Severely impaired health status of non-notified Q fever patients leads to an underestimation of the true burden of disease.

Q fever patients are often reported to experience a long-term impaired health status, including fatigue, which can persist for many years. During the large Q fever epidemic in The Netherlands, many patients with a laboratory-confirmed Coxiella burnetii infection were not notified as acute Q fever because they did not fulfil the clinical criteria of the acute Q fever case definition (fever, pneumonia and/or hepatitis). Our study assessed and compared the long-term health status of notified and non-notified Q fever patients at 4 years after onset of illness, using the Nijmegen Clinical Screening Instrument (NCSI). The study included 448 notified and 193 non-notified Q fever patients. The most severely affected subdomain in both patient groups was 'Fatigue' (50·5% of the notified and 54·6% of the non-notified patients had severe fatigue). Long-term health status did not differ significantly between the notified and non-notified patient groups, and patients scored worse on all subdomains compared to a healthy reference group. Our findings suggest that the magnitude of the 2007-2009 Q fever outbreak in The Netherlands was underestimated when only notified patients according to the European Union case definition are considered.

A cross-sectional study to assess the long-term health status of patients with lower respiratory tract infections, including Q fever.

Patients with a lower respiratory tract infection (LRTI) might be at risk for long-term impaired health status. We assessed whether LRTI patients without Q fever are equally at risk for developing long-term symptoms compared to LRTI patients with Q fever. The study was a cross-sectional cohort design. Long-term health status information of 50 Q fever-positive and 32 Q fever-negative LRTI patients was obtained. Health status was measured by the Nijmegen Clinical Screening Instrument. The most severely affected subdomains of the Q fever-positive group were 'general quality of life' (40%) and 'fatigue' (40%). The most severely affected subdomains of the Q fever-negative group were 'fatigue' (64%) and 'subjective pulmonary symptoms' (35%). Health status did not differ significantly between Q fever-positive LRTI patients and Q fever-negative LRTI patients for all subdomains, except for 'subjective pulmonary symptoms' (P = 0·048).

Afriflu--international conference on influenza disease burden in Africa, 1-2 June 2010, Marrakech, Morocco.

The burden of influenza disease is to a large extent unknown for the African continent. Moreover, the interaction of influenza with common infectious diseases in Africa remains poorly described. Solid scientific evidence on the influenza disease burden in Africa is critical for the development of effective influenza vaccine policies. On 1st and 2nd June 2010 in Marrakech, Morocco, over eighty surveillance and influenza experts from 22 African countries as well as Europe and America met at the 'Afriflu' conference to discuss influenza challenges and solutions for the continent. During the meeting, participants exchanged their experiences and discussed a wide variety of topics related to influenza in Africa, including diagnosis, surveillance, epidemiology, and interventions. The meeting concluded with a pledge to improve influenza knowledge and awareness in Africa, with an emphasis on accurate determination of disease burden to help orient public health policies.

Oseltamivir-resistant influenza A(H1N1) viruses detected in Europe during season 2007-8 had epidemiologic and clinical characteristics similar to co-circulating susceptible A(H1N1) viruses.

During the 2007-08 influenza season, high levels of oseltamivir resistance were detected among influenza A(H1N1) viruses ina number of European countries. We used surveillance data to describe influenza A(H1N1) cases for whom antiviral resistance testing was performed. We pooled data from national studies to identify possible risk factors for infection with a resistant virus and to ascertain whether such infections led to influenza illness of different severity. Information on demographic and clinical variables was obtained from patients or their physicians. Odds ratios for infection with an oseltamivir resistant virus and relative risks for developing certain clinical outcomes were computed and adjusted through multivariable analysis. Overall, 727 (24.3%) of 2,992 tested influenza A(H1N1) viruses from 22 of 30 European countries were oseltamivir-resistant. Levels of resistance ranged from 1% in Italy to 67% in Norway. Five countries provided detailed case-based data on 373 oseltamivir resistant and 796 susceptible cases. By multivariable analysis, none of the analysed factors was significantly associated with an increased risk of infection with anoseltamivir-resistant virus. Similarly, infection with an oseltamivir-resistant virus was not significantly associated with a different risk of pneumonia, hospitalisation or any clinical complication. The large-scale emergence of oseltamivir-resistant viruses in Europe calls for a review of guidelines for influenza treatment.

