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Charrel)] TJ ET 0.271 0.267 0.267 rg BT 26.250 639.438 Td /F1 9.8 Tf [(Nougairede A, Ninove L, Zandotti C, de Lamballerie X, Gazin C, Drancourt M, La Scola B, Raoult D, Charrel RN. Point of Care )] TJ ET BT 26.250 627.533 Td /F1 9.8 Tf [(Strategy for Rapid Diagnosis of Novel A/H1N1 Influenza Virus. PLOS Currents Influenza. 2009 Sep 22 . Edition 1. doi: )] TJ ET BT 26.250 615.628 Td /F1 9.8 Tf [(10.1371/currents.RRN1039.)] TJ ET q 15.000 14.878 577.500 598.370 re W n 0.271 0.267 0.267 rg BT 26.250 586.526 Td /F4 12.0 Tf [(Abstract)] TJ ET BT 26.250 566.571 Td /F1 9.8 Tf [(In late June 2009, we implemented for public hospitals of Marseille Point Of Care strategy for rapid diagnosis of novel A/H1N1 )] TJ ET BT 26.250 554.667 Td /F1 9.8 Tf [(influenza virus. During two months, we have tested more than 900 specimens in both Point Of Care laboratories. We believe )] TJ ET BT 26.250 542.762 Td /F1 9.8 Tf [(that implementation of Point of Care strategy for the largest number of suspects cases may improve quality of patients care and )] TJ ET BT 26.250 530.857 Td /F1 9.8 Tf [(our knowledge of the epidemiology of the pandemic.)] TJ ET BT 26.250 494.255 Td /F4 12.0 Tf [(Article Updated)] TJ ET BT 26.250 474.300 Td /F4 9.8 Tf [(This article has been updated:)] TJ ET BT 166.582 474.300 Td /F1 9.8 Tf [( )] TJ ET 0.267 0.267 0.267 rg BT 172.539 474.300 Td /F1 9.8 Tf [(Point of Care Strategy for Rapid Diagnosis of Novel A/H1N1 Influenza Virus)] TJ ET 0.271 0.267 0.267 rg BT 498.755 474.300 Td /F1 9.8 Tf [( in )] TJ ET BT 515.008 474.300 Td /F5 9.8 Tf [(PLOS ONE)] TJ ET BT 564.860 474.300 Td /F1 9.8 Tf [(, )] TJ ET BT 26.250 462.396 Td /F1 9.8 Tf [(doi: 10.1371/journal.pone.0009215. This update is in line with PLOS policy at the time of publication, see )] TJ ET 0.267 0.267 0.267 rg BT 479.869 462.396 Td /F1 9.8 Tf [(here)] TJ ET 0.271 0.267 0.267 rg BT 499.378 462.396 Td /F1 9.8 Tf [( for further details.)] TJ ET BT 26.250 425.793 Td /F4 12.0 Tf [(Introduction)] TJ ET BT 26.250 405.839 Td /F1 9.8 Tf [(In late April 2009, The World Health Organization \(WHO\) announced the emergence of a novel A/H1N1 influenza virus. This )] TJ ET BT 26.250 393.934 Td /F1 9.8 Tf [(virus spread rapidly, and after two months the WHO raised the alert level from phase 5 to phase 6 defining the first influenza )] TJ ET BT 26.250 382.029 Td /F1 9.8 Tf [(pandemic of the 21 )] TJ ET BT 111.884 385.918 Td /F1 8.7 Tf [(st)] TJ ET BT 118.627 382.029 Td /F1 9.8 Tf [( century [1] . At the beginning of the pandemic, some countries established measures to identify all )] TJ ET BT 26.250 370.125 Td /F1 9.8 Tf [(possible cases, but rapidly and due to the constant increase of suspected cases, they decided to stop the systematic screening.)] TJ ET BT 26.250 350.720 Td /F1 9.8 Tf [(In France, the initial strategy started at the end of April 2009 was relying on the early identification of suspect cases which were )] TJ ET BT 26.250 338.815 Td /F1 9.8 Tf [(directed into the hospital system to be tested for A/H1N1 virus, the positive cases being further hospitalized in isolation ward to )] TJ ET BT 26.250 326.910 Td /F1 9.8 Tf [(prevent secondary transmission. This approach allowed a good knowledge of the kinetics of the pandemic when the large )] TJ ET BT 26.250 315.006 Td /F1 9.8 Tf [(majority of positive cases are acquired abroad. The systematic screening of all suspect cases was stopped the July 7 )] TJ ET BT 533.465 318.894 Td /F1 8.7 Tf [(th)] TJ ET BT 540.692 315.006 Td /F1 9.8 Tf [( and )] TJ ET BT 26.250 303.101 Td /F1 9.8 Tf [(replaced by sentinel systems to estimate the number of cases from surveillance of certain populations and to target groups with )] TJ ET BT 26.250 291.196 Td /F1 9.8 Tf [(higher risk of morbidity or mortality [2] . The recent loss of laboratory-confirmed cases has rendered impossible to have now a )] TJ ET BT 26.250 279.291 Td /F1 9.8 Tf [(reliable estimation of the evolution of the pandemic in France. Figures varying from 20,000 \(Groupes Rgionaux dObservation )] TJ ET BT 26.250 267.387 Td /F1 9.8 Tf [(de la Grippe, France\) to 5,000 \(Institut de veille sanitaire, France\) cases weekly are claimed depending on the source data [3] . )] TJ ET BT 26.250 255.482 Td /F1 9.8 Tf [(The data gathered at the beginning of the pandemic clearly indicate that the positive predictive value of the consultation by )] TJ ET BT 26.250 243.577 Td /F1 9.8 Tf [(general practitioners or infectious diseases specialists is very low \(15%\). This is a strong argument to maintain laboratory )] TJ ET BT 26.250 231.672 Td /F1 9.8 Tf [(confirmation of A/H1N1 suspect cases to provide solid epidemiological data. Even if there may be bias, the calculated )] TJ ET BT 26.250 219.768 Td /F1 9.8 Tf [(proportion of laboratory-confirmed A/H1N1 cases amongst suspect cases allows to extrapolate the total number of cases )] TJ ET BT 26.250 207.863 Td /F1 9.8 Tf [(occurring during the study period. Because of the innate evolutive nature of an epidemic/pandemic of transmissible disease, this )] TJ ET BT 26.250 195.958 Td /F1 9.8 Tf [(extrapolation must be updated periodically from unambiguous data such as laboratory-confirmed diagnostics.)] TJ ET BT 26.250 176.553 Td /F1 9.8 Tf [(Moreover to assess influenza morbidity and mortality, the approach based on systematic screening is more efficient than )] TJ ET BT 26.250 164.649 Td /F1 9.8 Tf [(passive methods that produce under-estimate data [4] . Specifically, they cannot consider the role of unrecognized influenza )] TJ ET BT 26.250 152.744 Td /F1 9.8 Tf [(infection as decisive co-morbidity factor in patients with underlying cardiovascular disease, hypertension, chronic pulmonary )] TJ ET BT 26.250 140.839 Td /F1 9.8 Tf [(diseases and endocrine disorders. Therefore passive surveillance tends to hinder the knowledge of epidemiology of this )] TJ ET BT 26.250 128.934 Td /F1 9.8 Tf [(pandemic [4] . Systematic detection for each patient with severe influenza-associated pathology like acute respiratory distress )] TJ ET BT 26.250 117.030 Td /F1 9.8 Tf [(syndrome [5] or for each patient with high mortality risk like pregnant woman [6] may contribute to appreciate the incidence of )] TJ ET BT 26.250 105.125 Td /F1 9.8 Tf [(influenza infection in this specifics groups.)] TJ ET BT 26.250 85.720 Td /F1 9.8 Tf [(In this context, we believe that implementation of a rapid A/H1N1 influenza diagnostic for the largest number of suspects cases )] TJ ET BT 26.250 73.815 Td /F1 9.8 Tf [(may improve the level of quality of patients care, the monitoring of pandemic through the reduction of secondary cases, and our )] TJ ET BT 26.250 61.911 Td /F1 9.8 Tf [(knowledge of the epidemiology of the pandemic.)] TJ ET Q q 15.000 684.354 577.500 53.646 re W n 0.267 0.267 0.267 rg BT 15.000 718.042 Td /F2 21.0 Tf [(Point of Care Strategy for Rapid Diagnosis of Novel A/H1N1 )] TJ ET BT 15.000 693.094 Td /F2 21.0 Tf [(Influenza Virus)] TJ ET Q 0.271 0.267 0.267 rg BT 15.000 675.088 Td /F3 9.8 Tf [(September 22, 2009)] TJ ET BT 97.592 675.088 Td /F3 9.8 Tf [()] TJ ET 0.267 0.267 0.267 rg BT 102.467 675.088 Td /F3 9.8 Tf [(Epidemiology)] TJ ET BT 26.250 663.247 Td /F1 9.8 Tf [(Antoine Nougairede)] TJ ET 0.271 0.267 0.267 rg BT 112.421 663.247 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 117.842 663.247 Td /F1 9.8 Tf [(Laetitia Ninove)] TJ ET 0.271 0.267 0.267 rg BT 182.328 663.247 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 187.749 663.247 Td /F1 9.8 Tf [(Christine Zandotti)] TJ ET 0.271 0.267 0.267 rg BT 264.150 663.247 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 269.571 663.247 Td /F1 9.8 Tf [(Xavier de Lamballerie)] TJ ET 0.271 0.267 0.267 rg BT 363.854 663.247 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 369.275 663.247 Td /F1 9.8 Tf [(Celine Gazin)] TJ ET 0.271 0.267 0.267 rg BT 425.084 663.247 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 430.505 663.247 Td /F1 9.8 Tf [(Michel Drancourt)] TJ ET 0.271 0.267 0.267 rg BT 504.185 663.247 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 509.606 663.247 Td /F1 9.8 Tf [(Bernard La )] TJ ET BT 26.250 651.342 Td /F1 9.8 Tf [(Scola)] TJ ET 0.271 0.267 0.267 rg BT 50.635 651.342 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 56.056 651.342 Td /F1 9.8 Tf [(Didier Raoult)] TJ ET 0.271 0.267 0.267 rg BT 112.401 651.342 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 117.822 651.342 Td /F1 9.8 Tf [(Remi N. Charrel)] TJ ET 0.271 0.267 0.267 rg BT 26.250 639.438 Td /F1 9.8 Tf [(Nougairede A, Ninove L, Zandotti C, de Lamballerie X, Gazin C, Drancourt M, La Scola B, Raoult D, Charrel RN. Point of Care )] TJ ET BT 26.250 627.533 Td /F1 9.8 Tf [(Strategy for Rapid Diagnosis of Novel A/H1N1 Influenza Virus. PLOS Currents Influenza. 