Article

Does This Patient Have Influenza?

Duke University, Durham, North Carolina, United States
JAMA The Journal of the American Medical Association (Impact Factor: 30.39). 03/2005; 293(8):987-97. DOI: 10.1001/jama.293.8.987
Source: PubMed

ABSTRACT Influenza vaccination lowers, but does not eliminate, the risk of influenza. Making a reliable, rapid clinical diagnosis is essential to appropriate patient management that may be especially important during shortages of antiviral agents caused by high demand.
To systematically review the precision and accuracy of symptoms and signs of influenza. A secondary objective was to review the operating characteristics of rapid diagnostic tests for influenza (results available in <30 min).
Structured search strategy using MEDLINE (January 1966-September 2004) and subsequent searches of bibliographies of retrieved articles to identify articles describing primary studies dealing with the diagnosis of influenza based on clinical signs and symptoms. The MEDLINE search used the Medical Subject Headings EXP influenza or EXP influenza A virus or EXP influenza A virus human or EXP influenza B virus and the Medical Subject Headings or terms EXP sensitivity and specificity or EXP medical history taking or EXP physical examination or EXP reproducibility of results or EXP observer variation or symptoms.mp or clinical signs.mp or sensitivity.mp or specificity.mp.
Of 915 identified articles on clinical assessment of influenza-related illness, 17 contained data on the operating characteristics of symptoms and signs using an independent criterion standard. Of these, 11 were eliminated based on 4 inclusion criteria and availability of nonduplicative primary data.
Two authors independently reviewed and abstracted data for estimating the likelihood ratios (LRs) of clinical diagnostic findings. Differences were resolved by discussion and consensus.
No symptom or sign had a summary LR greater than 2 in studies that enrolled patients without regard to age. For decreasing the likelihood of influenza, the absence of fever (LR, 0.40; 95% confidence interval [CI], 0.25-0.66), cough (LR, 0.42; 95% CI, 0.31-0.57), or nasal congestion (LR, 0.49; 95% CI, 0.42-0.59) were the only findings that had summary LRs less than 0.5. In studies limited to patients aged 60 years or older, the combination of fever, cough, and acute onset (LR, 5.4; 95% CI, 3.8-7.7), fever and cough (LR, 5.0; 95% CI, 3.5-6.9), fever alone (LR, 3.8; 95% CI, 2.8-5.0), malaise (LR, 2.6; 95% CI, 2.2-3.1), and chills (LR, 2.6; 95% CI, 2.0-3.2) increased the likelihood of influenza to the greatest degree. The presence of sneezing among older patients made influenza less likely (LR, 0.47; 95% CI, 0.24-0.92).
Clinical findings identify patients with influenza-like illness but are not particularly useful for confirming or excluding the diagnosis of influenza. Clinicians should use timely epidemiologic data to ascertain if influenza is circulating in their communities, then either treat patients with influenza-like illness empirically or obtain a rapid influenza test to assist with management decisions.