Progress in the surveillance of respiratory syncytial virus (RSV) in Europe: 2001-2008.

Respiratory syncytial virus (RSV) surveillance is important to get insight into the burden of disease and epidemic pattern of RSV infection. This information is useful for healthcare resource allocation as well as the timing of preventive messages and palivizumab prophylaxis. For influenza surveillance the European Influenza Surveillance Scheme (EISS) was established in 1996, but no surveillance platform is available for RSV. To improve surveillance an RSV Task Group was established in 2003 and recommendations for RSV surveillance were developed. By 2008, progress was made for four out of six recommendations: the number of European countries testing specimens for RSV increased from six to fourteen; nose and/or throat swabs were generally used for detection of influenza and RSV; a total of 25 laboratories performed molecular testing for diagnosis and participated in a quality control assessment for RSV with an overall good performance; four of the ten countries that joined EISS in 2004 started reporting RSV detections in addition to influenza in the period 2004-8. Limited progress was achieved for standardising methods and the development of a sentinel surveillance system of representative hospitals. Improving RSV surveillance is possible by further harmonising the data collection and increased reporting of RSV.

The impact of laboratory characteristics on molecular detection of respiratory syncytial virus in a European multicentre quality control study.

The performance of nucleic acid amplification techniques for detecting respiratory syncytial virus (RSV) was evaluated in 25 laboratories across Europe by an external quality assessment study. In addition, factors related to the diagnostic performance of laboratories were explored. The results of this quality control study show that the performance of laboratories for RSV diagnosis in Europe is good, with an overall correct score of 88%. The type of assay (nested or real-time PCR vs. commercial tests) was identified as a significant factor (OR 8.39; 95% CI 1.91-36.78) in predicting a correct result.

Epidemiological and virological assessment of influenza activity in Europe, during the 2006-2007 winter.

Influenza surveillance in Europe is based on influenza surveillance networks that cooperate and share information through the European Influenza Surveillance Scheme (EISS). EISS collected clinical and virological data on influenza in 33 countries during the 2006-2007 winter. Influenza activity started around 1 January and first occurred in Greece, Scotland and Spain. It then moved gradually across Europe from south to north and lasted until the end of March. In 29 out of 33 countries, the consultation rates for influenza-like-illness or acute respiratory infections in the winter of 2006-2007 were similar or somewhat higher than in the 2005-2006 winter. The highest consultation rates for influenzal ike-illness were generally observed among children aged 0-4 years and 5-14 years. The predominant virus strain was influenza A (97% of total detections) of the H3 subtype (93% of H-subtyped A viruses; 7% were A(H1)). The influenza A(H3) and A(H1) viruses were similar to the vaccine reference strains for the 2006-2007 season, A/Wisconsin/67/2005 (H3N2) and A/New Caledonia/20/99 (H1N1) respectively. The majority of the influenza B viruses were similar to the reference strain B/Malaysia/2506/2004, included in the 2006-2007 vaccine. In conclusion, the 2006-2007 influenza season in Europe was characterised by moderate clinical activity, a south to north spread pattern across Europe, and a dominance of influenza A(H3). Overall there was a good match between the vaccine virus strains and the reported virus strains.

An approach to monitoring influenza vaccination uptake across Europe.

Currently, the monitoring of influenza vaccination uptake is mainly a national issue. As influenza infection easily crosses international borders, it is in the interest of all countries to have a high vaccine uptake in people who may be vulnerable when influenza spreads. A Europe-wide monitoring system can provide insight into the strengths and weaknesses of uptake rates in countries and, on ce sufficient levels are achieved, can safeguard the continuation of the achieved levels. This paper aims to address the following issues: a) How is influenza vaccination uptake monitored in Europe? b) What methods to monitor vaccination uptake are available and what are their limitations? c) What steps should be taken to implement a European-wide influenza vaccination uptake monitoring system? Based on existing literature and experiences in monitoring influenza vaccination uptake, an approach to set up a European-wide monitoring system is proposed. The following issues were identified as relevant for influenza vaccination uptake monitoring: a) Agreement on the population groups in which vaccination uptake should be monitored; b) The frequency of data collection; c) The importance of sharing experiences regarding existing influenza vaccination campaigns in order to learn from each other, and develop 'best practices'; d) The need to publish uptake data in close relation with influenza surveillance data and other European efforts on dissemination of vaccination knowledge. To stimulate the discussion on implementing a pan-European influenza uptake monitoring scheme the following recommendations were suggested : a) Develop a common set of variables; b) Build on experience from individual countries; c) Create a coordinating body; d) Create or identify a platform to publish the data; e) Start small and expand rapidly.

