Diapositiva 1

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Diapositiva 1

Severe disease surveillance
Spanish experience with severe disease surveillance
ECDC/WHO Annual Influenza Meeting
Warsaw, Poland, 30 May – 1 June 2012
Concha Delgado Sanz
Amparo Larrauri Cámara
National Centre of Epidemiology
Institute of Health Carlos III, Madrid, Spain
Context
 New national surveillance strategy from pandemic 2009:
Surveillance of laboratory-confirmed severe influenza
hospitalised cases
Objectives:
 To detect severe influenza cases
 To describe clinical, epidemiological and virological
characteristics
 To identify patterns of disease by age and clinical risk group and
to quantify their level of risk
 To assess the impact on the healthcare system
Centro Nacional de Epidemiología
Surveillance of laboratory-confirmed severe influenza
hospitalised cases. Season 2011-12
 Severe influenza cases from 111
hospitals belonging to every Spanish
region according to an established
protocol
 Those with clinical features compatible
with influenza requiring hospitalization
for clinical severity and were
laboratory-confirmed
 Inpatients and intensive care units
 Demographic data (age and gender),
type and subtype influenza virus,
underlying conditions, clinical
complications, admission to an
intensive care unit (ICU), antiviral
treatment, influenza vaccination status
and outcome.
 Denominators: hospital catchment
area (20,206,617 population)
 Information uploaded weekly in a
Internet based application of the
Spanish Influenza Surveillance System
http://vgripe.isciii.es/gripe/inicio.do
Analysis
 Descriptive analysis (medians and interquartile range (IQR) and
percentages)
 Level of influenza severity:
 non critical care cases (hospitalized none admitted to ICU and no deadfatal)
 critical care case (admitted to ICU and no dead)
 fatal cases.
 Ordinal logistic regression to identify risk factors associated with
level of severity: crude and adjusted odds ratio (OR) and the
corresponding CI 95%
 Case fatality rate (CFR) by age group and severity level
 Comparison with 2010-11 season
Laboratory-confirmed severe influenza hospitalised
cases. Season 2011-2012, Spain
601 laboratory-confirmed influenza cases
384 (64%) Non critical care cases
170 (28%) Critical care cases
47 (8%) Fatal cases
Number of cases
90
250
80
200
70
60
150
50
40
100
30
20
50
10
0
0
40 42 44 46 48 50 52 2
4 6
Weeks
8 10 12 14 16 18 20
Non critical care cases
Critical care cases
Fatal cases
Influenza rates 2011-12
Influenza-like illness rates /100.00h
100
Age group distribution and underlying conditions in
influenza hospitalised cases, 2011-12, Spain
266 (44%) Female
334 (56%) Male
NUC (21%)
≥ 2 UC (45%)
26%
24%
1 UC (34%)
22%
19%
13%
13%
10%
8%
4%
CRD
CCVD
OTHERS
MD
PREGN
IMNUN
CRenalD
OBES
CLD
% Hospitalised cases
Influenza hospitalised cases by age group.
Season 2010-11 and 2011-12, Spain
45
40
35
30
25
20
15
10
5
0
<5
5-14
Season 2010-11
15-44
45-64
Season 2011-12
65 y +
Type/subtype distribution in sentinel ILI cases and
influenza hospitalised cases, 2011-12, Spain
Cases per 100,000
Weeks
Weeks
Rate
Low L.
Baseline T.
Nº positive specimens
 Hospitalised cases
Nº positive specimens
 Sentinel ILI cases
Upper L.
Type/subtypes influenza virus in sentinel ILI cases and
influenza severe hospitalised cases.
2010-11 and 2011-12 seasons, Spain
Type/subtive virus
ANS
A(H1N1)pdm09
A(H3)
B
C
Total
Type/subtive virus
ANS
A(H1N1)pdm09
A(H3)
B
C
Total
Season 2010-11
Sentinel specimens
n
%
IC95%
53
2.1
1.6 - 2.8
1523
61.7
59.8 - 63.6
35
1.4
1.0 -2.0
852
34.5
32.7 - 36.4
4
0.2
0.1 - 0.4
2467
100.0
Influenza hospitalised cases
n
%
IC95%
127
7.8
6.6 - 9.2
1,372
84.4
82.6 - 86.1
7
0.4
0.2 - 0.8
115
7.1
5.9 - 8.4
4
0.3
0.1 - 0.6
1625
100.0
Season 2011-12
Sentinel specimens
n
%
IC95%
139
4.8
4.0 - 5.6
3
0.1
0.0 -0.3
2498
85.6
84.3 - 86.8
274
9.4
8.4 - 10.5
4
0.1
0.0 -0.4
2918
100.0
Influenza hospitalised cases
n
%
IC95%
135
22.5
19.3 - 26.0
3
0.5
0.2 - 1.5
433
72.0
68.3 - 75.5
30
5.0
3.5 - 7.0
0
0.0
0.0 - 0.6
601
100
Factors associated with severity level in influenza
hospitalized cases. Season 2011-12, Spain
Season 2011-12
(n = 384)
