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Self-Reported Influenza-Like Illness During the 2009 H1N1 Influenza Pandemic --- United States, September 2009--March 2010

CDC identified the first case of 2009 H1N1 pandemic influenza on April 15, 2009. During the first 3 months of the outbreak, approximately 43,000 cases were reported to CDC (1). In June 2009, the World Health Organization declared the outbreak an influenza pandemic. Because no existing influenza surveillance system in the United States monitored influenza-like illness (ILI) among persons with ILI who did not seek health care, CDC initiated community-based surveillance of self-reported ILI (defined as the presence of fever with cough or sore throat) and health-care--seeking behavior through a supplementary module of the Behavioral Risk Factor Surveillance System (BRFSS). This report summarizes results from BRFSS surveys conducted during September 2009--March 2010. Among 216,431 adults and 43,511 children (aged <18 years), the average monthly percentage of respondents reporting ILI in the 30 days preceding the interview was 8.1% among adults (range: 5.5% for September interviews to 9.5% for November) and 28.4% among children (range: 20.4% for September interviews to 35.9% for November). Health care was sought by 40% of adults and 56% of children with self-reported ILI. The results indicate that reported symptoms of ILI were widespread during the 2009--10 influenza season, with a substantial percentage of those reporting ILI seeking health care.

BRFSS conducts state-based, random-digit--dialed telephone surveys of the noninstitutionalized U.S. population aged ≥18 years to determine the prevalence of health conditions and health risk behaviors (2). From September 1, 2009, to March 31, 2010, BRFSS respondents in 49 states (excluding Vermont), the District of Columbia (DC), and Puerto Rico were interviewed using a new module for ILI. One of each respondent's children also was eligible to be the subject of the interview in 39 of the 49 states, DC, and Puerto Rico. Reported fever with cough or sore throat during the 30 days preceding the interview (for themselves or their child) was defined as having ILI in the past month.* Those respondents who reported ILI also were asked if they (or their child) visited a health-care professional for the illness.

Average monthly percentages of self-reported ILI were calculated. ILI was analyzed by age group, month of interview, sex, race/ethnicity,§ and U.S. Census region. Percentage estimates for race/ethnicity were age-adjusted by the direct method to the 2000 U.S. Census population. Respondents with missing ILI status or who resided in states where interviews were conducted for <6 months were excluded from analysis. Results were weighted to reflect selected demographic and geographic population estimates, in accordance with BRFSS weighting methodology (2). Response rates for BRFSS were calculated using Council of American Survey and Research Organizations (CASRO) guidelines. Median survey response rates were 55.2%, calculated as the percentage of persons who completed interviews among all eligible persons, including those who were not contacted. Median cooperation rates were 75.3%, calculated as the percentage of persons who completed interviews among all eligible persons who were contacted. Statistical significance was determined by t tests where appropriate; comparisons were considered statistically significant at p<0.05.

In interviews conducted during September 2009--March 2010, the average monthly percentage of adults reporting ILI was 8.1%, and the percentage of children with reported ILI was 28.4% (Table). Reported ILI among adults (9.5%) and children (35.9%) peaked in November interviews, which corresponds with illness in October or November. This pattern was observed in all census regions, except among adults in the South, where ILI peaked in December interviews (Figure 1). Reported ILI among adults (5.5%) and children (20.4%) was lowest for September interviews.

The monthly percentage of respondents reporting ILI decreased with age; the percentage was highest among children aged 0--4 years (32.7%) and lowest among adults aged ≥65 years (3.2%). Among all adults, a significantly higher percentage of women (9.0%) reported ILI than men (7.1%), but no statistically significant difference by sex was observed among children (p=0.11). Compared with white adults (8.4%) and children (29.9%), those identified as American Indian/Alaska Native adults (16.3%) and children (40.8%) reported significantly higher ILI prevalence, and those identified as black adults (7.2%) and children (23.3%) reported significantly lower ILI prevalence.