Epidemiological and virological assessment of influenza activity in Europe during the winter 2005-2006.

Influenza activity in Europe during the winter 2005-2006 started late January - early February 2006 and first occurred in the Netherlands, France, Greece and England. Subsequently, countries were affected in a random pattern across Europe and the period of influenza activity lasted till the end of April. In contrast to the winter seasons in the period 2001-2005, no west-east pattern was detected. In 12 out of 23 countries, the consultation rates for influenza-like illness or acute respiratory infection in the winter 2005-2006 were similar or higher than in the winter 2004-2005, despite a dominance of influenza B viruses that normally cause milder disease than influenza A viruses. In the remaining 11 countries the consultation rates were lower to much lower than in the winter 2004-2005. The highest consultation rates were usually observed among children aged 0-14. The circulating influenza virus types and subtypes were distributed heterogeneously across Europe. Although the figures for total virus detections in Europe indicated a predominance of influenza B virus (58% of all virus detections), in many countries influenza B virus was predominant only early in the winter, whilst later there was a marked increase in influenza A virus detections. Among the countries where influenza A viruses were co-dominant with B viruses (9/29) or were predominant (4/29), the dominant influenza A subtype was H3 in seven countries and H1 in four countries. The vast majority of characterised influenza B viruses (90%) were similar to the B/Victoria/2/87 lineage of influenza B viruses that re-emerged in Europe in the winter 2004-2005 but were not included in the vaccine for the influenza season 2005-2006. This might help to explain the dominance of influenza B viruses in many countries in Europe during the winter 2005-2006. The influenza A(H3) and A(H1) viruses were similar to the reference strains included in the 2005-2006 vaccine, A/California/7/2004 (H3N2) and A/New Caledonia/20/99 (H1N1), respectively. In conclusion, the 2005-2006 influenza epidemic in Europe was characterised by moderate clinical activity, a heterogeneous spread pattern across Europe, and a variable virus dominance by country, although an overall dominance of influenza B viruses that did not match the virus strain included in the vaccine was observed.

Epidemiological and virological assessment of influenza activity in Europe, during the 2004-2005 winter.

The 2004-2005 influenza season in Europe started in late December 2004 and the first influenza activity occurred in the west and southwest (Spain, United Kingdom and Ireland). Influenza activity then moved gradually east across Europe during January and early February 2005, and from late February until late March, most movement was south to north. The intensity of clinical influenza activity in ten out of 23 countries was higher than during the 2003-2004 season, and lower or equal to the 2003-2004 season in the other 13 countries. The highest consultation rates were generally observed among children aged 0-14 years. However, the peak consultation rates due to influenza-like illness or acute respiratory infection were not especially high when compared with historical data. The predominant virus strain was influenza A (83% of total detections) of the H3 subtype (85% of H-subtyped A viruses), with fewer influenza B (17% of total detections) or A(H1) viruses (15 % of H-subtyped A viruses) detected. The vast majority of A(H3) viruses were similar to the reference strains A/Wellington/1/2004 (H3N2) and, subsequently, A/California/7/2004 (H3N2) that are closely related drift variants of the A/Fujian/411/2002 (H3N2) prototype vaccine strain. The B viruses co-circulated with A viruses during the whole influenza season in 11 out of 24 countries. Seven of these were located in the northeast of Europe and in these countries the proportion of B viruses was higher (range: 31-60%) than in the rest of Europe (range: 6-26%). In 13 out of 24 countries the B viruses circulated relatively late in the season. About 43% of all antigenically characterised B viruses were B/Hong Kong/330/2001-like (B/Victoria/2/87 lineage), a strain that is distinguishable from the vaccine influenza B strain, which was a B/Yamagata/16/88 lineage virus. Based on the viruses detected worldwide until February 2005, the World Health Organization modified the composition of the 2005-2006 influenza vaccine from the 2004-2005 season vaccine to include a new A(H3N2) component: an A/California/7/2004 (H3N2)-like virus.

