Methods: An extensive literature search was carried out to identify serological studies of H1N1pdm with
estimates of age-stratified infection rates, sera collection during or after the start of the H1N1pdm pandemic, and
where the laboratory methods were well described. Studies with estimates based on clinical diagnosis with or
without laboratory PCR confirmation, household studies to estimate secondary attack rate, studies of seasonal
influenza only and studies without age stratification were excluded. Upon request, investigators provided seropositivity results stratified in harmonized age groups (0-4, 5-19, 20-44, 45-64, and >=65 years old). H1N1pdm
infection rates were estimated separately for two study groups categorized as A) paired or unpaired sera
(depending on whether sera were collected twice from the same subject [paired sera] or twice in the same
population but from different individuals before the start of the pandemic and after the pandemic began
[unpaired sera]), and B) single sera where sera were collected once during the pandemic period. Age-specific
cross-reactive antibodies to H1N1pdm virus were estimated among a baseline sera study group, where sera
samples were collected prior to April 2009. We used fixed and random effects logistic regressions for grouped
binary response (with study as the random effect) to calculate pooled estimate of infection rates separately for
single and baseline sera studies. An age-stratified meta-analysis was conducted estimating the overall infection
rate for the paired/unpaired sera studies and age-specific infection rates. A random effects meta regression was
used to estimate the extent to which covariates (e.g., region and other study characteristics) explain the
heterogeneity in the infection rates between studies.
Results: We identified a total of 58 serological studies (including 13 unpublished studies) from Europe (19),
Asia (16), Oceania (6), Americas (15) and Africa (2) eligible for inclusion. The fixed and random effects
logistic regression estimates the overall pooled baseline (pre-pandemic) prevalence of cross-reactive antibodies
of 9.21% (95% CI: 8.72 9.73) and 8.47% (95% CI: 5.60 12.62) respectively (19 baseline sera studies from
15 countries). Baseline infection rates varied significantly by age. Similarly, the overall prevalence of postpandemic H1N1 antibodies is 16.48% (95% CI: 11.25 23.51) (random effects model) and 16.39% (95% CI:
16.01 16.78) (fixed effects model) pooled from 23 single sera studies from 17 countries. We also calculated
estimates for incidence rate of H1N1pdm infection using the difference between post- and pre-pandemic H1N1
seroprevalence for the four paired sera and 12 unpaired sera studies from 14 countries. These estimates varied
significantly by age.
Discussion: This systematic review is the first to estimate age-specific global infection rates of the H1N1pdm
based on a meta-analysis of serological evidence. Despite limitations of serological evidence and geographic
representativeness, the study offers an insight of the impact of the 2009 influenza pandemic in its first year.

10

Nusrat Homaira, MBBS, MPH

Assistant Scientist, ICDDR,B, Bangladesh
Incidence of influenza-associated mortality in Bangladesh: 2009. Homaira N, Luby SP, Alamgir ASM, Paul
R, Rahman M, Azim T, Podder G, Islam K, Sohel BM, Brooks A, Fry AM, Bresee J, Rahman M, AzzizBaumgartner E.
Background: Although data on incidence of influenza deaths could help policy makers allocate scarce resource,
limited information is available from Bangladesh. We leveraged influenza surveillance data and a community
survey to estimate the incidence of influenza-associated mortality in Bangladesh.
Method: During 2009, we conducted influenza surveillance in four hospitals. Two days per month, surveillance
physicians collected respiratory samples from hospitalized severe pneumonia (aged< 5 years) and from all
hospitalized severe acute respiratory infection (aged>=5 years) case-patients who resided in the hospitals
catchment areas. We tested respiratory specimens for influenza viruses using polymerase chain reaction assays.
We identified twenty randomly selected unions (smallest administrative unit) from the hospitals catchment
areas and canvassed these to identify persons who died during 2009. To estimate the incidence of influenzaassociated deaths, we multiplied the number of descendents in the catchment areas who had sudden onset of
fever and cough or sore throat within 14 days of death by the proportion of sampled case-patients who were
positive for influenza at the sentinel hospitals and then divided this numerator by the census population of the
survey sites. As the 2009 pandemic influenza was first identified in Bangladesh in June 2009, for estimating the
incidence associated with the 2009 H1N1 pandemic influenza, we used only the identified deaths that occurred
during July-December 2009 and used the proportion of the all the respiratory samples collected from the sentinel
sites during the same period that tested positive for A (H1N1) 2009 influenza infection.
Results: Of 2500 deaths identified, 346 deaths (14%) had fever and cough and/or sore throat within 14 days of
death. In 2009, the annual incidence of influenza-associated death per 100,000 persons-years was 1.5 among
those aged <5 years, 6 among those aged 560 years, and 110 among those aged >60 years. The incidence of A
(H1N1) 2009 pandemic influenza-associated death/100,000 persons-years was 0.3 for children aged < 5 years, 3
for people aged 560 years and 0 for population aged > 60 years. The overall incidence of A (H1N1) 2009
pandemic influenza-associated death across all age group was 4/100,000 person-years. We estimate 2009
pandemic influenza killed approximately 6000 people in Bangladesh.
Conclusion: Our data suggests the highest burden of influenza mortality in Bangladesh is among the elderly.
Developing cost-effective scalable interventions may help lower influenza disease burden.
The abstract was presented at the Options for the control of influenza VII conference held in Hong Kong
between 3-7 September 2010

