Asymptomatic ratio for seasonal H1N1 influenza infection among schoolchildren in Taiwan

Abstract

Background: Studies indicate that asymptomatic infections do indeed occur frequently for both seasonal and pandemic influenza, accounting for about one-third of influenza infections. Studies carried out during the 2009 pH1N1 pandemic have found significant antibody response against seasonal H1N1 and H3N2 vaccine strains in schoolchildren receiving only pandemic H1N1 monovalent vaccine, yet reported either no symptoms or only mild symptoms.

Methods: Serum samples of 255 schoolchildren, who had not received vaccination and had pre-season HI Ab serotiters <40, were collected from urban, rural areas and an isolated island in Taiwan during the 2005-2006 influenza season. Their hemagglutination inhibition antibody (HI Ab) serotiters against the 2005 A/New Caledonia/20/99 (H1N1) vaccine strain at pre-season and post-season were measured to determine the symptoms with the highest correlation with infection, as defined by 4-fold rise in HI titer. We estimate the asymptomatic ratio, or the proportion of asymptomatic infections, for schoolchildren during the 2005-6 influenza season when this vaccine strain was found to be antigenically related to the circulating H1N1 strain.

Results: Fever has the highest correlation with the 2005-06 seasonal influenza A(H1N1) infection, followed by headache, cough, vomiting, and sore throat. Asymptomatic ratio for the schoolchildren is found to range between 55.6% (95% CI: 44.7-66.4)-77.9% (68.8-87.0) using different sets of predictive symptoms. Moreover, the asymptomatic ratio was 66.9% (56.6-77.2) when using US-CDC criterion of fever + (cough/sore throat), and 73.0 (63.3-82.8) when under Taiwan CDC definition of Fever + (cough or sore throat or nose) + ( headache or pain or fatigue).

Conclusions: Asymptomatic ratio for children is found to be substantially higher than that of the general population in literature. In providing reasonable quantification of the asymptomatic infected children spreading pathogens to others in a seasonal epidemic or a pandemic, our estimates of symptomatic ratio of infected children has important clinical and public health implications.

Figure 1

Logistic model of H1N1 influenza infection predicted by fever, headache, vomiting, and grade.

Figure 2

ROC curves of two logistic models (1) and (2) for influenza infection prediction, where the model (1) is a three-variable model based on predictors (fever, headache, and vomiting) and the model (2) is a four-variable model with the grade added to the model (1).

Figure 3

The plots of the logistic model and the ROC curves for Tables8,9for Younger Schoolchildren of grades 1–3. (a) Logistic model of H1N1 influenza infection predicted by fever, headache, vomiting, and cough. (b) ROC curves of combination of symptoms for influenza infection prediction in last 3 rows of younger schoolchildren of grades 1–3 in Table 9, denoted respectively by (1), (2), and (3).

Figure 4

The plots of the logistic model and the ROC curves for Tables8,9for Older Schoolchildren of grades 4–6. (a) Logistic model of H1N1 influenza infection predicted by fever, headache, vomiting, and sore-throat. (b) ROC curves of combination of symptoms for influenza infection prediction in last 3 rows of Table 9, denoted respectively by (1), (2), and (3).