Validity of clinical case definitions for influenza surveillance among hospitalized patients: results from a rural community in North India

Vivek Gupta, Fatimah S Dawood, Sanjay K Rai, Shobha Broor, Rajan Wigh, Akhilesh C Mishra, Kathryn Lafond, Joshua A Mott, Marc-Alain Widdowson, Renu B Lal, Anand Krishnan

Research output: Contribution to journalA1: Web of Science-articlepeer-review


OBJECTIVE: Clinical case definitions used for influenza surveillance among hospitalized patients vary and need systematic evaluation. DESIGN, SETTING AND SAMPLE: During July 2009-August 2011, we collected clinical data and specimens (nasal and throat swabs) from rural patients hospitalized for acute medical illnesses. Specimens were tested by rRT-PCR for influenza viruses.

MAIN OUTCOME MEASURES: Case definitions evaluated the following: influenza-like illness (ILI: measured fever plus cough or sore throat); severe acute respiratory illness (SARI: ILI with difficulty breathing in ≥5 years, Integrated Management of Childhood Illness-defined pneumonia or severe pneumonia, or physician diagnosed lower respiratory infection in <5 years); acute respiratory infection (ARI: ≥1 of cough, nasal discharge, difficulty breathing or sore throat); febrile acute respiratory illness (FARI: fever plus either cough, sore throat, runny nose, difficulty breathing, or earache). Variants that included "reported fever" and additional sign-symptom combinations were also evaluated.

RESULTS: We enrolled 1043 hospitalized patients, including 257 children <5 years of age (range 1 day-86 years). Seventy-four patients tested influenza virus positive (including 28 A(H1N1)pdm09). Sensitivity(95% CI) and specificity (95% CI) for influenza infection were 78% (67-87) and 60% (57-63) for ILI (measured/reported fever); 37% (26-49) and 78% (75-80) for SARI (measured/reported fever); 82% (72-90) and 57% (54-60) for FARI (measured/reported fever); 88% (78-94) and 45% (42-49) for ARI; and 74% (63-84) and 61% (58-64) for measured/reported fever plus cough. Case definitions including only measured fever had lower sensitivity.

CONCLUSION: ILI and FARI with measured/reported fever provided good balance between sensitivity and specificity among hospitalized patients. The simpler case definition of measured/reported fever plus cough is suited for field surveillance.

Original languageEnglish
JournalInfluenza and Other Respiratory Viruses
Issue number3
Pages (from-to)321-329
Number of pages9
Publication statusPublished - 2013


  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Child
  • Child, Preschool
  • Female
  • Hospitalization
  • Humans
  • India/epidemiology
  • Infant
  • Influenza, Human/epidemiology
  • Male
  • Middle Aged
  • Orthomyxoviridae/classification
  • Rural Population
  • Sentinel Surveillance
  • Young Adult


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