Among adults, no statistically significant differences were observed by census region. However, among children, those in the Midwest (29.4%) and South (29.5%) were significantly more likely to have reported ILI than those in the Northeast (26.2%). By state, adults in Arkansas were the most likely to report ILI (11.5%), whereas those in Delaware were the least likely (5.3%) (Figure 2). Among children, those in Oklahoma were the most likely to report ILI (33.4%), whereas those in DC were the least likely (21.5%). Health care was sought by 40% of adults and 56% of children with ILI.

Reported by

M Biggerstaff, MPH, L Kamimoto, MD, L Finelli, DrPH, Influenza Div, National Center for Immunization and Respiratory Diseases; L Balluz, PhD, ScD, Div of Behavioral Surveillance, Office of Surveillance, Epidemiology, and Laboratory Svcs, CDC.

Editorial Note

With the emergence of 2009 H1N1 influenza, CDC initiated community-based monitoring of self-reported ILI as a method for assessing the impact of 2009 H1N1 influenza on persons who did not seek health care. Results indicate that self-reported ILI was more common among younger respondents and less common among older respondents, a finding consistent with reports from other influenza surveillance systems (1).

After adjusting for age, the percentage of self-reported ILI in adults and children was similar among whites and Hispanics, moderately lower among black adults and children, and significantly higher among American Indian/Alaska Native adults and children. Reasons for these differences are not clear and are being investigated, but severe outcomes from influenza and other respiratory infections have been reported more commonly among children in certain racial/ethnic groups than in others (3).

The findings in this report are subject to at least five limitations. First, BRFSS ILI data are self-reported or reported by parents for their children; thus, symptoms, including fever, were not confirmed. However, self-reported symptoms of infectious illness, including respiratory illnesses, have shown close congruence with physician documentation (4). Second, the reported cases of ILI were not laboratory-confirmed as influenza infection. Influenza infection can cause illnesses that do not meet the ILI case definition (e.g., respiratory illness without fever); conversely, illnesses meeting the ILI criteria can be caused by multiple pathogens other than influenza (e.g., respiratory syncytial virus). Studies have indicated that 10%--25% of all respiratory illnesses occurring during periods when influenza viruses are known to be circulating are actually laboratory-confirmed influenza (5--7). The sensitivity and specificity of the ILI definition for influenza illness can vary substantially, but requiring fever as part of the ILI criteria has been shown to increase the specificity of ILI for influenza illness (8,9). Third, BRFSS data are collected only from households with a landline telephone. Selection bias related to exclusion of households with only cellular phones or no telephone service is possible; however, BRFSS weighting methodology partially compensates for the exclusion of households without telephones. Fourth, respondents from nine states were excluded from the analysis of ILI in children, and six of the excluded states were in the South census region. Therefore, results from the ILI analysis for children might not be representative of the United States overall and particularly of the South census region. Finally, the median state response rate for this survey period was only 55.2%; low response rates can increase the potential for bias.

Community-based ILI surveillance through BRFSS provided important information to help describe the 2009 H1N1 influenza pandemic and the epidemiology of ILI in the United States. These data were a useful adjunct to routine influenza surveillance and provided the only source of information for persons with ILI who did not seek health care. CDC continues to use the supplementary ILI module during the 2010--11 influenza season; the results will enable analysis of year-to-year trends and factors associated with self-reported ILI.

Acknowledgments

This report is based, in part, on contributions by BRFSS state coordinators; M Jhung, MD, Influenza Div, National Center for Immunization and Respiratory Diseases; and W Garvin and M Qayad, Div of Behavioral Surveillance, Office of Surveillance, Epidemiology, and Laboratory Svcs, CDC.