Epidemiological and virological assessment of influenza activity in Europe, during the 2004-2005 winter.

The 2004-2005 influenza season in Europe started in late December 2004 and the first influenza activity occurred in the west and southwest (Spain, United Kingdom and Ireland). Influenza activity then moved gradually east across Europe during January and early February 2005, and from late February until late March, most movement was south to north. The intensity of clinical influenza activity in ten out of 23 countries was higher than during the 2003-2004 season, and lower or equal to the 2003-2004 season in the other 13 countries. The highest consultation rates were generally observed among children aged 0-14 years. However, the peak consultation rates due to influenza-like illness or acute respiratory infection were not especially high when compared with historical data. The predominant virus strain was influenza A (83% of total detections) of the H3 subtype (85% of H-subtyped A viruses), with fewer influenza B (17% of total detections) or A(H1) viruses (15 % of H-subtyped A viruses) detected. The vast majority of A(H3) viruses were similar to the reference strains A/Wellington/1/2004 (H3N2) and, subsequently, A/California/7/2004 (H3N2) that are closely related drift variants of the A/Fujian/411/2002 (H3N2) prototype vaccine strain. The B viruses co-circulated with A viruses during the whole influenza season in 11 out of 24 countries. Seven of these were located in the northeast of Europe and in these countries the proportion of B viruses was higher (range: 31-60%) than in the rest of Europe (range: 6-26%). In 13 out of 24 countries the B viruses circulated relatively late in the season. About 43% of all antigenically characterised B viruses were B/Hong Kong/330/2001-like (B/Victoria/2/87 lineage), a strain that is distinguishable from the vaccine influenza B strain, which was a B/Yamagata/16/88 lineage virus. Based on the viruses detected worldwide until February 2005, the World Health Organization modified the composition of the 2005-2006 influenza vaccine from the 2004-2005 season vaccine to include a new A(H3N2) component: an A/California/7/2004 (H3N2)-like virus.

Epidemiological and virological assessment of influenza activity in Europe during the 2003-2004 season.

The 2003-2004 influenza season in Europe was dominated by the spread of the new drift variant A/Fujian/411/2002 (H3N2)-like virus which was not perfectly matched with the A(H3N2) component of the influenza vaccine. Sporadic cases of this virus were detected in Europe at the end of the 2002-2003 season and influenza activity associated with this virus began relatively early during the 2003-2004 season. Generally, influenza activity first occurred in the west of Europe (Ireland, the United Kingdom and the Iberian Peninsula) in October/November and gradually moved east across Europe, affecting Latvia, Lithuania and Poland during the months of January and February 2004. In general, the intensity of clinical activity was higher than during the 2002-2003 season (in 13 out of 20 networks) and, in countries reporting age specific data, the highest consultation incidences were observed among children aged 0-14. However, despite the emergence of the A(H3N2) drift variant, clinical incidences were not especially high compared with historical data. The composition of the 2004-2005 influenza vaccine has been modified compared with the 2003-2004 season and includes an A/Fujian/411/2002 (H3N2)-like virus strain and a new B virus strain (a B/Shanghai/361/2002-like virus).

Harmonisation of the acute respiratory infection reporting system in the Czech Republic with the European community networks.

Respiratory virus activity is detected in Europe each winter, yet the precise timing and size of this activity is highly unpredictable. The impact of influenza infection and/or acute respiratory infection in European countries is continuously monitored through a variety of surveillance systems. All of these sources of information are used to assess the nature and extent of activity of influenza and other respiratory viruses, and to offer guidance on the prevention and control of morbidity and mortality due to influenza at a local, national and international level. The early warning system for a forthcoming influenza epidemic is mainly based on the use of a set of thresholds. In the Czech Republic, the acute respiratory infection (ARI) reporting system, with automated data processing, uses a statistical model for the early detection of unusual increased rates of the monitored indicators. The collected data consists of the number of ARI, the number of complications due to ARI and the population registered with the reporting general practitioners and paediatricians, all collected separately in five age groups. To improve the reporting system in the Czech Republic, clinical data on the weekly incidence of influenza-like illness (ILI) within the same population and the same age groups was started in January 2004. These data fit the European Commission's recently adopted ILI case definition and allows a better comparison of data with other countries in Europe, in particular those participating in EISS (European Influenza Surveillance Scheme).