n (%)
Critical care
cases
(n = 170)
n (%)
203 (53.0)
Non critical cases
Fatal cases
(n = 47)
n (%)
OR (CI 95%)
101 (59.8)
29 (61.7)
1.34 (0.96 – 1.87)
49 (2-77)
50 (3-70)
73 (55-81)
< 45 year (Ref.)
181 (47.5)
66 (38.8)
5 (10.7)
45-64 year
55 (14.4)
34 (20.0)
12 (25.5)
2.28 (1.43 – 3.65)
Chracteristics
Sex
Male (Ref.:Female)
Age median (IQR )
> 64 year
Type/subtype influenza virus
B
A(H3N2)
Antiviral treatment (48 h. after
symptoms onset)
146(38.1)
70 (41.2)
30 (63.8)
1.93 (1.34 – 2.80)
19 (6.3)
283 (93.7)
8 (6.6)
144 (93.4)
2 (5.4)
35 (94.6)
1.02 (0.47 – 2.21)
123 (76.8)
64 (73.6)
19 (86.4)
1.25 (0.89 -1.75)
2011-12 seasonal trivalent influenza
vaccine (Recommended groups)
38 (36.2)
21 (35.6)
8 (44.4)
0.89 (0.56 – 1.42)
Factors associated with severity level in influenza
hospitalized cases. Season 2011-12, Spain
Non critical
cases
Critical care
cases
Fatal cases
(n = 384)
n (%)
(n = 170)
n (%)
(n = 47)
n (%)
OR (CI 95%)
Underlying conditions 1
202 (77.0)
86 (78.9)
31 (93.9)
1.49 (0.90 – 2.49)
Chronic respiratory disease
49 (18.3)
41 (40.6)
11 (42.3)
2.97 (1.88 – 4.68)
Diabetes
65 (18.2)
30 (22.7)
5 (13.2)
1.10 (0.70 – 1.73)
Chronic renal disease
38 (10.6)
11 (8.3)
2(5.4)
0.69 (0.36 – 1.32)
Chronic cardiovascular disease
86 (24.2)
27 (20.3)
12 (31.6)
0.98 (0.64– 1.50)
Chronic liver disease
10(2.8)
6 (4.6)
4(10.5)
2.43 (1.01 - 5.81)
Immunodeficiency
50 14.1)
6 (4.6)
10 (25.6)
0.74 (0.41 – 1.35)
Morbid obesity (BMI ≥ 40)
19 (5.5)
20 (15.3)
2 (5.3)
2.10 (1.16 – 3.80)
Pregnancy
3 (13.6)
1 (11.1)
0 (0)
0.79 (0.71 – 8.8)
Pneumonia
251 (66.6)
83 (50.6)
30 (66.7)
0.64 (0.49– 0.90)
Co-infections
74 (26.8)
23 (23.7)
18 (58.1)
1.48 (0.94 – 2.33)
Acute respiratory distress syndrome
47 (13.7)
45 (28.7)
24 (54.6)
3.67 (2.44 -5.52)
3 (0.9)
19 (12.2)
21 (48.8)
22.23 (11.32 – 43.68)
Season 2011-12
Complications
Multiorgan failure
1
Underlying conditions (excluded pregnancy)
Multivariate analysis of factors associated with severity
level outcome in hospitalized severe laboratory-confirmed
influenza cases. Season 2011-12, Spain
Season 2011-12
Characteristics
Sex (Ref.: female)
Crude OR (CI 95%) Adjusted OR (CI 95%)1
1.34 (0.96 – 1.87)
1.02 (0.65 - 1.59)
45-64 years
2.28 (1.43 – 3.65)
1.93 (0.98 – 3.78)
> 64 years
1.93 (1.34 – 2.80)
2.17 (1.31 - 3.60)
Chronic respiratory disease
2.97 (1.88 – 4.68)
2.63 (1.59 – 4.33)
Chronic liver disease
2.43 (1.01 - 5.81)
1.11 (0.34 - 3.59)
Morbid obesity (BMI ≥ 40)
2.10 (1.16 – 3.80)
1.31 (0.58 – 2.98)
Age (Ref.: < 44 years)
Adjusted for sex, age, chronic respiratory disease, chronic liver disease, morbid obesity (BMI ≥ 40)
Ref.: Reference group
1
Influenza fatal cases by aged group
Season 2009-10 / 2011-12, Spain.
% Influenza fatal cases
75
60
45
30
15
0
<5
5-14
Season 2009-10
15-44
Season 2010-11
45-64
65 y +
Season 2011-12
Case fatality rates by age group and severity level.
Season 2011-12, Spain
25
20
15
%
10
5
0
<15
15-44
Age group
Non critical care cases
45-64
Critical care cases
65 y +
Case fatality rates by age group.
Seasons 2010-11 and 2011-12, Spain
20
15
%
10
5
0
<1
1-4
5-14
15-44
45-64
Age group
CFRs 2010-11
CFRs 2011-12
65 y +
CFR 2010-11: 12.3 (10.8 – 14.0)
CFR 2011-12: 7.8 (5.9 -10.2)
Findings
 The youngest and eldest age groups are the most severe affected
age groups during the 2011-12 season
 AH3 has been the dominant virus in mild and severe cases. The
proportion of B cases has been lower in hospitalised than in milder
influenza cases
 Higher severity level was associated with adults aged more than 64
years and chronic respiratory disease
 There has been a progressively increase in the age of influenza
deaths, from 2009-10 season t o 2011-12.
 CFR increase with age group in non critical and critical cases
 Lower CFR than in the 2010-11 (A(H1N1)pdm09 season)
 There were no unusual pressures on primary and secondary health
care services in Spain.
Perspectives
Influenza season 2012-13
 To continue with the Surveillance of severe hospitalized
confirmed influenza cases in Spain
 Annually approved by the Public Health Commission of
the Inter-Regional Health Council
On behalf of the
Spanish Influenza Sentinel Surveillance System