2009 Sep 22 . Edition 1. doi: )] TJ ET BT 26.250 615.628 Td /F1 9.8 Tf [(10.1371/currents.RRN1039.)] TJ ET q 15.000 14.878 577.500 598.370 re W n 0.271 0.267 0.267 rg BT 26.250 586.526 Td /F4 12.0 Tf [(Abstract)] TJ ET BT 26.250 566.571 Td /F1 9.8 Tf [(In late June 2009, we implemented for public hospitals of Marseille Point Of Care strategy for rapid diagnosis of novel A/H1N1 )] TJ ET BT 26.250 554.667 Td /F1 9.8 Tf [(influenza virus. During two months, we have tested more than 900 specimens in both Point Of Care laboratories. We believe )] TJ ET BT 26.250 542.762 Td /F1 9.8 Tf [(that implementation of Point of Care strategy for the largest number of suspects cases may improve quality of patients care and )] TJ ET BT 26.250 530.857 Td /F1 9.8 Tf [(our knowledge of the epidemiology of the pandemic.)] TJ ET BT 26.250 494.255 Td /F4 12.0 Tf [(Article Updated)] TJ ET BT 26.250 474.300 Td /F4 9.8 Tf [(This article has been updated:)] TJ ET BT 166.582 474.300 Td /F1 9.8 Tf [( )] TJ ET 0.267 0.267 0.267 rg BT 172.539 474.300 Td /F1 9.8 Tf [(Point of Care Strategy for Rapid Diagnosis of Novel A/H1N1 Influenza Virus)] TJ ET 0.271 0.267 0.267 rg BT 498.755 474.300 Td /F1 9.8 Tf [( in )] TJ ET BT 515.008 474.300 Td /F5 9.8 Tf [(PLOS ONE)] TJ ET BT 564.860 474.300 Td /F1 9.8 Tf [(, )] TJ ET BT 26.250 462.396 Td /F1 9.8 Tf [(doi: 10.1371/journal.pone.0009215. This update is in line with PLOS policy at the time of publication, see )] TJ ET 0.267 0.267 0.267 rg BT 479.869 462.396 Td /F1 9.8 Tf [(here)] TJ ET 0.271 0.267 0.267 rg BT 499.378 462.396 Td /F1 9.8 Tf [( for further details.)] TJ ET BT 26.250 425.793 Td /F4 12.0 Tf [(Introduction)] TJ ET BT 26.250 405.839 Td /F1 9.8 Tf [(In late April 2009, The World Health Organization \(WHO\) announced the emergence of a novel A/H1N1 influenza virus. This )] TJ ET BT 26.250 393.934 Td /F1 9.8 Tf [(virus spread rapidly, and after two months the WHO raised the alert level from phase 5 to phase 6 defining the first influenza )] TJ ET BT 26.250 382.029 Td /F1 9.8 Tf [(pandemic of the 21 )] TJ ET BT 111.884 385.918 Td /F1 8.7 Tf [(st)] TJ ET BT 118.627 382.029 Td /F1 9.8 Tf [( century [1] . At the beginning of the pandemic, some countries established measures to identify all )] TJ ET BT 26.250 370.125 Td /F1 9.8 Tf [(possible cases, but rapidly and due to the constant increase of suspected cases, they decided to stop the systematic screening.)] TJ ET BT 26.250 350.720 Td /F1 9.8 Tf [(In France, the initial strategy started at the end of April 2009 was relying on the early identification of suspect cases which were )] TJ ET BT 26.250 338.815 Td /F1 9.8 Tf [(directed into the hospital system to be tested for A/H1N1 virus, the positive cases being further hospitalized in isolation ward to )] TJ ET BT 26.250 326.910 Td /F1 9.8 Tf [(prevent secondary transmission. This approach allowed a good knowledge of the kinetics of the pandemic when the large )] TJ ET BT 26.250 315.006 Td /F1 9.8 Tf [(majority of positive cases are acquired abroad. The systematic screening of all suspect cases was stopped the July 7 )] TJ ET BT 533.465 318.894 Td /F1 8.7 Tf [(th)] TJ ET BT 540.692 315.006 Td /F1 9.8 Tf [( and )] TJ ET BT 26.250 303.101 Td /F1 9.8 Tf [(replaced by sentinel systems to estimate the number of cases from surveillance of certain populations and to target groups with )] TJ ET BT 26.250 291.196 Td /F1 9.8 Tf [(higher risk of morbidity or mortality [2] . The recent loss of laboratory-confirmed cases has rendered impossible to have now a )] TJ ET BT 26.250 279.291 Td /F1 9.8 Tf [(reliable estimation of the evolution of the pandemic in France. Figures varying from 20,000 \(Groupes Rgionaux dObservation )] TJ ET BT 26.250 267.387 Td /F1 9.8 Tf [(de la Grippe, France\) to 5,000 \(Institut de veille sanitaire, France\) cases weekly are claimed depending on the source data [3] . )] TJ ET BT 26.250 255.482 Td /F1 9.8 Tf [(The data gathered at the beginning of the pandemic clearly indicate that the positive predictive value of the consultation by )] TJ ET BT 26.250 243.577 Td /F1 9.8 Tf [(general practitioners or infectious diseases specialists is very low \(15%\). This is a strong argument to maintain laboratory )] TJ ET BT 26.250 231.672 Td /F1 9.8 Tf [(confirmation of A/H1N1 suspect cases to provide solid epidemiological data. Even if there may be bias, the calculated )] TJ ET BT 26.250 219.768 Td /F1 9.8 Tf [(proportion of laboratory-confirmed A/H1N1 cases amongst suspect cases allows to extrapolate the total number of cases )] TJ ET BT 26.250 207.863 Td /F1 9.8 Tf [(occurring during the study period. Because of the innate evolutive nature of an epidemic/pandemic of transmissible disease, this )] TJ ET BT 26.250 195.958 Td /F1 9.8 Tf [(extrapolation must be updated periodically from unambiguous data such as laboratory-confirmed diagnostics.)] TJ ET BT 26.250 176.553 Td /F1 9.8 Tf [(Moreover to assess influenza morbidity and mortality, the approach based on systematic screening is more efficient than )] TJ ET BT 26.250 164.649 Td /F1 9.8 Tf [(passive methods that produce under-estimate data [4] . Specifically, they cannot consider the role of unrecognized influenza )] TJ ET BT 26.250 152.744 Td /F1 9.8 Tf [(infection as decisive co-morbidity factor in patients with underlying cardiovascular disease, hypertension, chronic pulmonary )] TJ ET BT 26.250 140.839 Td /F1 9.8 Tf [(diseases and endocrine disorders. Therefore passive surveillance tends to hinder the knowledge of epidemiology of this )] TJ ET BT 26.250 128.934 Td /F1 9.8 Tf [(pandemic [4] . Systematic detection for each patient with severe influenza-associated pathology like acute respiratory distress )] TJ ET BT 26.250 117.030 Td /F1 9.8 Tf [(syndrome [5] or for each patient with high mortality risk like pregnant woman [6] may contribute to appreciate the incidence of )] TJ ET BT 26.250 105.125 Td /F1 9.8 Tf [(influenza infection in this specifics groups.)] TJ ET BT 26.250 85.720 Td /F1 9.8 Tf [(In this context, we believe that implementation of a rapid A/H1N1 influenza diagnostic for the largest number of suspects cases )] TJ ET BT 26.250 73.815 Td /F1 9.8 Tf [(may improve the level of quality of patients care, the monitoring of pandemic through the reduction of secondary cases, and our )] TJ ET BT 26.250 61.911 Td /F1 9.8 Tf [(knowledge of the epidemiology of the pandemic.)] TJ ET Q q 15.000 684.354 577.500 53.646 re W n 0.267 0.267 0.267 rg BT 15.000 718.042 Td /F2 21.0 Tf [(Point of Care Strategy for Rapid Diagnosis of Novel A/H1N1 )] TJ ET BT 15.000 693.094 Td /F2 21.0 Tf [(Influenza Virus)] TJ ET Q 0.271 0.267 0.267 rg BT 15.000 675.088 Td /F3 9.8 Tf [(September 22, 2009)] TJ ET BT 97.592 675.088 Td /F3 9.8 Tf [()] TJ ET 0.267 0.267 0.267 rg BT 102.467 675.088 Td /F3 9.8 Tf [(Epidemiology)] TJ ET BT 26.250 663.247 Td /F1 9.8 Tf [(Antoine Nougairede)] TJ ET 0.271 0.267 0.267 rg BT 112.421 663.247 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 117.842 663.247 Td /F1 9.8 Tf [(Laetitia Ninove)] TJ ET 0.271 0.267 0.267 rg BT 182.328 663.247 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 187.749 663.247 Td /F1 9.8 Tf [(Christine Zandotti)] TJ ET 0.271 0.267 0.267 rg BT 264.150 663.247 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 269.571 663.247 Td /F1 9.8 Tf [(Xavier de Lamballerie)] TJ ET 0.271 0.267 0.267 rg BT 363.854 663.247 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 369.275 663.247 Td /F1 9.8 Tf [(Celine Gazin)] TJ ET 0.271 0.267 0.267 rg BT 425.084 663.247 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 430.505 663.247 Td /F1 9.8 Tf [(Michel Drancourt)] TJ ET 0.271 0.267 0.267 rg BT 504.185 663.247 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 509.606 663.247 Td /F1 9.8 Tf [(Bernard La )] TJ ET BT 26.250 651.342 Td /F1 9.8 Tf [(Scola)] TJ ET 0.271 0.267 0.267 rg BT 50.635 651.342 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 56.056 651.342 Td /F1 9.8 Tf [(Didier Raoult)] TJ ET 0.271 0.267 0.267 rg BT 112.401 651.342 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 117.822 651.342 Td /F1 9.8 Tf [(Remi N. Charrel)] TJ ET 0.271 0.267 0.267 rg BT 26.250 639.438 Td /F1 9.8 Tf [(Nougairede A, Ninove L, Zandotti C, de Lamballerie X, Gazin C, Drancourt M, La Scola B, Raoult D, Charrel RN. Point of Care )] TJ ET BT 26.250 627.533 Td /F1 9.8 Tf [(Strategy for Rapid Diagnosis of Novel A/H1N1 Influenza Virus. PLOS Currents Influenza. 2009 Sep 22 . Edition 1. doi: )] TJ ET BT 26.250 615.628 Td /F1 9.8 Tf [(10.1371/currents.RRN1039.)] TJ ET q 15.000 14.878 577.500 598.370 re W n 0.271 0.267 0.267 rg BT 26.250 586.526 Td /F4 12.0 Tf [(Abstract)] TJ ET BT 26.250 566.571 Td /F1 9.8 Tf [(In late June 2009, we implemented for public hospitals of Marseille Point Of Care strategy for rapid diagnosis of novel A/H1N1 )] TJ ET BT 26.250 554.667 Td /F1 9.8 Tf [(influenza virus. During two months, we have tested more than 900 specimens in both Point Of Care laboratories. We believe )] TJ ET BT 26.250 542.762 Td /F1 9.8 Tf [(that implementation of Point of Care strategy for the largest number of suspects cases may improve quality of patients care and )] TJ ET BT 26.250 530.857 Td /F1 9.8 Tf [(our knowledge of the epidemiology of the pandemic.)] TJ ET BT 26.250 494.255 Td /F4 12.0 Tf [(Article Updated)] TJ ET BT 26.250 474.300 Td /F4 9.8 Tf [(This article has been updated:)] TJ ET BT 166.582 474.300 Td /F1 9.8 Tf [( )] TJ ET 0.267 0.267 0.267 rg BT 172.539 474.300 Td /F1 9.8 Tf [(Point of Care Strategy for Rapid Diagnosis of Novel A/H1N1 Influenza Virus)] TJ ET 0.271 0.267 0.267 rg BT 498.755 474.300 Td /F1 9.8 Tf [( in )] TJ ET BT 515.008 474.300 Td /F5 9.8 Tf [(PLOS ONE)] TJ ET BT 564.860 474.300 Td /F1 9.8 Tf [(, )] TJ ET BT 26.250 462.396 Td /F1 9.8 Tf [(doi: 10.1371/journal.pone.0009215. This update is in line with PLOS policy at the time of publication, see )] TJ ET 0.267 0.267 0.267 rg BT 479.869 462.396 Td /F1 9.8 Tf [(here)] TJ ET 0.271 0.267 0.267 rg BT 499.378 462.396 Td /F1 9.8 Tf [( for further details.)] TJ ET BT 26.250 425.793 Td /F4 12.0 Tf [(Introduction)] TJ ET BT 26.250 405.839 Td /F1 9.8 Tf [(In late April 2009, The World Health Organization \(WHO\) announced the emergence of a novel A/H1N1 influenza virus. This )] TJ ET BT 26.250 393.934 Td /F1 9.8 Tf [(virus spread rapidly, and after two months the WHO raised the alert level from phase 5 to phase 6 defining the first influenza )] TJ ET BT 26.250 382.029 Td /F1 9.8 Tf [(pandemic of the 21 )] TJ ET BT 111.884 385.918 Td /F1 8.7 Tf [(st)] TJ ET BT 118.627 382.029 Td /F1 9.8 Tf [( century [1] . At the beginning of the pandemic, some countries established measures to identify all )] TJ ET BT 26.250 370.125 Td /F1 9.8 Tf [(possible cases, but rapidly and due to the