References

  1. Jhung M, Swerdlow D, Olsen S, et al. Epidemiology of 2009 pandemic influenza A (H1N1) in the United States. Clin Infect Dis 2011;52(Suppl 1):S13--26.
  2. CDC. Behavioral Risk Factor Surveillance System operational and user's guide. 2006. Atlanta, GA: US Department of Health and Human Services, CDC; 2006. Available at ftp://ftp.cdc.gov/pub/data/brfss/userguide.pdf. Accessed January 14, 2011.
  3. Iwane M, Edwards K, Szilagyi P, et al. Population-based surveillance for hospitalizations associated with respiratory syncytial virus, influenza virus, and parainfluenza viruses among young children. Pediatrics 2004;113:1758--64.
  4. Orts K, Sheridan J, Robinson-Whelen S, Glaser R, Malarkey WB, Kiecolt-Glaser JK. The reliability and validity of a structured interview for the assessment of infectious disease symptoms. J Behav Med 1995;18:517--29.
  5. Monto A, Ullman B. Acute respiratory illness in an American community. The Tecumseh study. JAMA 1974;227:164--9.
  6. Bridges C, Thompson W, Meltzer M, et al. Effectiveness and cost-benefit of influenza vaccination of healthy working adults: a randomized controlled trial. JAMA 2000;284:1655--63.
  7. Ren L, Gonzalez R, Wang Z, et al. Prevalence of human respiratory viruses in adults with acute respiratory tract infections in Beijing, 2005--2007. Clin Microbiol Infect 2009;15:1146--53.
  8. Monto A, Gravenstein S, Elliott M, Colopy M, Schweinle J. Clinical signs and symptoms predicting influenza infection. Arch Intern Med 2000;160:3243--7.
  9. Ong A, Chen M, Lin L, et al. Improving the clinical diagnosis of influenza---a comparative analysis of new influenza A (H1N1) cases. PLoS ONE 2009;4:e8453.

* To determine the presence of ILI among adult respondents, two questions were asked: "During the past month, were you ill with a fever?" and "Did you also have a cough and/or sore throat?" A "yes" response to both was classified as ILI. To determine the presence of ILI among children, adult respondents were asked one question about their child: "Has the child had a fever with cough and/or sore throat during the past month?" A "yes" response was classified as ILI.

To determine whether medical care was sought among those with ILI, respondents were asked: "Did you [or your child] visit a doctor, nurse, or other health professional for this illness?"

§ Respondents were categorized into four non-Hispanic racial populations: white, black, American Indian/Alaska Native, and other race. Person categorized as Hispanic might be of any race.

Northeast: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont. Midwest: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin. South: Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia. West: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming.


What is already known on this topic?

CDC identified the first case of 2009 H1N1 pandemic influenza on April 15, 2009. In June 2009, the World Health Organization declared the outbreak an influenza pandemic. Routine U.S. influenza surveillance systems provided information describing visits to health-care providers for influenza-like illness (ILI) and reports of influenza-associated hospitalizations and deaths, but did not monitor ILI among persons who did not seek health care.

What is added by this report?

During September 2009--March 2010, the average monthly percentage of adults and children with reported symptoms of ILI during the preceding 30 days was 8.1% and 28.4%, respectively. Health care was sought by 40% of adults and 56% of children with ILI.

What are the implications for public health practice?

The results indicate that a large segment of the population reported symptoms of ILI and sought health care for those symptoms during the 2009--10 influenza season. Community-based surveillance of influenza was a useful adjunct to routine influenza surveillance and provided the only source of information regarding persons with ILI who did not seek health care.


TABLE. Average monthly percentage of children* and adults with reported influenza-like illness (ILI) during the preceding 30 days, by selected characteristics --- Behavioral Risk Factor Surveillance System, United States, September 2009--March 2010

Children

Adults

Characteristic

Sample size

%

(95% CI)

Sample size

%

(95% CI)

Total

43,511

28.4

(27.6--29.2)

216,431

8.1

(7.8--8.4)

Sex

Male

21,619

27.9

(26.8--29.1)

81,931

7.1

(6.7--7.6)

Female

19,821

29.3

(28.1--30.5)

134,500

9.0

(8.6--9.4)

Race/Ethnicity

White

28,930

29.9

(29.0--30.9)

169,376

8.4

(8.1--8.7)

Black

3,756

23.3

(21.0--25.8)