Médicos centinela de las redes: Andalucía, Aragón, Asturias, Baleares, Canarias, Cantabria, Castilla la
Mancha, Castilla y León, Cataluña, Comunidad Valenciana, Extremadura, Madrid, Navarra, País Vasco, La
Rioja, Ceuta y Melilla.
Epidemiólogos del SVGE: Servicio de Vigilancia Epidemiológica y Evaluación, Consejería de Salud, Junta
de Andalucía; Servicio de Vigilancia en Salud Pública, Dirección General de Salud Pública, Aragón;
Dirección General de Salud Pública y Planificación, Conserjería de Salud y Servicios Sanitarios, Asturias;
Servicio de Epidemiología, Dirección General de Salut Pública, Baleares; Servicio de Epidemiología y
Prevención, Consejería de Sanidad de Canarias; Sección de Epidemiología, Consejería de Sanidad,
Trabajo y Servicios Sociales de Cantabria; Servicio de Epidemiología, Consejería de Sanidad de Castilla
la Mancha; Dirección General de Salud Pública e Investigación, Desarrollo e Innovación, Consejería de
Sanidad de Castilla y León; Servicio de Vigilancia Epidemiológica, DGSP, Departament de Salut,
Generalitat Catalunya ; Àrea d'Epidemiologia, Conselleria de Sanitat, Comunitat Valenciana; Servicio de
Epidemiología, Consejería de Bienestar Social, Junta de Extremadura; Dirección Xeral Saúde Pública de
Galicia; Dirección General de Atención Primaria de la Comunidad de Madrid; Servicio de Epidemiología.
Consejería de Sanidad de la Región de Murcia; Sección de Vigilancia de Enfermedades Transmisibles,
Instituto de Salud Pública de Navarra; Servicio de Vigilancia Epidemiológica, Consejería de Sanidad del
País Vasco; Servicio de Epidemiología, Subdirección de Salud Pública de La Rioja; Sección de Vigilancia
Epidemiológica, Consejería de Sanidad y Bienestar Social de Ceuta; Dirección General de Sanidad y
Consumo de Melilla; Centro Nacional de Epidemiología.
Virólogos del SVGE: Centro Nacional de Referencia de Gripe (Centro Nacional de Gripe de la OMS del
Centro Nacional de Microbiología (CNM), ISCIII, Majadahonda, Madrid); Hospital Virgen de las Nieves de
Granada, Andalucía; Laboratorio del Hospital Miguel Servet de Zaragoza, Aragón; Laboratorio del
Hospital Nª Srª de Covadonga de Oviedo, Asturias; Laboratorio del Hospital Son Dureta de Palma de
Mallorca, Baleares; Laboratorio del Hospital Dr. Negrín de Las Palmas de Gran Canaria, Canarias;
Laboratorio del Hospital Universitario Marqués de Valdecilla de Santander; Centro Nacional de Gripe de la
Facultad de Medicina de Valladolid; Instituto Valenciano de Microbiología, Valencia, Comunitat
Valenciana; Centro Nacional de Gripe del Hospital Clínico de Barcelona; Hospital San Pedro de Alcántara
de Cáceres, Extremadura; Servicio de Microbiología del Hospital Universitario Ramón y Cajal; Madrid,
Comunidad de Madrid; Laboratorio de la Clínica Universitaria de Navarra, Pamplona, Navarra;
Laboratorio de Microbiología. Hospital Donostia, País Vasco; Hospital San Pedro de la Rioja de Logroño,
La Rioja; Laboratorio de Microbiología del Hospital de INGESA de Ceuta; Laboratorios de Microbioloxía
CH de Vigo y de Ourense (Galicia) y Hospital Virgen de la Arrixaca de Murcia.




Concha Delgado
Silvia Jiménez-Jorge
Salvador de Mateo
Amparo Larrauri Cámara
Thank you!

Diapositiva 1

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