constant increase of suspected cases, they decided to stop the systematic screening.)] TJ ET BT 26.250 350.720 Td /F1 9.8 Tf [(In France, the initial strategy started at the end of April 2009 was relying on the early identification of suspect cases which were )] TJ ET BT 26.250 338.815 Td /F1 9.8 Tf [(directed into the hospital system to be tested for A/H1N1 virus, the positive cases being further hospitalized in isolation ward to )] TJ ET BT 26.250 326.910 Td /F1 9.8 Tf [(prevent secondary transmission. This approach allowed a good knowledge of the kinetics of the pandemic when the large )] TJ ET BT 26.250 315.006 Td /F1 9.8 Tf [(majority of positive cases are acquired abroad. The systematic screening of all suspect cases was stopped the July 7 )] TJ ET BT 533.465 318.894 Td /F1 8.7 Tf [(th)] TJ ET BT 540.692 315.006 Td /F1 9.8 Tf [( and )] TJ ET BT 26.250 303.101 Td /F1 9.8 Tf [(replaced by sentinel systems to estimate the number of cases from surveillance of certain populations and to target groups with )] TJ ET BT 26.250 291.196 Td /F1 9.8 Tf [(higher risk of morbidity or mortality [2] . The recent loss of laboratory-confirmed cases has rendered impossible to have now a )] TJ ET BT 26.250 279.291 Td /F1 9.8 Tf [(reliable estimation of the evolution of the pandemic in France. Figures varying from 20,000 \(Groupes Rgionaux dObservation )] TJ ET BT 26.250 267.387 Td /F1 9.8 Tf [(de la Grippe, France\) to 5,000 \(Institut de veille sanitaire, France\) cases weekly are claimed depending on the source data [3] . )] TJ ET BT 26.250 255.482 Td /F1 9.8 Tf [(The data gathered at the beginning of the pandemic clearly indicate that the positive predictive value of the consultation by )] TJ ET BT 26.250 243.577 Td /F1 9.8 Tf [(general practitioners or infectious diseases specialists is very low \(15%\). This is a strong argument to maintain laboratory )] TJ ET BT 26.250 231.672 Td /F1 9.8 Tf [(confirmation of A/H1N1 suspect cases to provide solid epidemiological data. Even if there may be bias, the calculated )] TJ ET BT 26.250 219.768 Td /F1 9.8 Tf [(proportion of laboratory-confirmed A/H1N1 cases amongst suspect cases allows to extrapolate the total number of cases )] TJ ET BT 26.250 207.863 Td /F1 9.8 Tf [(occurring during the study period. Because of the innate evolutive nature of an epidemic/pandemic of transmissible disease, this )] TJ ET BT 26.250 195.958 Td /F1 9.8 Tf [(extrapolation must be updated periodically from unambiguous data such as laboratory-confirmed diagnostics.)] TJ ET BT 26.250 176.553 Td /F1 9.8 Tf [(Moreover to assess influenza morbidity and mortality, the approach based on systematic screening is more efficient than )] TJ ET BT 26.250 164.649 Td /F1 9.8 Tf [(passive methods that produce under-estimate data [4] . Specifically, they cannot consider the role of unrecognized influenza )] TJ ET BT 26.250 152.744 Td /F1 9.8 Tf [(infection as decisive co-morbidity factor in patients with underlying cardiovascular disease, hypertension, chronic pulmonary )] TJ ET BT 26.250 140.839 Td /F1 9.8 Tf [(diseases and endocrine disorders. Therefore passive surveillance tends to hinder the knowledge of epidemiology of this )] TJ ET BT 26.250 128.934 Td /F1 9.8 Tf [(pandemic [4] . Systematic detection for each patient with severe influenza-associated pathology like acute respiratory distress )] TJ ET BT 26.250 117.030 Td /F1 9.8 Tf [(syndrome [5] or for each patient with high mortality risk like pregnant woman [6] may contribute to appreciate the incidence of )] TJ ET BT 26.250 105.125 Td /F1 9.8 Tf [(influenza infection in this specifics groups.)] TJ ET BT 26.250 85.720 Td /F1 9.8 Tf [(In this context, we believe that implementation of a rapid A/H1N1 influenza diagnostic for the largest number of suspects cases )] TJ ET BT 26.250 73.815 Td /F1 9.8 Tf [(may improve the level of quality of patients care, the monitoring of pandemic through the reduction of secondary cases, and our )] TJ ET BT 26.250 61.911 Td /F1 9.8 Tf [(knowledge of the epidemiology of the pandemic.)] TJ ET Q q 0.000 0.000 0.000 rg BT 291.710 19.825 Td /F1 11.0 Tf [(1)] TJ ET BT 25.000 19.825 Td /F1 11.0 Tf [(PLOS Currents Influenza)] TJ ET Q endstream endobj 8 0 obj << /Type /Font /Subtype /Type1 /Name /F1 /BaseFont /Helvetica /Encoding /WinAnsiEncoding >> endobj 9 0 obj << /Type /Font /Subtype /Type1 /Name /F2 /BaseFont /Times-Bold /Encoding /WinAnsiEncoding >> endobj 10 0 obj << /Type /Font /Subtype /Type1 /Name /F3 /BaseFont /Times-Italic /Encoding /WinAnsiEncoding >> endobj 11 0 obj << /Type /Font /Subtype /Type1 /Name /F4 /BaseFont /Helvetica-Bold /Encoding /WinAnsiEncoding >> endobj 12 0 obj << /Type /Font /Subtype /Type1 /Name /F5 /BaseFont /Helvetica-Oblique /Encoding /WinAnsiEncoding >> endobj 13 0 obj << /Type /XObject /Subtype /Image /Width 500 /Height 52 /Filter /FlateDecode /DecodeParms << /Predictor 15 /Colors 1 /Columns 500 /BitsPerComponent 8>> /ColorSpace /DeviceGray /BitsPerComponent 8 /Length 144>> stream x1 0 'ݲ؎"e{dzAdzAdzAdzAdzAdzAdzAdzAdzAdzAdzAdzAtlM0\ endstream endobj 14 0 obj << /Type /XObject /Subtype /Image /Width 500 /Height 52 /SMask 13 0 R /Filter /FlateDecode /DecodeParms << /Predictor 15 /Colors 3 /Columns 500 /BitsPerComponent 8>> /ColorSpace /DeviceRGB /BitsPerComponent 8 /Length 3574>> stream x}ƕK*8+0T ֮ S L*0߇d" sl2FBiFwY0 00 0ŝa0 aqgR܋x||lu2 03UL۶BxI 0:UU0x;֝($z%șHڶ ÐVz ]IS> â(.* TQUuL5 $>BvpH0U:xkkGJT{OɗRNyGOΙyn)q7`(~_Ji2vgk]qVꔷ3N'ȴy4Ikm6!q:FJ)-0n܋v!^}_Z l61va_~Bxw8mv;EJY8}zzQ3]Pȹ,2_jfY4MQ[ '.uO O͋kշ9b6.#ߦUUzhf09+nKɿ4 f7Bu7ĨMfrF0`s8429j1}ZWDW;A4ҫ'TQ{7Cb[$ -"ΨMQgzN/2R7Tco*W:N݋6TUu8`RSi O>r;z^m(0w`:m=]գCE&t |ZYQ%{X[nR+zbEFΧ5pzq`ުం Ih{9G 4wMx' nmvEZ sg7?ZQ}&ҎKGuPu.j8UgNKꓙQC)s#$1䧈x[Z(|Xzc;t<~50Hh_T3Ur>a$]B8Fz[?K>Y/rQ=E4?EaLqzpX!(nNut]}e(/S\fz,<ZOEa]0 sCS_}I Y}n۶r(fg7#)h6ա}$ üvq]Aא$c0ddBDQ)ueypU-z~9Hk<$I©y'Tk`yY d}e{䨙ǐu>&w񚓶('GI\rm[G4 Sk7$B pEkYYC/ 9&Ʋ[V9MQ':X|C֨ʉ jt"ޡ+rttBռGdiM FuTEi(łv]fk"8Ldp' ^הMup2`M?dE!|KJ-\.MzکC=&¾HfR7$ev,La0+$OFuEQ"i,ːN?~E*t4qΚF:t`,{RkR]ޜ(Ԕѣ$IbN}5لS1(Ȱ$I$(eWp8Lٱ3߯ky۶&. 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Ce'\K@ WAwEUtO+k39nq?|9GK]gNL"NԀ8Y? +FѴkvk$XUb+lH8 gwG*{}C_xwl5+v:_GiUd~u~^y G4XnGAQy.[HZ|vP3d~K/(p7mO.!΢Yn!0]l)gG{Ǧ6[4c>Ӝ 3^I`='Q/4+ς^/>ε[ۋEكa@lʨJ9*ƁKNjsy5;kV,DzjdH^A.`J;ϪM~4?֚k4FO|]Ztv|ڄY'h6i l1\$<]' ~OX<ܷ,峗I*6tUcRWPrڟi/Iky Ʀ]RWlup÷,iu?[ws5uK٤M9"@5 @c=e?3Xƫit8#F8x[.mXZx7No.v:qXІ!8@B +*,SPHp%J<7|C}wX;ssc}>ڟ.,R+ʛIj~ C$w]--BMH2Ѧ;c2d?5[0Z^k+Ož+dڳp5=<1ݴIYw=uy|s7{QΊ\zfj7{WG stQǦnuyr1雅T%5U{G裐\Ǩnuyrn3@=3u裐9LF:(c7{QΊ9n3@=3u裐9LF:(c7{QΊ9o*@mAIyvQ.c7{QΊ9zf7WG stQǦnuyr1雨^gEzf7WG sL>?מw@NG^gE=3u裐9LFj:(c7QΊ\zYy\_ [Bs endstream endobj 113 0 obj << /Type /Annot /Subtype /Link /A 114 0 R /Border [0 0 0] /H /I /Rect [ 35.2500 322.0147 352.5000 639.2647 ] >> endobj 114 0 obj << /Type /Action /S /URI /URI (http://currents.plos.org/influenza/files/2009/09/figure-1.jpg) >> endobj 115 0 obj << /Type /Annot /Subtype /Link /A 116 0 R /Border [0 0 0] /H /I /Rect [ 35.2500 -37.1400 485.2500 269.6100 ] >> endobj 116 0 obj << /Type /Action /S /URI /URI (http://currents.plos.org/influenza/files/2009/09/table-1.jpg) >> endobj 117 0 obj << /Type /Annot /Subtype /Link /A 118 0 R /Border [0 0 0] /H /I /Rect [ 35.2500 322.0147 352.5000 639.2647 ] >> endobj 118 0 obj << /Type /Action /S /URI /URI (http://currents.plos.org/influenza/files/2009/09/figure-1.jpg) >> endobj 119 0 obj << /Type /Annot /Subtype /Link /A 120 0 R /Border [0 0 0] /H /I /Rect [ 35.2500 -37.1400 485.2500 269.6100 ] >> endobj 120 0 obj << /Type /Action /S /URI /URI (http://currents.plos.org/influenza/files/2009/09/table-1.jpg) >> endobj 121 0 obj << /Type /Page /Parent 3 0 R /Annots [ 123 0 R 126 0 R 130 0 R 132 0 R 136 0 R 138 0 R ] /Contents 122 0 R >> endobj 122 0 obj << /Length 15550 >> stream q 15.000 -261.200 577.500 1038.200 re W n 0.965 0.965 0.965 rg 26.250 744.514 555.000 32.486 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 744.514 m 581.250 744.514 l 581.250 745.264 l 26.250 745.264 l f q 35.250 755.764 537.000 21.236 re W n 0.271 0.267 0.267 rg BT 35.250 766.011 Td /F4 9.8 Tf [(Table 1: List of POC analysis.)] TJ ET Q BT 26.250 727.490 Td /F1 9.8 Tf [(When secondary cases of influenza A/H1N1 were documented in France, we decided to implement rapid diagnosis of pandemic )] TJ ET BT 26.250 715.585 Td /F1 9.8 Tf [(A/H1N1 virus in POC laboratory to investigate the level of virus circulation. Both POC laboratories were adapted to manage )] TJ ET BT 26.250 703.680 Td /F1 9.8 Tf [(specimens processing in appropriate biosafety conditions, and to perform A/H1N1 virus detection via immuno-chromatographic )] TJ ET BT 26.250 691.776 Td /F1 9.8 Tf [(tests \(ICT\) and one step qRT-PCR on SmartCycler \(Cepheid\). POC manipulators were trained to perform these analyses and to )] TJ ET BT 26.250 679.871 Td /F1 9.8 Tf [(work with class II pathogen agents \(see figure 2\). For PCR testing we selected the qRT-PCR assay recommended by the )] TJ ET BT 26.250 667.966 Td /F1 9.8 Tf [(French Influenza Reference National Center which was adapted to be run on SmartCycler. In parallel, all specimens were )] TJ ET BT 26.250 656.061 Td /F1 9.8 Tf [(spiked with an internal control which allowed to monitor all steps through specific qRT-PCR detection. Comparative evaluation )] TJ ET BT 26.250 644.157 Td /F1 9.8 Tf [(with the same protocol operated onto thermocycler MX3005P \(stratagene\) showed a lower sensitivity for low copy number )] TJ ET BT 26.250 632.252 Td /F1 9.8 Tf [(specimens, but no significant difference in term of specificity. The core laboratory was processing all samples received at POC )] TJ ET BT 26.250 620.347 Td /F1 9.8 Tf [(laboratories with \(i\) the qRT-PCR A/H1N1 assay aforementioned and \(ii\) a qRT-PCR SYBR Green system which detect all )] TJ ET BT 26.250 608.442 Td /F1 9.8 Tf [(Influenza A viruses [8] . Both reactions were performed onto either Mx3005p thermocycler \(Stratagene\) or LC480 thermocycler )] TJ ET BT 26.250 596.538 Td /F1 9.8 Tf [(\(Roche\). The maximal flow capacity \(upper limit\) of the POC laboratory for detection of A/H1N1 virus is 36 samples per day \(see )] TJ ET BT 26.250 584.633 Td /F1 9.8 Tf [(figure 2\).)] TJ ET 0.965 0.965 0.965 rg 26.250 201.442 555.000 373.310 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 574.752 m 581.250 574.752 l 581.250 574.002 l 26.250 574.002 l f 26.250 201.442 m 581.250 201.442 l 581.250 202.192 l 26.250 202.192 l f q 450.000 0 0 316.500 35.250 248.502 cm /I5 Do Q q 35.250 212.692 537.000 29.810 re W n 0.271 0.267 0.267 rg BT 35.250 232.978 Td /F4 9.8 Tf [(Fig. 2: Flow capacity in POC lab for detection of Influenza A/H1N1 pandemic virus \( A \), and equipment/cost )] TJ ET BT 35.250 221.073 Td /F4 9.8 Tf [(required for POC lab \( B,C \).)] TJ ET Q BT 26.250 184.419 Td /F1 9.8 Tf [(From April 25 )] TJ ET BT 87.470 188.307 Td /F1 8.7 Tf [(th)] TJ ET BT 94.698 184.419 Td /F1 9.8 Tf [( 2009 to August 31 )] TJ ET BT 179.260 188.307 Td /F1 8.7 Tf [(th)] TJ ET BT 186.488 184.419 Td /F1 9.8 Tf [( , the core laboratory received and processed 1815 samples to be tested for the presence )] TJ ET BT 26.250 172.514 Td /F1 9.8 Tf [(influenza A/H1N1 virus. A total of 236 samples were positive \(13%\). During the entire period, our laboratory was in charge of )] TJ ET BT 26.250 160.609 Td /F1 9.8 Tf [(testing human samples corresponding to 9 French departments \(south-eastern France\) representing 8 millions of inhabitants. )] TJ ET BT 26.250 148.704 Td /F1 9.8 Tf [(From April 25 )] TJ ET BT 87.470 152.593 Td /F1 8.7 Tf [(th)] TJ ET BT 94.698 148.704 Td /F1 9.8 Tf [( and late June, the attitude recommended by the authorities was to test all suspect cases. During this period a )] TJ ET BT 26.250 136.800 Td /F1 9.8 Tf [(maximum of 50 specimens were received weekly. On June 23 )] TJ ET BT 296.637 140.688 Td /F1 8.7 Tf [(th)] TJ ET BT 303.865 136.800 Td /F1 9.8 Tf [( 2009, we began to implement the POC strategy for all samples )] TJ ET BT 26.250 124.895 Td /F1 9.8 Tf [(received from Marseille publics hospitals, while samples received from hospitals and practitioners outside of Marseille were )] TJ ET BT 26.250 112.990 Td /F1 9.8 Tf [(processed directly in the core laboratory. This strategic change was synchronous with a drastic increase of weekly volume of )] TJ ET BT 26.250 101.085 Td /F1 9.8 Tf [(samples. At this period, about 100-150 samples were received per week until late August which witnessed a novel obvious )] TJ ET BT 26.250 89.181 Td /F1 9.8 Tf [(increase in the activity with 230 and 350 samples for the two latest weeks \(see figure 3\).)] TJ ET 0.965 0.965 0.965 rg 26.250 -261.200 555.000 340.500 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 79.300 m 581.250 79.300 l 581.250 78.550 l 26.250 78.550 l f q 450.000 0 0 324.750 35.250 -255.200 cm /I7 Do Q q 35.250 -261.200 537.000 0.000 re W n Q Q q 15.000 -261.200 577.500 1038.200 re W n 0.965 0.965 0.965 rg 26.250 744.514 555.000 32.486 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 744.514 m 581.250 744.514 l 581.250 745.264 l 26.250 745.264 l f q 35.250 755.764 537.000 21.236 re W n 0.271 0.267 0.267 rg BT 35.250 766.011 Td /F4 9.8 Tf [(Table 1: List of POC analysis.)] TJ ET Q BT 26.250 727.490 Td /F1 9.8 Tf [(When secondary cases of influenza A/H1N1 were documented in France, we decided to implement rapid diagnosis of pandemic )] TJ ET BT 26.250 715.585 Td /F1 9.8 Tf [(A/H1N1 virus in POC laboratory to investigate the level of virus circulation. Both POC laboratories were adapted to manage )] TJ ET BT 26.250 703.680 Td /F1 9.8 Tf [(specimens processing in appropriate biosafety conditions, and to perform A/H1N1 virus detection via immuno-chromatographic )] TJ ET BT 26.250 691.776 Td /F1 9.8 Tf [(tests \(ICT\) and one step qRT-PCR on SmartCycler \(Cepheid\). POC manipulators were trained to perform these analyses and to )] TJ ET BT 26.250 679.871 Td /F1 9.8 Tf [(work with class II pathogen agents \(see figure 2\). For PCR testing we selected the qRT-PCR assay recommended by the )] TJ ET BT 26.250 667.966 Td /F1 9.8 Tf [(French Influenza Reference National Center which was adapted to be run on SmartCycler. In parallel, all specimens were )] TJ ET BT 26.250 656.061 Td /F1 9.8 Tf [(spiked with an internal control which allowed to monitor all steps through specific qRT-PCR detection. Comparative evaluation )] TJ ET BT 26.250 644.157 Td /F1 9.8 Tf [(with the same protocol operated onto thermocycler MX3005P \(stratagene\) showed a lower sensitivity for low copy number )] TJ ET BT 26.250 632.252 Td /F1 9.8 Tf [(specimens, but no significant difference in term of specificity. The core laboratory was processing all samples received at POC )] TJ ET BT 26.250 620.347 Td /F1 9.8 Tf [(laboratories with \(i\) the qRT-PCR A/H1N1 assay aforementioned and \(ii\) a qRT-PCR SYBR Green system which detect all )] TJ ET BT 26.250 608.442 Td /F1 9.8 Tf [(Influenza A viruses [8] . Both reactions were performed onto either Mx3005p thermocycler \(Stratagene\) or LC480 thermocycler )] TJ ET BT 26.250 596.538 Td /F1 9.8 Tf [(\(Roche\). The maximal flow capacity \(upper limit\) of the POC laboratory for detection of A/H1N1 virus is 36 samples per day \(see )] TJ ET BT 26.250 584.633 Td /F1 9.8 Tf [(figure 2\).)] TJ ET 0.965 0.965 0.965 rg 26.250 201.442 555.000 373.310 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 574.752 m 581.250 574.752 l 581.250 574.002 l 26.250 574.002 l f 26.250 201.442 m 581.250 201.442 l 581.250 202.192 l 26.250 202.192 l f q 450.000 0 0 316.500 35.250 248.502 cm /I5 Do Q q 35.250 212.692 537.000 29.810 re W n 0.271 0.267 0.267 rg BT 35.250 232.978 Td /F4 9.8 Tf [(Fig. 2: Flow capacity in POC lab for detection of Influenza A/H1N1 pandemic virus \( A \), and equipment/cost )] TJ ET BT 35.250 221.073 Td /F4 9.8 Tf [(required for POC lab \( B,C \).)] TJ ET Q BT 26.250 184.419 Td /F1 9.8 Tf [(From April 25 )] TJ ET BT 87.470 188.307 Td /F1 8.7 Tf [(th)] TJ ET BT 94.698 184.419 Td /F1 9.8 Tf [( 2009 to August 31 )] TJ ET BT 179.260 188.307 Td /F1 8.7 Tf [(th)] TJ ET BT 186.488 184.419 Td /F1 9.8 Tf [( , the core laboratory received and processed 1815 samples to be tested for the presence )] TJ ET BT 26.250 172.514 Td /F1 9.8 Tf [(influenza A/H1N1 virus. A total of 236 samples were positive \(13%\). During the entire period, our laboratory was in charge of )] TJ ET BT 26.250 160.609 Td /F1 9.8 Tf [(testing human samples corresponding to 9 French departments \(south-eastern France\) representing 8 millions of inhabitants. )] TJ ET BT 26.250 148.704 Td /F1 9.8 Tf [(From April 25 )] TJ ET BT 87.470 152.593 Td /F1 8.7 Tf [(th)] TJ ET BT 94.698 148.704 Td /F1 9.8 Tf [( and late June, the attitude recommended by the authorities was to test all suspect cases. During this period a )] TJ ET BT 26.250 136.800 Td /F1 9.8 Tf [(maximum of 50 specimens were received weekly. On June 23 )] TJ ET BT 296.637 140.688 Td /F1 8.7 Tf [(th)] TJ ET BT 303.865 136.800 Td /F1 9.8 Tf [( 2009, we began to implement the POC strategy for all samples )] TJ ET BT 26.250 124.895 Td /F1 9.8 Tf [(received from Marseille publics hospitals, while samples received from hospitals and practitioners outside of Marseille were )] TJ ET BT 26.250 112.990 Td /F1 9.8 Tf [(processed directly in the core laboratory. This strategic change was synchronous with a drastic increase of weekly volume of )] TJ ET BT 26.250 101.085 Td /F1 9.8 Tf [(samples. At this period, about 100-150 samples were received per week until late August which witnessed a novel obvious )] TJ ET BT 26.250 89.181 Td /F1 9.8 Tf [(increase in the activity with 230 and 350 samples for the two latest weeks \(see figure 3\).)] TJ ET 0.965 0.965 0.965 rg 26.250 -261.200 555.000 340.500 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 79.300 m 581.250 79.300 l 581.250 78.550 l 26.250 78.550 l f q 450.000 0 0 324.750 35.250 -255.200 cm /I9 Do Q q 35.250 -261.200 537.000 0.000 re W n Q Q q 15.000 -261.200 577.500 1038.200 re W n 0.965 0.965 0.965 rg 26.250 744.514 555.000 32.486 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 744.514 m 581.250 744.514 l 581.250 745.264 l 26.250 745.264 l f q 35.250 755.764 537.000 21.236 re W n 0.271 0.267 0.267 rg BT 35.250 766.011 Td /F4 9.8 Tf [(Table 1: List of POC analysis.)] TJ ET Q BT 26.250 727.490 Td /F1 9.8 Tf [(When secondary cases of influenza A/H1N1 were documented in France, we decided to implement rapid diagnosis of pandemic )] TJ ET BT 26.250 715.585 Td /F1 9.8 Tf [(A/H1N1 virus in POC laboratory to investigate the level of virus circulation. Both POC laboratories were adapted to manage )] TJ ET BT 26.250 703.680 Td /F1 9.8 Tf [(specimens processing in appropriate biosafety conditions, and to perform A/H1N1 virus detection via immuno-chromatographic )] TJ ET BT 26.250 691.776 Td /F1 9.8 Tf [(tests \(ICT\) and one step qRT-PCR on SmartCycler \(Cepheid\). POC manipulators were trained to perform these analyses and to )] TJ ET BT 26.250 679.871 Td /F1 9.8 Tf [(work with class II pathogen agents \(see figure 2\). For PCR testing we selected the qRT-PCR assay recommended by the )] TJ ET BT 26.250 667.966 Td /F1 9.8 Tf [(French Influenza Reference National Center which was adapted to be run on SmartCycler. In parallel, all specimens were )] TJ ET BT 26.250 656.061 Td /F1 9.8 Tf [(spiked with an internal control which allowed to monitor all steps through specific qRT-PCR detection. Comparative evaluation )] TJ ET BT 26.250 644.157 Td /F1 9.8 Tf [(with the same protocol operated onto thermocycler MX3005P \(stratagene\) showed a lower sensitivity for low copy number )] TJ ET BT 26.250 632.252 Td /F1 9.8 Tf [(specimens, but no significant difference in term of specificity. The core laboratory was processing all samples received at POC )] TJ ET BT 26.250 620.347 Td /F1 9.8 Tf [(laboratories with \(i\) the qRT-PCR A/H1N1 assay aforementioned and \(ii\) a qRT-PCR SYBR Green system which detect all )] TJ ET BT 26.250 608.442 Td /F1 9.8 Tf [(Influenza A viruses [8] . Both reactions were performed onto either Mx3005p thermocycler \(Stratagene\) or LC480 thermocycler )] TJ ET BT 26.250 596.538 Td /F1 9.8 Tf [(\(Roche\). The maximal flow capacity \(upper limit\) of the POC laboratory for detection of A/H1N1 virus is 36 samples per day \(see )] TJ ET BT 26.250 584.633 Td /F1 9.8 Tf [(figure 2\).)] TJ ET 0.965 0.965 0.965 rg 26.250 201.442 555.000 373.310 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 574.752 m 581.250 574.752 l 581.250 574.002 l 26.250 574.002 l f 26.250 201.442 m 581.250 201.442 l 581.250 202.192 l 26.250 202.192 l f q 450.000 0 0 316.500 35.250 248.502 cm /I5 Do Q q 35.250 212.692 537.000 29.810 re W n 0.271 0.267 0.267 rg BT 35.250 232.978 Td /F4 9.8 Tf [(Fig. 2: Flow capacity in POC lab for detection of Influenza A/H1N1 pandemic virus \( A \), and equipment/cost )] TJ ET BT 35.250 221.073 Td /F4 9.8 Tf [(required for POC lab \( B,C \).)] TJ ET Q BT 26.250 184.419 Td /F1 9.8 Tf [(From April 25 )] TJ ET BT 87.470 188.307 Td /F1 8.7 Tf [(th)] TJ ET BT 94.698 184.419 Td /F1 9.8 Tf [( 2009 to August 31 )] TJ ET BT 179.260 188.307 Td /F1 8.7 Tf [(th)] TJ ET BT 186.488 184.419 Td /F1 9.8 Tf [( , the core laboratory received and processed 1815 samples to be tested for the presence )] TJ ET BT 26.250 172.514 Td /F1 9.8 Tf [(influenza A/H1N1 virus. A total of 236 samples were positive \(13%\). During the entire period, our laboratory was in charge of )] TJ ET BT 26.250 160.609 Td /F1 9.8 Tf [(testing human samples corresponding to 9 French departments \(south-eastern France\) representing 8 millions of inhabitants. )] TJ ET BT 26.250 148.704 Td /F1 9.8 Tf [(From April 25 )] TJ ET BT 87.470 152.593 Td /F1 8.7 Tf [(th)] TJ ET BT 94.698 148.704 Td /F1 9.8 Tf [( and late June, the attitude recommended by the authorities was to test all suspect cases. During this period a )] TJ ET BT 26.250 136.800 Td /F1 9.8 Tf [(maximum of 50 specimens were received weekly. On June 23 )] TJ ET BT 296.637 140.688 Td /F1 8.7 Tf [(th)] TJ ET BT 303.865 136.800 Td /F1 9.8 Tf [( 2009, we began to implement the POC strategy for all samples )] TJ ET BT 26.250 124.895 Td /F1 9.8 Tf [(received from Marseille publics hospitals, while samples received from hospitals and practitioners outside of Marseille were )] TJ ET BT 26.250 112.990 Td /F1 9.8 Tf [(processed directly in the core laboratory. This strategic change was synchronous with a drastic increase of weekly volume of )] TJ ET BT 26.250 101.085 Td /F1 9.8 Tf [(samples. At this period, about 100-150 samples were received per week until late August which witnessed a novel obvious )] TJ ET BT 26.250 89.181 Td /F1 9.8 Tf [(increase in the activity with 230 and 350 samples for the two latest weeks \(see figure 3\).)] TJ ET 0.965 0.965 0.965 rg 26.250 -261.200 555.000 340.500 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 79.300 m 581.250 79.300 l 581.250 78.550 l 26.250 78.550 l f q 450.000 0 0 324.750 35.250 -255.200 cm /I11 Do Q q 35.250 -261.200 537.000 0.000 re W n Q Q q 450.000 0 0 316.500 35.250 248.502 cm /I5 Do Q q 450.000 0 0 324.750 35.250 -255.200 cm /I13 Do Q q 0.000 0.000 0.000 rg BT 291.710 19.825 Td /F1 11.0 Tf [(3)] TJ ET BT 25.000 19.825 Td /F1 11.0 Tf [(PLOS Currents Influenza)] TJ ET Q endstream endobj 123 0 obj << /Type /Annot /Subtype /Link /A 124 0 R /Border [0 0 0] /H /I /Rect [ 35.2500 248.5020 485.2500 565.0020 ] >> endobj 124 0 obj << /Type /Action /S /URI /URI (http://currents.plos.org/influenza/files/2009/09/figure-2.jpg) >> endobj 125 0 obj << /Type /XObject /Subtype /Image /Width 600 /Height 422 /ColorSpace /DeviceRGB /Filter /DCTDecode /BitsPerComponent 8 /Length 60851>> stream JFIF;CREATOR: gd-jpeg v1.0 (using IJG JPEG v62), quality = 90 C     C   X" }!1AQa"q2#BR$3br %&'()*456789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz w!1AQaq"2B #3Rbr $4%&'()*56789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz ?QE# i#4Ҿ&h[ C3ekVcĆ+ +z k9L1XŃ9C_[|;Ο#4WpGb 4z;3sKLaEPRR@ KҊ(QI(h%/z? ~4QK֒QE%- (QFh(IK@h4}(4A4jMsſ0;όn4Sȳ4f[l-S73 msW?5IGT:ivc(n79S$ ZrP3L(R ;QGJ:EQIK@Q@Pړږ ( ( )( ):RE(PEQE!l_SV~ ִ|F oӧtêGq_1~|_j|{|5^K?./A~u뛯 FcDL0hsz5_i/ߌM;{#C#3=kJ0)Z(*_y|\]?}F0>9+W%>WKF Us t|Dn(4<_J~.0~y|\]?}{%_?O?G<_J..~(y|\]?*b>9+W%=WKF|s=WK{%_?O?_c`Q{%??O?G<_J..~ Ss t|Dl 1|s=WK{%_?O?_cb }%_?O?G<_J.0~<_J..~y|\]?}HE|s>WK}%_?O?_cb<_J~..~y|\]?}KQ>,>|U]xr8}Y^?Ë"sMəU׌W~~CJ?GM?Ey~-foF84PԤj8t Uk-'MK[[u"8aFJxIF(Z+ zjn??᪾~O+LQj"jn?`P_ ??'U|4qWP_ ??'U|4qW5WO7E_ ??'&(} U G5WO7E| 1@te%3kYN]?iA?"g]v:ΟJ^_$0=#3"jn?gwH᪾~O(iA?Mw\ޕ>|*$I UYݴs*+m)V}~ M.QYBH4ڈG=*Kvcmym)56ϸV>85Dųw?Kx/k@_ ??'U|4qW46S[k5xA&3c'[⇠~U|4qQ U _Vȱ%bzIv ^@Q@Ph3@hJZ((EQEt6`fҨ[Ʉx[#D[LCJo&oto@WUԡѴBok !QA'պ6M27yk- .A?'(i9tu;:E 3je YCܷqlXF&ЌUB^{oWt `[0$DʷB+kTmi^iVWP^B$F(!}jQk%ẚKX.e wyPXa:#7;y!mgOIhQT'G#k_z֛m#Qxgu;4909jŷl_7tCI$˿ ۽%=.z<0b9m&b\r0>¥EUٮHN7cnsЃ6Ծ s^ iwڙZF}IP [24!-@wNqcOi>5n(x\7++9dzknvq,3THφpFq]=Q"QKIHgi/ֵbO^^}{BO[|Fɨqm4 6 7ڭw 㯇%<]Akx5.>Y_(am# oޓeޝqw|ƍ[,jx$HG52O6Bd3C̛ BdI|G4[]uyofn…c:o HHFýklBQXma*ðʏ\[_Zsmm%+HfEb)+[V:iO76 gKV.֟hl-T7C $`^~OzW-_\|;]oGRMQ B8QqڲciȻӭ- FK{$F 0Tt$ryAO{,巕B?oֱsY >qsg>vKs[?EkNGƳp,em {KpTcӎk N[k7F$[e29v󏼘'N1]kKKiQ0In'd-P k kJSU]d9cs1֥tڽc.},bY2=xϱfpc {!7ϻH#+>}spkվ%L4\&e2lM)Gp+?K_urSNNZH)aNF@%t% w> -aO4vVz-fPh q^ܧ1Bю\NQ#53I".S;9]Z׶S [đJO NXOWs?H?Q b@{^+&'Sm_dI)REQEKA@̷%OI_Ho3;0Wg%OI_Ho3;0P'o 6X8~ߴǎ<7>Iq4^ZۮrTuJw'V0E~ÿ:3W=?y~Դ_]1Xt` 2`3׽Wg 5TQ((QEQGz(4PEPEPE(6`fҨ[Ʉx[#D[LCJox<{>UcОPT?<%Q /_GZ>_JN^mBKHX[uR9P $ fs sBr"Ie# A3}jʋE6䚴0-Ķ3!K''(LF9}7//A40%sLH6c;T>?{jp}? 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?_qj}挖 ɇA dee͚5kFK6 ~۷o C;e2yyyeeeW]u^WgdFt9DP&agTyP޺=ZLG $껫*m۶uW_ڵwi{~Iy7p Pac[~{g o&Ծ S USRAR =C Ѯ g w)3 P|:+ \P#H*vAEnUS,zQx'tخٳgO9@9)]v8㌛o9P>$<>YRw(8{¹˵$q0886%zQ3&%^:p@ƠL~2F>2\p˖-3≋a@V/f1iU TsOu?H A-߅og`ڑMMY`.cP*NГRʳگpt|M')Ԍ e xLU $`/b4dN W>I{7ŧF&UX*瞧; o71ScPժ[_hI ڏ~ɌOP@23'B&>=a%)1vl>y7@8b+Qp 4:|l+>.0>f|ԌQ~€]hIX[zaII$ݪF%@ϴzͽCl-}w@F5W(0KvQB`Ή9!@``]ET×6j"qHݭvKqKr >[8ա*aYCYbP" d*&ky@ H;=R JAɰ#kMsh8pC|naI=SXcaI*rT FEZVTϖDIl%5 pL,o1"4Ǚ[X5`2@*rv_JfzAV~1T4"a3Zu. c3.DT1TgCQr0 uC8yU rEZjmC׃GLP[UuJT*Ԣ\l1`BHl=9Ra]ـ F3YV䅤P!s|htf5 HlE %0sR,9 'IZ94P €PB[!5/ڕ؍PJ)[T<_NG (d}0Z5_* ypiU* d| 4L1pJ5@8C˭ɳA.A d}.^5^f>(09T@J5lQ=rT&U!j*XP@^L^xP.̑,4-l:K"-o^cS`%}>r室Z60qȪ3>I%;LJa)ނ^i4GA@e ڑ^0Zר,y,C@YFd)pX'\ɒaݵT.~¡d5~_ɔ6L!KfC9#V' LCEz`X1^ϫ4uH|!PvvJL_kYo>aQ+ I@|eQcǕ#x [UP+C-b-]`F \TfdEC;HheKԜsܢ̀LK9ژXaIuhMỌG՟G^ +Nj I5aV {}N -j$T:dMY&>/R"7gJO2MF}C-/*tX%UImM'TsIL3QƿҌ:p?)7khI-iuѰIgU:j}3$eT6<Ҵ&>6q^TV%\,sE&bg΀ﬓI Rqd/ұ"% endstream endobj 144 0 obj << /Type /Page /Parent 3 0 R /Annots [ 146 0 R 150 0 R 153 0 R 157 0 R 159 0 R 163 0 R ] /Contents 145 0 R >> endobj 145 0 obj << /Length 10823 >> stream q 15.000 24.119 577.500 752.881 re W n 0.965 0.965 0.965 rg 26.250 735.941 555.000 41.059 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 735.941 m 581.250 735.941 l 581.250 736.691 l 26.250 736.691 l f q 35.250 747.191 537.000 29.809 re W n 0.271 0.267 0.267 rg BT 35.250 767.476 Td /F4 9.8 Tf [(Fig. 3: Cumulative number of laboratory confirmed cases of Influenza A/H1N1 pandemic infection announced by )] TJ ET BT 35.250 755.571 Td /F4 9.8 Tf [(WHO [9] \(panel 1\) and observed in Marseille virology laboratory \(panel 2\).)] TJ ET Q BT 26.250 718.917 Td /F1 9.8 Tf [(From June 23 )] TJ ET BT 89.108 722.805 Td /F1 8.7 Tf [(th)] TJ ET BT 96.336 718.917 Td /F1 9.8 Tf [( 2009 to August 31 )] TJ ET BT 180.898 722.805 Td /F1 8.7 Tf [(th)] TJ ET BT 188.126 718.917 Td /F1 9.8 Tf [( 2009, 990 samples were analyzed in POC laboratories \(see figure 4\). A majority of )] TJ ET BT 26.250 707.012 Td /F1 9.8 Tf [(samples originated from emergency wards \(pediatrics and adults\) \(66.3%\) and from the specific influenza consultation located )] TJ ET BT 26.250 695.107 Td /F1 9.8 Tf [(in the North Hospital \(19.2%\). The respective activity of the two POC laboratories was similar. Each laboratory tested about 30-)] TJ ET BT 26.250 683.202 Td /F1 9.8 Tf [(40 samples per week, but the last two weeks showed an increasing activity with respectively 149 and 191 samples tested \(see )] TJ ET BT 26.250 671.298 Td /F1 9.8 Tf [(figure 4\).)] TJ ET 0.965 0.965 0.965 rg 26.250 381.107 555.000 280.309 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 661.417 m 581.250 661.417 l 581.250 660.667 l 26.250 660.667 l f 26.250 381.107 m 581.250 381.107 l 581.250 381.857 l 26.250 381.857 l f q 450.000 0 0 223.500 35.250 428.167 cm /I15 Do Q q 35.250 392.357 537.000 29.809 re W n 0.271 0.267 0.267 rg BT 35.250 412.643 Td /F4 9.8 Tf [(Fig. 4: Time distribution of samples tested for each POC. The number upon the bar chart represents the number of )] TJ ET BT 35.250 400.738 Td /F4 9.8 Tf [(positive samples \(% of positives samples\).)] TJ ET Q BT 26.250 364.083 Td /F1 9.8 Tf [(Among the 990 samples tested in POC laboratories, 21 were positive with rapid ICT. After RNA extraction, some samples were )] TJ ET BT 26.250 352.179 Td /F1 9.8 Tf [(tested directly by the core laboratory. A total of 563 samples were tested using the one step qRT-PCR on SmartCycler, of which )] TJ ET BT 26.250 340.274 Td /F1 9.8 Tf [(33 \(5.9%\) were positive. Finally, 65 samples were positives after core laboratory confirmation test \(6.6%\). Therefore, the )] TJ ET BT 26.250 328.369 Td /F1 9.8 Tf [(sensitivity of POC strategy for A/H1N1 was 63,1% after rapid ICT and 84.6% after qRT-PCR assay. We determined the positive )] TJ ET BT 26.250 316.464 Td /F1 9.8 Tf [(and negative predictive value \(PPV and NPV\) for each step of POC process \(see figure 5\).)] TJ ET 0.965 0.965 0.965 rg 26.250 55.429 555.000 251.155 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 306.583 m 581.250 306.583 l 581.250 305.833 l 26.250 305.833 l f 26.250 55.429 m 581.250 55.429 l 581.250 56.179 l 26.250 56.179 l f q 450.000 0 0 206.250 35.250 90.583 cm /I16 Do Q q 35.250 66.679 537.000 17.905 re W n 0.271 0.267 0.267 rg BT 35.250 75.060 Td /F4 9.8 Tf [(Fig. 5: Flow chart of POC samples with sensitivity, specificity, PPV and NPV of each step.)] TJ ET Q BT 26.250 38.405 Td /F1 9.8 Tf [(The number of positive samples fluctuated between weeks but increased during the last two weeks. Percentages also fluctuated )] TJ ET Q q 15.000 24.119 577.500 752.881 re W n 0.965 0.965 0.965 rg 26.250 735.941 555.000 41.059 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 735.941 m 581.250 735.941 l 581.250 736.691 l 26.250 736.691 l f q 35.250 747.191 537.000 29.809 re W n 0.271 0.267 0.267 rg BT 35.250 767.476 Td /F4 9.8 Tf [(Fig. 3: Cumulative number of laboratory confirmed cases of Influenza A/H1N1 pandemic infection announced by )] TJ ET BT 35.250 755.571 Td /F4 9.8 Tf [(WHO [9] \(panel 1\) and observed in Marseille virology laboratory \(panel 2\).)] TJ ET Q BT 26.250 718.917 Td /F1 9.8 Tf [(From June 23 )] TJ ET BT 89.108 722.805 Td /F1 8.7 Tf [(th)] TJ ET BT 96.336 718.917 Td /F1 9.8 Tf [( 2009 to August 31 )] TJ ET BT 180.898 722.805 Td /F1 8.7 Tf [(th)] TJ ET BT 188.126 718.917 Td /F1 9.8 Tf [( 2009, 990 samples were analyzed in POC laboratories \(see figure 4\). A majority of )] TJ ET BT 26.250 707.012 Td /F1 9.8 Tf [(samples originated from emergency wards \(pediatrics and adults\) \(66.3%\) and from the specific influenza consultation located )] TJ ET BT 26.250 695.107 Td /F1 9.8 Tf [(in the North Hospital \(19.2%\). The respective activity of the two POC laboratories was similar. Each laboratory tested about 30-)] TJ ET BT 26.250 683.202 Td /F1 9.8 Tf [(40 samples per week, but the last two weeks showed an increasing activity with respectively 149 and 191 samples tested \(see )] TJ ET BT 26.250 671.298 Td /F1 9.8 Tf [(figure 4\).)] TJ ET 0.965 0.965 0.965 rg 26.250 381.107 555.000 280.309 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 661.417 m 581.250 661.417 l 581.250 660.667 l 26.250 660.667 l f 26.250 381.107 m 581.250 381.107 l 581.250 381.857 l 26.250 381.857 l f q 450.000 0 0 223.500 35.250 428.167 cm /I18 Do Q q 35.250 392.357 537.000 29.809 re W n 0.271 0.267 0.267 rg BT 35.250 412.643 Td /F4 9.8 Tf [(Fig. 4: Time distribution of samples tested for each POC. The number upon the bar chart represents the number of )] TJ ET BT 35.250 400.738 Td /F4 9.8 Tf [(positive samples \(% of positives samples\).)] TJ ET Q BT 26.250 364.083 Td /F1 9.8 Tf [(Among the 990 samples tested in POC laboratories, 21 were positive with rapid ICT. After RNA extraction, some samples were )] TJ ET BT 26.250 352.179 Td /F1 9.8 Tf [(tested directly by the core laboratory. A total of 563 samples were tested using the one step qRT-PCR on SmartCycler, of which )] TJ ET BT 26.250 340.274 Td /F1 9.8 Tf [(33 \(5.9%\) were positive. Finally, 65 samples were positives after core laboratory confirmation test \(6.6%\). Therefore, the )] TJ ET BT 26.250 328.369 Td /F1 9.8 Tf [(sensitivity of POC strategy for A/H1N1 was 63,1% after rapid ICT and 84.6% after qRT-PCR assay. We determined the positive )] TJ ET BT 26.250 316.464 Td /F1 9.8 Tf [(and negative predictive value \(PPV and NPV\) for each step of POC process \(see figure 5\).)] TJ ET 0.965 0.965 0.965 rg 26.250 55.429 555.000 251.155 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 306.583 m 581.250 306.583 l 581.250 305.833 l 26.250 305.833 l f 26.250 55.429 m 581.250 55.429 l 581.250 56.179 l 26.250 56.179 l f q 450.000 0 0 206.250 35.250 90.583 cm /I16 Do Q q 35.250 66.679 537.000 17.905 re W n 0.271 0.267 0.267 rg BT 35.250 75.060 Td /F4 9.8 Tf [(Fig. 5: Flow chart of POC samples with sensitivity, specificity, PPV and NPV of each step.)] TJ ET Q BT 26.250 38.405 Td /F1 9.8 Tf [(The number of positive samples fluctuated between weeks but increased during the last two weeks. Percentages also fluctuated )] TJ ET Q q 15.000 24.119 577.500 752.881 re W n 0.965 0.965 0.965 rg 26.250 735.941 555.000 41.059 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 735.941 m 581.250 735.941 l 581.250 736.691 l 26.250 736.691 l f q 35.250 747.191 537.000 29.809 re W n 0.271 0.267 0.267 rg BT 35.250 767.476 Td /F4 9.8 Tf [(Fig. 3: Cumulative number of laboratory confirmed cases of Influenza A/H1N1 pandemic infection announced by )] TJ ET BT 35.250 755.571 Td /F4 9.8 Tf [(WHO [9] \(panel 1\) and observed in Marseille virology laboratory \(panel 2\).)] TJ ET Q BT 26.250 718.917 Td /F1 9.8 Tf [(From June 23 )] TJ ET BT 89.108 722.805 Td /F1 8.7 Tf [(th)] TJ ET BT 96.336 718.917 Td /F1 9.8 Tf [( 2009 to August 31 )] TJ ET BT 180.898 722.805 Td /F1 8.7 Tf [(th)] TJ ET BT 188.126 718.917 Td /F1 9.8 Tf [( 2009, 990 samples were analyzed in POC laboratories \(see figure 4\). A majority of )] TJ ET BT 26.250 707.012 Td /F1 9.8 Tf [(samples originated from emergency wards \(pediatrics and adults\) \(66.3%\) and from the specific influenza consultation located )] TJ ET BT 26.250 695.107 Td /F1 9.8 Tf [(in the North Hospital \(19.2%\). The respective activity of the two POC laboratories was similar. Each laboratory tested about 30-)] TJ ET BT 26.250 683.202 Td /F1 9.8 Tf [(40 samples per week, but the last two weeks showed an increasing activity with respectively 149 and 191 samples tested \(see )] TJ ET BT 26.250 671.298 Td /F1 9.8 Tf [(figure 4\).)] TJ ET 0.965 0.965 0.965 rg 26.250 381.107 555.000 280.309 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 661.417 m 581.250 661.417 l 581.250 660.667 l 26.250 660.667 l f 26.250 381.107 m 581.250 381.107 l 581.250 381.857 l 26.250 381.857 l f q 450.000 0 0 223.500 35.250 428.167 cm /I20 Do Q q 35.250 392.357 537.000 29.809 re W n 0.271 0.267 0.267 rg BT 35.250 412.643 Td /F4 9.8 Tf [(Fig. 4: Time distribution of samples tested for each POC. The number upon the bar chart represents the number of )] TJ ET BT 35.250 400.738 Td /F4 9.8 Tf [(positive samples \(% of positives samples\).)] TJ ET Q BT 26.250 364.083 Td /F1 9.8 Tf [(Among the 990 samples tested in POC laboratories, 21 were positive with rapid ICT. After RNA extraction, some samples were )] TJ ET BT 26.250 352.179 Td /F1 9.8 Tf [(tested directly by the core laboratory. A total of 563 samples were tested using the one step qRT-PCR on SmartCycler, of which )] TJ ET BT 26.250 340.274 Td /F1 9.8 Tf [(33 \(5.9%\) were positive. Finally, 65 samples were positives after core laboratory confirmation test \(6.6%\). Therefore, the )] TJ ET BT 26.250 328.369 Td /F1 9.8 Tf [(sensitivity of POC strategy for A/H1N1 was 63,1% after rapid ICT and 84.6% after qRT-PCR assay. We determined the positive )] TJ ET BT 26.250 316.464 Td /F1 9.8 Tf [(and negative predictive value \(PPV and NPV\) for each step of POC process \(see figure 5\).)] TJ ET 0.965 0.965 0.965 rg 26.250 55.429 555.000 251.155 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 306.583 m 581.250 306.583 l 581.250 305.833 l 26.250 305.833 l f 26.250 55.429 m 581.250 55.429 l 581.250 56.179 l 26.250 56.179 l f q 450.000 0 0 206.250 35.250 90.583 cm /I16 Do Q q 35.250 66.679 537.000 17.905 re W n 0.271 0.267 0.267 rg BT 35.250 75.060 Td /F4 9.8 Tf [(Fig. 5: Flow chart of POC samples with sensitivity, specificity, PPV and NPV of each step.)] TJ ET Q BT 26.250 38.405 Td /F1 9.8 Tf [(The number of positive samples fluctuated between weeks but increased during the last two weeks. Percentages also fluctuated )] TJ ET Q q 450.000 0 0 223.500 35.250 428.167 cm /I22 Do Q q 450.000 0 0 206.250 35.250 90.583 cm /I16 Do Q q 0.000 0.000 0.000 rg BT 291.710 19.825 Td /F1 11.0 Tf [(4)] TJ ET BT 25.000 19.825 Td /F1 11.0 Tf [(PLOS Currents Influenza)] TJ ET Q endstream endobj 146 0 obj << /Type /Annot /Subtype /Link /A 147 0 R /Border [0 0 0] /H /I /Rect [ 35.2500 428.1667 485.2500 651.6667 ] >> endobj 147 0 obj << /Type /Action /S /URI /URI (http://currents.plos.org/influenza/files/2009/09/figure-41.png) >> endobj 148 0 obj << /Type /XObject /Subtype /Image /Width 600 /Height 298 /Filter /FlateDecode /DecodeParms << /Predictor 15 /Colors 1 /Columns 600 /BitsPerComponent 8>> /ColorSpace /DeviceGray /BitsPerComponent 8 /Length 807>> stream xұ P_d*Oa .#ޛuɶX_?8{hHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH{epcF endstream endobj 149 0 obj << /Type /XObject /Subtype /Image /Width 600 /Height 298 /SMask 148 0 R /Filter /FlateDecode /DecodeParms << /Predictor 15 /Colors 3 /Columns 600 /BitsPerComponent 8>> /ColorSpace /DeviceRGB /BitsPerComponent 8 /Length 59836>> stream xw@UG>P.EPXkL1n6fcMlkLYMYnLH[DE*6,4=Yyc39s9 I.,˒$GB0&-%I^ %;[ZъV^h?a$FV!\ aII$Q:dPQ]qd07&_QvyPvA5Fo-FXT[Y饞GGGhE+ZъV~ڵkϟ'iJNIIaeA"zeG/b]d^o) M!+=Y8}bd$P!kd,lG@dBHnn.!D'I ,2H3#]CþB2d<Ҷ)d2ia&Hbo+$C±`_V\XY%$:"D)!%5r3%pE \Eu@סJB}M!џ͋ "dzp> !Y22݂Fv2$B&MDK"6 {l%!Y8ƑyQxӣ.Hm$wN Y#va`J5r&Ӻ S@y8:UB=YId!^]327ta2"qbP2Y##2I^Rl_PFndVKB.BvLڝotRߴ0y Yc28󷄗,>jd̓%šFv2r RJ' &fa;kdĄd#:]ɰ;| 5: KC2k$V2d^E(mtLa (ٴdiYA+69d4|dب5C2tfH'c 8Ѣ]*: AY;kt5QwB2*hnDfkP/pE]dvy3%kdD{ꉄyog2}9TWћػ  ᥐ m4Ye~]̯9w? 