17,129

7.2

(6.3--8.2)

Hispanic

6,112

27.6

(25.6--29.6)

14,508

7.5

(6.7--8.4)

American Indian/Alaska Native

960

40.8

(31.4--51.0)

2,916

16.3

(12.2--21.5)

Other race

3,127

28.8

(26.0--31.8)

8,618

9.1

(7.8--10.6)

Age group (yrs)

0--4

9,985

32.7

(30.9--34.6)

---

---

---

5--11

15,506

29.4

(28.1--30.7)

---

---

---

12--17

17,944

24.2

(23.0--25.4)

---

---

---

18--49

---

---

---

71,684

10.1

(9.7--10.6)

50--64

---

---

---

72,167

6.8

(6.4--7.2)

≥65

---

---

---

70,880

3.2

(3.0--3.5)

U.S. Census§

Northeast

6,812

26.2

(24.4--28.2)

33,440

7.7

(7.0--8.4)

Midwest

11,604

29.4

(27.8--31.0)

51,872

7.8

(7.3--8.3)

South

11,259

29.5

(28.0--31.1)

74,424

8.4

(8.0--8.9)

West

13,288

28.0

(26.5--29.6)

54,423

8.2

(7.5--8.8)

Abbreviation: CI = confidence interval.

* Aged <18 years.

Persons categorized as white, black, American Indian/Alaska Native, and other race are all non-Hispanic. Persons categorized as Hispanic might be of any race.

§ Northeast: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont. Midwest: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin. South: Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia. West: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming.


FIGURE 1. Percentage of children* and adults with reported influenza-like illness (ILI) during the preceding 30 days, by U.S. Census region and interview month --- Behavioral Risk Factor Surveillance System, United States, September 2009--March 2010

The figure shows the percentage of children and adults with reported influenza-like illness (ILI) during the preceding 30 days, by U.S. Census region and interview month, in the United States during September 2009-March 2010. Reported ILI among adults (9.5%) and children (35.9%) peaked in November interviews, which corresponds with illness in October or November. This pattern was observed in all census regions, except among adults in the South, where ILI peaked in December interviews. Reported ILI among adults (5.5%) and children (20.4%) was lowest for September interviews.

* Aged <18 years.

Northeast: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont. Midwest: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin. South: Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia. West: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming.

Alternate Text: The figure above shows the percentage of children and adults with reported influenza-like illness (ILI) during the preceding 30 days, by U.S. Census region and interview month, in the United States during September 2009-March 2010. Reported ILI among adults (9.5%) and children (35.9%) peaked in November interviews, which corresponds with illness in October or November. This pattern was observed in all census regions, except among adults in the South, where ILI peaked in December interviews. Reported ILI among adults (5.5%) and children (20.4%) was lowest for September interviews.


FIGURE 2. Percentage of adults reporting influenza-like illness (ILI) during the preceding 30 days --- Behavioral Risk Factor Surveillance System, United States,* September 2009--March 2010

The figure is a U.S. map showing the percentage of adults reporting influenza-like illness (ILI) during the preceding 30 days in the United States during September 2009-March 2010. Adults in Arkansas were the most likely to report ILI (11.5%), whereas those in Delaware were the least likely (5.3%). Among children, those in Oklahoma were the most likely to report ILI (33.4%), whereas those in the District of Columbia were the least likely (21.5%). Health care was sought by 40% of adults and 56% of children with ILI.

* 49 states (Vermont did not collect data), District of Columbia, and Puerto Rico.

Alternate Text: The figure above is a U.S. map showing the percentage of adults reporting influenza-like illness (ILI) during the preceding 30 days in the United States during September 2009-March 2010. Adults in Arkansas were the most likely to report ILI (11.5%), whereas those in Delaware were the least likely (5.3%). Among children, those in Oklahoma were the most likely to report ILI (33.4%), whereas those in the District of Columbia were the least likely (21.5%). Health care was sought by 40% of adults and 56% of children with ILI.



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