11

Rajesh Chudasama, MD
Associate Professor, Community Medicine Department, M.P. Shah Medical
College, India
Clinico-epidemiological features of the hospitalized patients with 2009 pandemic influenza A (H1N1)
virus infection in Saurashtra region, India (September, 2009 to February, 2010). Chudasama RK, Patel
UV, Verma PB, Amin CD, Savaria D, Ninama R, Fichadiya N.
Background: The first case of 2009 pandemic influenza A (H1N1) virus infection in India was reported in May
2009, and in the Saurashtra region in August 2009. Here, we describe the clinico-epidemiological
characteristics of patients who were hospitalized with 2009 influenza A (H1N1) infection in the Saurashtra
region.
Materials and Methods: From September 2009 to February 2010 we observed 274 persons infected with 2009
influenza A (H1N1) virus who were admitted in different hospitals in Rajkot city. Real-time reversetranscriptase polymerase chain reaction (RT-PCR) testing was used to confirm infection; the clinicoepidemiological features of the disease were closely monitored.
Results: Of 274 patients, median age was 29.5 years, and 51.5% were males. Only 1.1% patients had recent
travel history to infected regions. Median time of five days was observed from onset of illness to influenza A
(H1N1) diagnosis, while the median time of six days was reported for hospital stay. All admitted patients
received oseltamivir drug, but only 16.1% received it within two days of onset of illness. One-fourth of
admitted patients expired. The most common symptoms were cough (96.7%), fever (92%), sore throat, and
shortness of breath, and coexisting conditions included diabetes mellitus (9.9%), hypertension (8.8%), chronic
pulmonary diseases (5.5%), and pregnancy (5.5%) (P<0.05). Pneumonia was reported in 93% patients with
chest radiography.
Conclusion: We have demonstrated that infection-related illness affects both children and adults with a patient
survival rate of 74%. The median time of onset from illness to virus detection with the use of real-time RT-PCR
was five days. Pregnancy was found as a significant (P<0.05) risk factor for severe disease.
Web references:
http://www.lungindia.com/article.asp?issn=09702113;year=2011;volume=28;issue=1;spage=11;epage=16;aulast=Chudasama
http://www.lungindia.com/text.asp?2011/28/1/11/76294

12

Mark Steinhoff, MD
Professor, Cincinnati Childrens Hospital, USA
Influenza immunization in pregnancy and newborn outcomes. Steinhoff MD, Omer SB, Roy E, Arifeen SE,
Raqib R, Dodd C, Breiman RF, Zaman K.
Background: We analyzed data from a randomized controlled trial of antenatal influenza immunization to assess
the effect on the fetus.
Methods: The Mothers Gift project was a blinded, randomized trial of 340 pregnant urban Bangladeshi women
who were randomized in the third trimester to receive either inactivated influenza vaccine or pneumococcal
vaccine (control group). Gestational age, proportions of small for gestational age (SGA) infants, and mean birth
weights were compared in 327 neonates.
Results: Influenza virus had limited circulation from August 2004 through January 2005. In this interval, the
study groups were similar in the incidence of respiratory illness with fever (RIF) (RR=0.99 p=0.99); and during
this interval, % SGA infants and mean birth weights were similar in both study groups. In contrast, during the
interval of influenza virus circulation from February-June 2005, there was a 49% reduction of RIF episodes in
the influenza vaccine group (RR=0.51 p=0.0003). During this interval, the proportion of SGA infants was
substantially lower in the influenza vaccine group to 29% versus 44% in controls (RR=0.66, p=0.03). Similarly,
the mean birth weight of infants was 3178g in the influenza vaccine group vs. 2978g in controls (+200g,
p=0.03).
Interpretation: During the interval of influenza virus circulation, influenza immunization of pregnant women
was associated with a lower risk of SGA infants and an increase in mean birth weights in this South Asian
setting. These unique randomized vaccine trial data need confirmation, but suggest that epidemic influenza
infections in late pregnancy may be a preventable cause of diminished intrauterine growth.