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Computer-)] TJ ET BT 26.250 736.167 Td /F1 9.8 Tf [(based communication of results allowed to save time dedicated to telephone calls for both physician and POC person.)] TJ ET BT 26.250 699.564 Td /F4 12.0 Tf [(Discussion)] TJ ET BT 26.250 679.610 Td /F1 9.8 Tf [(POC strategy for A/H1N1 requires minimal training \(8 hours with written protocols\), necessitates a small dedicated laboratory )] TJ ET BT 26.250 667.705 Td /F1 9.8 Tf [(area which can be implemented in any hospital settings, and can be operated by one person at the time. It allows diagnosis )] TJ ET BT 26.250 655.800 Td /F1 9.8 Tf [(within the clinical time that can help the decision to treat the patient, to isolate the patient or to discharge the patient. It provides )] TJ ET BT 26.250 643.896 Td /F1 9.8 Tf [(reliable data to timely study the local epidemiology and its evolution. It helps to define and to monitor the epidemiology at a )] TJ ET BT 26.250 631.991 Td /F1 9.8 Tf [(larger scale \(regional, national, international\) via extrapolation based on the percentage of confirmed cases over suspect cases.)] TJ ET BT 26.250 612.586 Td /F1 9.8 Tf [(The usefulness of POC strategy in the context of A/H1N1 pandemic proves that POC should be implemented throughout the )] TJ ET BT 26.250 600.681 Td /F1 9.8 Tf [(country not only for emergency situations but also as a daily tool to improve the quality of care for hospitalized patients via )] TJ ET BT 26.250 588.777 Td /F1 9.8 Tf [(shortening the delays and allowing decisions within the clinical time. It is likely that hospitalization costs will also directly )] TJ ET BT 26.250 576.872 Td /F1 9.8 Tf [(beneficiate from POC strategy, through reduction of the duration of hospitalization as previously demonstrated [10][11] .)] TJ ET BT 26.250 557.467 Td /F1 9.8 Tf [(The decision to abandon systematic laboratory testing of suspect patients has been equivalent to break the thermometer and to )] TJ ET BT 26.250 545.562 Td /F1 9.8 Tf [(attempt to define body temperature curve. We believe that implementing diagnostic tools for pulmonary infections including flu )] TJ ET BT 26.250 533.658 Td /F1 9.8 Tf [(may allow to fight efficiently this group of diseases that is the more common cause of death worldwide [12] and the most )] TJ ET BT 26.250 521.753 Td /F1 9.8 Tf [(neglected cause of life reduction [13] . In the current situation where less than 10% of tested specimens are found positive, the )] TJ ET BT 26.250 509.848 Td /F1 9.8 Tf [(economic impact of rapid testing through the POC strategy is very important. Indeed, all negative patients the large majority of )] TJ ET BT 26.250 497.943 Td /F1 9.8 Tf [(suspect patients can therefore go back to their professional activities immediately. Beside, readmission of suspect students in )] TJ ET BT 26.250 486.039 Td /F1 9.8 Tf [(the educational course is often conditioned by a certificate assessing the absence of contagiousness, which need to be based )] TJ ET BT 26.250 474.134 Td /F1 9.8 Tf [(on specific virological diagnostic such as implemented in the POC strategy.)] TJ ET BT 26.250 437.531 Td /F4 12.0 Tf [(Funding information)] TJ ET BT 26.250 417.577 Td /F1 9.8 Tf [(No specific funding was received for the work presented in this manuscript.)] TJ ET BT 26.250 380.975 Td /F4 12.0 Tf [(Competing interests)] TJ ET BT 26.250 361.020 Td /F1 9.8 Tf [(The authors have declared that no competing interests exist.)] TJ ET BT 26.250 324.418 Td /F4 12.0 Tf [(References)] TJ ET BT 26.250 296.964 Td /F1 9.8 Tf [(1.)] TJ ET BT 38.132 296.964 Td /F1 9.8 Tf [(Organization, W.H., Statement to the press by WHO Director-General Dr Margaret Chan. )] TJ ET BT 26.250 285.059 Td /F1 9.8 Tf [(http://www.who.int/mediacentre/news/statements/2009/h1n1_pandemic_phase6_20090611/en/index.html, 2009.)] TJ ET 0.267 0.267 0.267 rg BT 26.250 276.573 Td /F1 7.5 Tf [(REFERENCE LINK)] TJ ET 0.271 0.267 0.267 rg BT 26.250 258.023 Td /F1 9.8 Tf [(2.)] TJ ET BT 38.132 258.023 Td /F1 9.8 Tf [(Levy-Bruhl, D. and S. Vaux, Modified surveillance of influenza A\(H1N1\)v virus infections in France. Euro Surveill, 2009. )] TJ ET BT 26.250 246.118 Td /F1 9.8 Tf [(14\(29\).)] TJ ET BT 26.250 226.713 Td /F1 9.8 Tf [(3.)] TJ ET BT 38.132 226.713 Td /F1 9.8 Tf [(Perez, M. and Y. Miserey, Controverse sur le nombre de cas de grippe A, in Le Figaro.fr. 2009 Sep 8.)] TJ ET BT 26.250 207.309 Td /F1 9.8 Tf [(4.)] TJ ET BT 38.132 207.309 Td /F1 9.8 Tf [(Hanshaoworakul, W., et al., Severe human influenza infections in Thailand: oseltamivir treatment and risk factors for fatal )] TJ ET BT 26.250 195.404 Td /F1 9.8 Tf [(outcome. PLoS One, 2009. 4\(6\): p. e6051.)] TJ ET BT 26.250 175.999 Td /F1 9.8 Tf [(5.)] TJ ET BT 38.132 175.999 Td /F1 9.8 Tf [(Intensive-care patients with severe novel influenza A \(H1N1\) virus infection - Michigan, June 2009. MMWR Morb Mortal Wkly )] TJ ET BT 26.250 164.094 Td /F1 9.8 Tf [(Rep, 2009. 58\(27\): p. 749-52.)] TJ ET BT 26.250 144.690 Td /F1 9.8 Tf [(6.)] TJ ET BT 38.132 144.690 Td /F1 9.8 Tf [(Jamieson, D.J., et al., H1N1 2009 influenza virus infection during pregnancy in the USA. Lancet, 2009. 374\(9688\): p. 451-8.)] TJ ET BT 26.250 125.285 Td /F1 9.8 Tf [(7.)] TJ ET BT 38.132 125.285 Td /F1 9.8 Tf [(Raoult, D., P.E. Fournier, and M. Drancourt, What does the future hold for clinical microbiology? Nat Rev Microbiol, 2004. )] TJ ET BT 26.250 113.380 Td /F1 9.8 Tf [(2\(2\): p. 151-9.)] TJ ET BT 26.250 93.975 Td /F1 9.8 Tf [(8.)] TJ ET BT 38.132 93.975 Td /F1 9.8 Tf [(Ninove, L., et al., A Simple Method for Molecular Detection of Swine-Origin and Human-Origin Influenza A Virus. Vector )] TJ ET BT 26.250 82.071 Td /F1 9.8 Tf [(Borne Zoonotic Dis, 2009.)] TJ ET BT 26.250 62.666 Td /F1 9.8 Tf [(9.)] TJ ET BT 38.132 62.666 Td /F1 9.8 Tf [(WHO, Situation updates - Pandemic \(H1N1\) 2009 in www.who.int.)] TJ ET 0.267 0.267 0.267 rg BT 26.250 54.180 Td /F1 7.5 Tf [(REFERENCE LINK)] TJ ET Q q 15.000 45.154 577.500 731.846 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(but increased during the last four weeks with positive results representing more than 10% of tested specimens.)] TJ ET BT 26.250 748.071 Td /F1 9.8 Tf [(The time necessary to obtain the results was 1-2h for the 21 samples positives with rapid ICT and 4-7h for the others. Computer-)] TJ ET BT 26.250 736.167 Td /F1 9.8 Tf [(based communication of results allowed to save time dedicated to telephone calls for both physician and POC person.)] TJ ET BT 26.250 699.564 Td /F4 12.0 Tf [(Discussion)] TJ ET BT 26.250 679.610 Td /F1 9.8 Tf [(POC strategy for A/H1N1 requires minimal training \(8 hours with written protocols\), necessitates a small dedicated laboratory )] TJ ET BT 26.250 667.705 Td /F1 9.8 Tf [(area which can be implemented in any hospital settings, and can be operated by one person at the time. It allows diagnosis )] TJ ET BT 26.250 655.800 Td /F1 9.8 Tf [(within the clinical time that can help the decision to treat the patient, to isolate the patient or to discharge the patient. It provides )] TJ ET BT 26.250 643.896 Td /F1 9.8 Tf [(reliable data to timely study the local epidemiology and its evolution. It helps to define and to monitor the epidemiology at a )] TJ ET BT 26.250 631.991 Td /F1 9.8 Tf [(larger scale \(regional, national, international\) via extrapolation based on the percentage of confirmed cases over suspect cases.)] TJ ET BT 26.250 612.586 Td /F1 9.8 Tf [(The usefulness of POC strategy in the context of A/H1N1 pandemic proves that POC should be implemented throughout the )] TJ ET BT 26.250 600.681 Td /F1 9.8 Tf [(country not only for emergency situations but also as a daily tool to improve the quality of care for hospitalized patients via )] TJ ET BT 26.250 588.777 Td /F1 9.8 Tf [(shortening the delays and allowing decisions within the clinical time. It is likely that hospitalization costs will also directly )] TJ ET BT 26.250 576.872 Td /F1 9.8 Tf [(beneficiate from POC strategy, through reduction of the duration of hospitalization as previously demonstrated [10][11] .)] TJ ET BT 26.250 557.467 Td /F1 9.8 Tf [(The decision to abandon systematic laboratory testing of suspect patients has been equivalent to break the thermometer and to )] TJ ET BT 26.250 545.562 Td /F1 9.8 Tf [(attempt to define body temperature curve. We believe that implementing diagnostic tools for pulmonary infections including flu )] TJ ET BT 26.250 533.658 Td /F1 9.8 Tf [(may allow to fight efficiently this group of diseases that is the more common cause of death worldwide [12] and the most )] TJ ET BT 26.250 521.753 Td /F1 9.8 Tf [(neglected cause of life reduction [13] . In the current situation where less than 10% of tested specimens are found positive, the )] TJ ET BT 26.250 509.848 Td /F1 9.8 Tf [(economic impact of rapid testing through the POC strategy is very important. Indeed, all negative patients the large majority of )] TJ ET BT 26.250 497.943 Td /F1 9.8 Tf [(suspect patients can therefore go back to their professional activities immediately. Beside, readmission of suspect students in )] TJ ET BT 26.250 486.039 Td /F1 9.8 Tf [(the educational course is often conditioned by a certificate assessing the absence of contagiousness, which need to be based )] TJ ET BT 26.250 474.134 Td /F1 9.8 Tf [(on specific virological diagnostic such as implemented in the POC strategy.)] TJ ET BT 26.250 437.531 Td /F4 12.0 Tf [(Funding information)] TJ ET BT 26.250 417.577 Td /F1 9.8 Tf [(No specific funding was received for the work presented in this manuscript.)] TJ ET BT 26.250 380.975 Td /F4 12.0 Tf [(Competing interests)] TJ ET BT 26.250 361.020 Td /F1 9.8 Tf [(The authors have declared that no competing interests exist.)] TJ ET BT 26.250 324.418 Td /F4 12.0 Tf [(References)] TJ ET BT 26.250 296.964 Td /F1 9.8 Tf [(1.)] TJ ET BT 38.132 296.964 Td /F1 9.8 Tf [(Organization, W.H., Statement to the press by WHO Director-General Dr Margaret Chan. )] TJ ET BT 26.250 285.059 Td /F1 9.8 Tf [(http://www.who.int/mediacentre/news/statements/2009/h1n1_pandemic_phase6_20090611/en/index.html, 2009.)] TJ ET 0.267 0.267 0.267 rg BT 26.250 276.573 Td /F1 7.5 Tf [(REFERENCE LINK)] TJ ET 0.271 0.267 0.267 rg BT 26.250 258.023 Td /F1 9.8 Tf [(2.)] TJ ET BT 38.132 258.023 Td /F1 9.8 Tf [(Levy-Bruhl, D. and S. Vaux, Modified surveillance of influenza A\(H1N1\)v virus infections in France. Euro Surveill, 2009. )] TJ ET BT 26.250 246.118 Td /F1 9.8 Tf [(14\(29\).)] TJ ET BT 26.250 226.713 Td /F1 9.8 Tf [(3.)] TJ ET BT 38.132 226.713 Td /F1 9.8 Tf [(Perez, M. and Y. Miserey, Controverse sur le nombre de cas de grippe A, in Le Figaro.fr. 2009 Sep 8.)] TJ ET BT 26.250 207.309 Td /F1 9.8 Tf [(4.)] TJ ET BT 38.132 207.309 Td /F1 9.8 Tf [(Hanshaoworakul, W., et al., Severe human influenza infections in Thailand: oseltamivir treatment and risk factors for fatal )] TJ ET BT 26.250 195.404 Td /F1 9.8 Tf [(outcome. PLoS One, 2009. 