Syndromic influenza surveillance in Germany is based on a network of primary care physicians that report consultations for acute respiratory infections (ARI) [1]. Weekly reports of ARI activity and corresponding results from virological sentinel surveillance are published year-round and data are sent to ECDC and WHO for inclusion in the international influenza surveillance networks (EISN, FluID, FluNet [2, 3]). This sentinel system (Working Group Influenza/Arbeitsgemeinschaft Influenza (AGI)) has proven its value in providing timely and reliable information on influenza activity in Germany and the burden of disease, especially during the pandemic 2009 [4,5,6].
However, during the process of pandemic preparedness planning and especially since the influenza pandemic 2009 the need to implement a routine sentinel surveillance system for severe acute respiratory infections (SARI) became obvious [7, 8]. In the course of the pandemic three ad hoc systems were established to capture severe respiratory cases. The first was the Pandemic Hospital Based Surveillance (Pandemische Influenza Krankenhaus-Surveillance (PIKS)) that was implemented by the Robert Koch Institute (RKI) to collect data on hospital admissions diagnosed with laboratory confirmed influenza [9]. The second was a SARI-Surveillance study that was part of a hospital-based pandemic influenza vaccine effectiveness study [10]. Lastly, there was enhanced surveillance of influenza during the pandemic with systematic collection of additional variables supplementary to the national regular mandatory notifications of laboratory confirmed influenza cases. For the mandatory system, it was only possible to record information on severity and risk factors according the WHO recommendations as long as the pandemic was under the scope of the Public Health Emergency of international Concern (PHEIC [11]) and an additional national pandemic notification ordinance was in force [12]. Although the information gathered on severe influenza cases and risk factors for severe course of disease were not only important in the national context but also used for global analyses [13], none of the three approaches were continued on a routine basis. Thus, the aim to establish a sustainable, timely and cost-efficient approach that could collect data during seasonal influenza epidemics and pandemics remained a priority.
The WHO recommends the national development of SARI surveillance for hospital inpatients for influenza surveillance. The approach combines a syndromic surveillance part, where severe acute respiratory illness is monitored, and a virological surveillance part, where all or a systematically selected subset of patients were tested for influenza [14]. While European countries have a long-standing tradition of national outpatient syndromic influenza surveillance systems, only a few have established hospital inpatient SARI surveillance systems [15]. Other European countries concentrate on laboratory-confirmed influenza cases admitted to hospitals or intensive care units only [2, 16].
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The maintenance of continuous influenza surveillance systems requires sufficient financial and personnel resources. Therefore approaches using secondary data offer an attractive possibility [17]. In 2015, the RKI set up a research collaboration with a private network of hospitals in order to develop a SARI sentinel surveillance system. This used case-based data coded according to the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) [18] and additional information on relevant procedures such as ventilation. A similar approach was used previously in the German primary care syndromic sentinel system to integrate case based ICD-10 coded reports. This led to fundamental improvements as it provided more detailed information on single ARI cases such as age, sex and single respiratory diagnosis [19, 20].
We described the establishment of an ICD-10-based inpatient syndromic sentinel system and its application to the analysis of five influenza seasons. We compared the impact of different case definitions on the ability to capture SARI cases, to allow a timely trend analysis of the seasonal epidemic and to reflect the burden caused by influenza when compared to routine outpatient surveillance.
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