Trial Registration. ClinicalTrials.gov:

NCT 00142389

13

Abdullah Mamun, MBBS, MPH

Research Investigator, ICDDR,B, Dhaka, Bangladesh
Effectiveness of 2009 pandemic influenza A (H1N1) vaccine in Bangladesh, 2010: A program evaluation.
Mamun AA, Azziz-Baumgartner E, Alamgir ASM, Rahman M, Bhuyian MU, Homaira N, Nasreen S, Brooks
A, Mah-e-Muneer S, Cox C, Fry A, Widdowson M, Bresee J, et al.
Introduction: During 2010, WHO and other international partners donated 15.5 million doses of 2009 pandemic
influenza A (H1N1) (pH1N1) monovalent vaccine to Bangladesh in an effort to protect those at highest risk of
complications from influenza illness. While the Government of Bangladesh vaccinated the groups at high risk
for severe influenza, we took the opportunity to estimate the effectiveness of the vaccine (VE) among healthcare
workers (HCW) and pregnant women.
Methods: Beginning in May 2010, we visited 12 geographically-diverse hospitals and the vaccination centers in
the three unions (i.e. an administrative unit of Bangladesh with about 10,000 persons) nearest to those hospitals
during the vaccination campaign to randomly enroll participants recorded as vaccinated. Healthcare workers
were vaccinated at the hospitals, and pregnant women were vaccinated at vaccination centers. We enrolled
unvaccinated individuals at a 1:1 ratio from the same hospitals and vaccination centers of the same unions.
Following enrollment, investigators telephoned and/or visited participants weekly and collected nasal and oropharyngeal swabs of persons reporting an episode of influenza-like illness (ILI, defined as new fever with cough
or sore throat) during July-October 2010. Specimens were tested with influenza real time reverse transcriptase
polymerase chain reaction assays. Vaccine effectiveness was calculated controlling for age and sex by
multivariate analysis.
Results: We enrolled 590 vaccinated HCWs, 1056 vaccinated pregnant women, and the same number of
controls/group. A total of 58 (3%) vaccinated and 65 (3%) unvaccinated participants were lost to follow-up.
Between enrollment and start of follow-up, a total of 11 (1%) vaccinated and 9 (0.5%) unvaccinated participants
had fever with seizure. One hundred thirty two (8%) vaccinated and 179 (11%) unvaccinated participants had
ILI before follow up (p= 0.01) and were excluded from the analysis, except those who tested positive for
influenza during follow-up. The median age of the pH1N1-infected vaccinated and unvaccinated HCWs was
28.5 and 45 years (p= 0.05), respectively. Four (40%) of 10 vaccinated HCWs who tested positive for influenza
had influenza A (H3N2), 2 (20%) had pH1N1, and 4 (40%) had influenza B. Two (25%) of 8 unvaccinated
HCWs who tested positive for influenza had influenza A (H3N2), 5 (63%) had pH1N1, and 1 (12%) had
influenza B. Of seven HCWs who were infected with pH1N1, 2 (28%) were vaccinated compared to 5 (72%)
who were unvaccinated (VE=62%, p=0.25; adjusted for age and sex). Of 11 pregnant women who were
infected with pH1N1, 5 (45%) were vaccinated compared to 6 (55%) unvaccinated (VE=17%, p=0.75).
Conclusion: Although the vaccine may have been effective against pH1N1, low circulation of pH1N1
hampered our ability to differentiate the proportion of pH1N1 infections among vaccine recipients and those
unvaccinated.
Citation of previous presentation/publication: Abdullah Al Mamun, E. Aziz-Baumgartner, ASM Alamgir, et.
al. (2011). Effectiveness of 2009 pandemic influenza A (H1N1) vaccine in Bangladesh, 2010; a Program
Evaluation. Accepted for poster presentation XIII International Symposium on Respiratory Viral Infections, 13
16 March 2011, Rome, Italy.

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Mejbah U Bhuiyan, MPH

Research Investigator, International Centre for Diarrheal Disease Research,
Bangladesh
Costs associated with hospitalizations with respiratory viral infections in Bangladesh. Bhuiyan MU, Luby
SP, Alamgir NI, Homaira N, Mamun AA, Gurley E, Zaman RU, Widdowson M, Azziz-Baumgartner E.
Background: The incidence of influenza-associated severe pneumonia among children aged < 5 years was
significant at 2.2/1000 person-years and severe acute respiratory infections among persons aged 5 years was
1.3/10,000 person-years during the 2010 season. We estimated the costs for treatment of patients hospitalized
for viral respiratory illnesses in four tertiary level teaching hospitals in Bangladesh.
Methods: Each month during May to October 2010, we listed all patients identified through national influenza
surveillance in four hospitals, who were hospitalized with respiratory illnesses and tested positive by real time
reverse transcriptase polymerase chain reaction method for any of the following respiratory viruses: influenza,
respiratory syncytial virus, parainfluenza type 1, 2 & 3, rhinovirus, adenovirus or metapneumovirus. Within 30
days of discharge from the hospital, interviewers administered a structured questionnaire at the patients
residence and collected information about the total direct cost of treatment which included medical costs
(physician consultation fees, hospital bed, medicines and diagnostic tests) and non-medical costs (food and
travel).We used the prescription and discharge reports to estimate medical costs; patients helped us to
distinguish between out-of-pocket medical cost or hospital supported medical cost. We also asked patients the
strategies families used to meet the treatment costs (e.g. borrowing or savings).
Results: We enrolled 38 patients aged < 5 years and 34 patients 5 years. The median monthly household
income was US$ 123 (IQR: 85165). The median direct cost per episode was US$39 (IQR: 2459) among
patients aged <5 years and US$49 (IQR: 2871) among patients aged 5 years. On average, medical cost was
64% of the direct cost. The majority of medical cost was out-of-pocket because hospital supported 31% of the
median medical cost for patients aged <5 years and 3% of the median medical cost for patients aged 5 years.
One-third of families (22/72) spent >50% of their household monthly income for the treatment of an episode of
respiratory viral illness. Forty three (60%) of 72 families borrowed money to manage associated expenditures
and 19 (44%) of these 43 families borrowed with a mean monthly interest of 78% (range: 10% 180%).
Almost two-thirds (43/72) of families reported that they had to reduce their monthly food expense to manage the
expenditure of treatment.
Conclusion: Costs for hospitalizations with respiratory viral infections resulted in significant financial hardship
to interviewed families. Cost-effective respiratory infection prevention programs can reduce both clinical
morbidity and related cost of treatment.

Citation of previous presentation/publication: XIII International Symposium on Respiratory Viral Infections,

13-16 March, 2011, Rome, Italy.

15

Paul White, PhD

Spatial Epidemiologist, Food & Agriculture Organisation of the United Nations
Emergency Centre for Transboundary Animal Diseases India
The science and art of coordinated national response to pandemics: Lessons learned during the influenza
A (H1N1) 2009 outbreaks in New Zealand.
This talk discusses the use of epidemiological analysis to meet mainly media and high-level ministerial
information needs rather than operational decision support during the influenza A (H1N1) 2009 pandemic in
New Zealand. I was afforded a unique position to view the human health response to the 2009 pandemic having
worked in Public Health Intelligence (PHI) the then Epidemiology Unit of the NZ MoH and the Ministry of
Agriculture Biosecurity New Zealand (MAF BNZ). The observations were made during my time as member of
the epidemiological (Planning and Intelligence (P&I)) team of the New Zealand (NZ) Ministry of Health (MoH)
National Health Coordination Centre (NHCC).
New Zealand has a devolved public health infrastructure with a central MoH providing policy direction mainly
geared to chronic diseases. Operational public health, including outbreak investigation and management is
vested in the 12 regional Public Health Units.
The NHCC was operational 24 hours a day 7 days a week in the initial months of the pandemic response and
was run using a Coordinated Incident Management System (CIMS) approach with a number of functional areas
including epidemiology capacity in Planning and Intelligence. With PHI having been disestablished the year
before as a result of health reforms, available epidemiological expertise was limited. This scarcity of expertise
within the MoH meant that most epidemiological expertise during the outbreak was external and came from
MAF BNZ, a small pool of public health medicine specialist registrars, and one local university.
While CIMS had been practiced in recent national exercises it had never before been used in NZ to manage a
real outbreak and so senior response leadership had little operational experience to draw from. Furthermore,
most of the personnel in the P&I team were not from the MoH or had used CIMS. Thus there was little live
experience in assigning P&I tasks and managing information requests and information flows. The result was a
disproportionate analytical effort geared toward meeting the loudest voice. The high pressure demand for
regular (twice daily) updates of basic case count information to meet ministerial and media demands put a great
deal of pressure on limited epidemiological resources that were diverted away from other equally important
outbreak management analytical needs.
My conclusion from the response to this outbreak is that scarce epidemiological resources should be
appropriately deployed. Firstly, this requires that information needs, and importantly information customers,
are fully understood; secondly, separate teams should be deployed to meet media and operational information
needs; and finally, staff should be practiced in large-scale CIMS-type outbreak responses.

No criticism of the New Zealand Ministry of Health is implied or intended and the observations are entirely
mine.

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