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    • "The decreased sensitivity of ILI is likely related to the patient population, which included several patient groups that may not be able to mount an appropriate immune response or fever (eg, immunosuppressed or elderly). This is consistent with previous findings that the sensitivity of symptoms such as cough and fever for diagnosing influenza is decreased in elderly patients (30%) compared to the larger population (64%) [13] [16] [17]. Thus, in those recommended to receive antiviral treatment in whom diagnosis is most essential, the classic symptoms of ILI are less reliable. "
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    ABSTRACT: Timely and accurate diagnosis of influenza remains a challenge but is critical for patients who may benefit from antiviral therapy. This study determined the test characteristics of provider diagnosis of influenza, final ED electronic medical record (EMR) diagnosis of influenza, and influenza-like illness (ILI) in patients recommended to receive antiviral treatment according to Centers for Disease Control and Prevention (CDC) guidelines. In addition, we evaluated the compliance with CDC antiviral guidelines. A prospective cohort of adults presenting to a tertiary care ED with an acute respiratory illness who met CDC criteria for recommended antiviral treatment were enrolled and tested for influenza. A clinical diagnosis of influenza was assessed by asking the clinician: "Do you think this patient has influenza?" Influenza-like illness was defined according to current CDC criteria. In this cohort of 270 subjects, 42 (16%; 95% confidence interval [CI], 11%-20%) had influenza. Clinician diagnosis had a sensitivity of 36% (95% CI, 22%-52%) and specificity of 78% (95% CI, 72%-83%); EMR final ED diagnosis had a sensitivity of 26% (95% CI, 14%-42%) and specificity of 97% (95% CI, 94%-99%); ILI had a sensitivity of 31% (95% CI, 18%-47%) and specificity of 88% (95% CI, 83%-92%). Only 15 influenza-positive patients (36%) received antiviral treatment. Clinician diagnosis, final ED EMR diagnosis, and ILI have low sensitivity for diagnosing influenza, and there is overall poor compliance with CDC antiviral treatment recommendations. Improved methods of influenza diagnosis are needed to help guide management in the clinical setting. Copyright © 2015. Published by Elsevier Inc.
    The American journal of emergency medicine 03/2015; 33(6). DOI:10.1016/j.ajem.2015.03.008 · 1.15 Impact Factor
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    • "Nevertheless, influenza A viral infection propensity is attributed to frequent antigenic shifts and drifts as well as possessing a capacity to cause annual epidemics and occasional pandemics [2] . Prompt and appropriate diagnosis and therapy affect individual patients as well as whole society, because local outbreaks may be detected and control measures can be initiated [3] . "
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    ABSTRACT: To screen children with influenza like illness or with symptoms of acute respiratory tract infections for influenza A virus infection - post swine flu pandemic era - using rapid influenza diagnostic tests. During two years (2010 & 2011), 1 200 children with influenza like illness or acute respiratory tract infections (according to World Health Organization criteria) were recruited. Their ages ranged from 2-60 months. Nasopharyngeal aspirates specimens were collected from all children for rapid influenza A diagnostic test. Influenza A virus rapid test was positive in 47.5% of the children; the majority (89.6%) were presented with lower respiratory tract infections. Respiratory rate and temperature were significantly higher among positive rapid influenza test patients. Influenza A virus infection is still a major cause of respiratory tract infections in Egyptian children. It should be considered in all cases with cough and febrile episodes and influenza like symptoms even post swine flu pandemic.
    Asian Pacific Journal of Tropical Medicine 09/2013; 6(9):693-8. DOI:10.1016/S1995-7645(13)60120-0 · 0.93 Impact Factor
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    • "This indicates that ILI incorrectly identifies 75% of true negative individuals as possible influenza cases, and that the RDT which follows ILI screening appears to miss as many as 50% of true positive influenza cases. It should be noted that β 1 is even smaller than published estimates of ILI specificity for those with medical attendance [4] [35]. Both β 1 and α 2 are based on data for general populations with and without influenza and are not conditioned on any pre-defined medical state. "
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    ABSTRACT: The influenza A (H1N1) pandemic 2009 posed an epidemiological challenge in ascertaining all cases. Although the counting of all influenza cases in real time is often not feasible, empirical observations always involve diagnostic test procedures. This offers an opportunity to jointly quantify transmission dynamics and diagnostic accuracy. We have developed a joint estimation procedure that exploits parsimonious models to describe the epidemic dynamics and that parameterizes the number of test positives and test negatives as a function of time. Our analyses of simulated data and data from the empirical observation of interpandemic influenza A (H1N1) from 2007-08 in Japan indicate that the proposed approach permits a more precise quantification of the transmission dynamics compared to methods that rely on test positive cases alone. The analysis of entry screening data for the H1N1 pandemic 2009 at Tokyo-Narita airport helped us quantify the very limited specificity of influenza-like illness in detecting actual influenza cases in the passengers. The joint quantification does not require us to condition diagnostic accuracy on any pre-defined study population. Our study suggests that by consistently reporting both test positive and test negative cases, the usefulness of extractable information from routine surveillance record of infectious diseases would be maximized.
    Mathematical Biosciences and Engineering 01/2011; 8(1):49-64. DOI:10.3934/mbe.2011.8.49
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