4\(6\): p. e6051.)] TJ ET BT 26.250 175.999 Td /F1 9.8 Tf [(5.)] TJ ET BT 38.132 175.999 Td /F1 9.8 Tf [(Intensive-care patients with severe novel influenza A \(H1N1\) virus infection - Michigan, June 2009. MMWR Morb Mortal Wkly )] TJ ET BT 26.250 164.094 Td /F1 9.8 Tf [(Rep, 2009. 58\(27\): p. 749-52.)] TJ ET BT 26.250 144.690 Td /F1 9.8 Tf [(6.)] TJ ET BT 38.132 144.690 Td /F1 9.8 Tf [(Jamieson, D.J., et al., H1N1 2009 influenza virus infection during pregnancy in the USA. Lancet, 2009. 374\(9688\): p. 451-8.)] TJ ET BT 26.250 125.285 Td /F1 9.8 Tf [(7.)] TJ ET BT 38.132 125.285 Td /F1 9.8 Tf [(Raoult, D., P.E. Fournier, and M. Drancourt, What does the future hold for clinical microbiology? Nat Rev Microbiol, 2004. )] TJ ET BT 26.250 113.380 Td /F1 9.8 Tf [(2\(2\): p. 151-9.)] TJ ET BT 26.250 93.975 Td /F1 9.8 Tf [(8.)] TJ ET BT 38.132 93.975 Td /F1 9.8 Tf [(Ninove, L., et al., A Simple Method for Molecular Detection of Swine-Origin and Human-Origin Influenza A Virus. Vector )] TJ ET BT 26.250 82.071 Td /F1 9.8 Tf [(Borne Zoonotic Dis, 2009.)] TJ ET BT 26.250 62.666 Td /F1 9.8 Tf [(9.)] TJ ET BT 38.132 62.666 Td /F1 9.8 Tf [(WHO, Situation updates - Pandemic \(H1N1\) 2009 in www.who.int.)] TJ ET 0.267 0.267 0.267 rg BT 26.250 54.180 Td /F1 7.5 Tf [(REFERENCE LINK)] TJ ET Q q 15.000 45.154 577.500 731.846 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(but increased during the last four weeks with positive results representing more than 10% of tested specimens.)] TJ ET BT 26.250 748.071 Td /F1 9.8 Tf [(The time necessary to obtain the results was 1-2h for the 21 samples positives with rapid ICT and 4-7h for the others. Computer-)] TJ ET BT 26.250 736.167 Td /F1 9.8 Tf [(based communication of results allowed to save time dedicated to telephone calls for both physician and POC person.)] TJ ET BT 26.250 699.564 Td /F4 12.0 Tf [(Discussion)] TJ ET BT 26.250 679.610 Td /F1 9.8 Tf [(POC strategy for A/H1N1 requires minimal training \(8 hours with written protocols\), necessitates a small dedicated laboratory )] TJ ET BT 26.250 667.705 Td /F1 9.8 Tf [(area which can be implemented in any hospital settings, and can be operated by one person at the time. It allows diagnosis )] TJ ET BT 26.250 655.800 Td /F1 9.8 Tf [(within the clinical time that can help the decision to treat the patient, to isolate the patient or to discharge the patient. It provides )] TJ ET BT 26.250 643.896 Td /F1 9.8 Tf [(reliable data to timely study the local epidemiology and its evolution. It helps to define and to monitor the epidemiology at a )] TJ ET BT 26.250 631.991 Td /F1 9.8 Tf [(larger scale \(regional, national, international\) via extrapolation based on the percentage of confirmed cases over suspect cases.)] TJ ET BT 26.250 612.586 Td /F1 9.8 Tf [(The usefulness of POC strategy in the context of A/H1N1 pandemic proves that POC should be implemented throughout the )] TJ ET BT 26.250 600.681 Td /F1 9.8 Tf [(country not only for emergency situations but also as a daily tool to improve the quality of care for hospitalized patients via )] TJ ET BT 26.250 588.777 Td /F1 9.8 Tf [(shortening the delays and allowing decisions within the clinical time. It is likely that hospitalization costs will also directly )] TJ ET BT 26.250 576.872 Td /F1 9.8 Tf [(beneficiate from POC strategy, through reduction of the duration of hospitalization as previously demonstrated [10][11] .)] TJ ET BT 26.250 557.467 Td /F1 9.8 Tf [(The decision to abandon systematic laboratory testing of suspect patients has been equivalent to break the thermometer and to )] TJ ET BT 26.250 545.562 Td /F1 9.8 Tf [(attempt to define body temperature curve. We believe that implementing diagnostic tools for pulmonary infections including flu )] TJ ET BT 26.250 533.658 Td /F1 9.8 Tf [(may allow to fight efficiently this group of diseases that is the more common cause of death worldwide [12] and the most )] TJ ET BT 26.250 521.753 Td /F1 9.8 Tf [(neglected cause of life reduction [13] . In the current situation where less than 10% of tested specimens are found positive, the )] TJ ET BT 26.250 509.848 Td /F1 9.8 Tf [(economic impact of rapid testing through the POC strategy is very important. Indeed, all negative patients the large majority of )] TJ ET BT 26.250 497.943 Td /F1 9.8 Tf [(suspect patients can therefore go back to their professional activities immediately. Beside, readmission of suspect students in )] TJ ET BT 26.250 486.039 Td /F1 9.8 Tf [(the educational course is often conditioned by a certificate assessing the absence of contagiousness, which need to be based )] TJ ET BT 26.250 474.134 Td /F1 9.8 Tf [(on specific virological diagnostic such as implemented in the POC strategy.)] TJ ET BT 26.250 437.531 Td /F4 12.0 Tf [(Funding information)] TJ ET BT 26.250 417.577 Td /F1 9.8 Tf [(No specific funding was received for the work presented in this manuscript.)] TJ ET BT 26.250 380.975 Td /F4 12.0 Tf [(Competing interests)] TJ ET BT 26.250 361.020 Td /F1 9.8 Tf [(The authors have declared that no competing interests exist.)] TJ ET BT 26.250 324.418 Td /F4 12.0 Tf [(References)] TJ ET BT 26.250 296.964 Td /F1 9.8 Tf [(1.)] TJ ET BT 38.132 296.964 Td /F1 9.8 Tf [(Organization, W.H., Statement to the press by WHO Director-General Dr Margaret Chan. )] TJ ET BT 26.250 285.059 Td /F1 9.8 Tf [(http://www.who.int/mediacentre/news/statements/2009/h1n1_pandemic_phase6_20090611/en/index.html, 2009.)] TJ ET 0.267 0.267 0.267 rg BT 26.250 276.573 Td /F1 7.5 Tf [(REFERENCE LINK)] TJ ET 0.271 0.267 0.267 rg BT 26.250 258.023 Td /F1 9.8 Tf [(2.)] TJ ET BT 38.132 258.023 Td /F1 9.8 Tf [(Levy-Bruhl, D. and S. Vaux, Modified surveillance of influenza A\(H1N1\)v virus infections in France. Euro Surveill, 2009. )] TJ ET BT 26.250 246.118 Td /F1 9.8 Tf [(14\(29\).)] TJ ET BT 26.250 226.713 Td /F1 9.8 Tf [(3.)] TJ ET BT 38.132 226.713 Td /F1 9.8 Tf [(Perez, M. and Y. Miserey, Controverse sur le nombre de cas de grippe A, in Le Figaro.fr. 2009 Sep 8.)] TJ ET BT 26.250 207.309 Td /F1 9.8 Tf [(4.)] TJ ET BT 38.132 207.309 Td /F1 9.8 Tf [(Hanshaoworakul, W., et al., Severe human influenza infections in Thailand: oseltamivir treatment and risk factors for fatal )] TJ ET BT 26.250 195.404 Td /F1 9.8 Tf [(outcome. PLoS One, 2009. 4\(6\): p. e6051.)] TJ ET BT 26.250 175.999 Td /F1 9.8 Tf [(5.)] TJ ET BT 38.132 175.999 Td /F1 9.8 Tf [(Intensive-care patients with severe novel influenza A \(H1N1\) virus infection - Michigan, June 2009. MMWR Morb Mortal Wkly )] TJ ET BT 26.250 164.094 Td /F1 9.8 Tf [(Rep, 2009. 58\(27\): p. 749-52.)] TJ ET BT 26.250 144.690 Td /F1 9.8 Tf [(6.)] TJ ET BT 38.132 144.690 Td /F1 9.8 Tf [(Jamieson, D.J., et al., H1N1 2009 influenza virus infection during pregnancy in the USA. Lancet, 2009. 374\(9688\): p. 451-8.)] TJ ET BT 26.250 125.285 Td /F1 9.8 Tf [(7.)] TJ ET BT 38.132 125.285 Td /F1 9.8 Tf [(Raoult, D., P.E. Fournier, and M. Drancourt, What does the future hold for clinical microbiology? Nat Rev Microbiol, 2004. )] TJ ET BT 26.250 113.380 Td /F1 9.8 Tf [(2\(2\): p. 151-9.)] TJ ET BT 26.250 93.975 Td /F1 9.8 Tf [(8.)] TJ ET BT 38.132 93.975 Td /F1 9.8 Tf [(Ninove, L., et al., A Simple Method for Molecular Detection of Swine-Origin and Human-Origin Influenza A Virus. Vector )] TJ ET BT 26.250 82.071 Td /F1 9.8 Tf [(Borne Zoonotic Dis, 2009.)] TJ ET BT 26.250 62.666 Td /F1 9.8 Tf [(9.)] TJ ET BT 38.132 62.666 Td /F1 9.8 Tf [(WHO, Situation updates - Pandemic \(H1N1\) 2009 in www.who.int.)] TJ ET 0.267 0.267 0.267 rg BT 26.250 54.180 Td /F1 7.5 Tf [(REFERENCE LINK)] TJ ET Q q 0.000 0.000 0.000 rg BT 291.710 19.825 Td /F1 11.0 Tf [(5)] TJ ET BT 25.000 19.825 Td /F1 11.0 Tf [(PLOS Currents Influenza)] TJ ET Q endstream endobj 169 0 obj << /Type /Annot /Subtype /Link /A 170 0 R /Border [0 0 0] /H /I /Rect [ 26.2500 275.8793 91.2600 283.5105 ] >> endobj 170 0 obj << /Type /Action /S /URI /URI (http://www.who.int/mediacentre/news/statements/2009/h1n1_pandemic_phase6_20090611/en/index.html) >> endobj 171 0 obj << /Type /Annot /Subtype /Link /A 172 0 R /Border [0 0 0] /H /I /Rect [ 26.2500 53.4862 91.2600 61.1175 ] >> endobj 172 0 obj << /Type /Action /S /URI /URI (http://www.who.int) >> endobj 173 0 obj << /Type /Annot /Subtype /Link /A 174 0 R /Border [0 0 0] /H /I /Rect [ 26.2500 275.8793 91.2600 283.5105 ] >> endobj 174 0 obj << /Type /Action /S /URI /URI (http://www.who.int/mediacentre/news/statements/2009/h1n1_pandemic_phase6_20090611/en/index.html) >> endobj 175 0 obj << /Type /Annot /Subtype /Link /A 176 0 R /Border [0 0 0] /H /I /Rect [ 26.2500 53.4862 91.2600 61.1175 ] >> endobj 176 0 obj << /Type /Action /S /URI /URI (http://www.who.int) >> endobj 177 0 obj << /Type /Annot /Subtype /Link /A 178 0 R /Border [0 0 0] /H /I /Rect [ 26.2500 275.8793 91.2600 283.5105 ] >> endobj 178 0 obj << /Type /Action /S /URI /URI (http://www.who.int/mediacentre/news/statements/2009/h1n1_pandemic_phase6_20090611/en/index.html) >> endobj 179 0 obj << /Type /Annot /Subtype /Link /A 180 0 R /Border [0 0 0] /H /I /Rect [ 26.2500 53.4862 91.2600 61.1175 ] >> endobj 180 0 obj << /Type /Action /S /URI /URI (http://www.who.int) >> endobj 181 0 obj << /Type /Page /Parent 3 0 R /Contents 182 0 R >> endobj 182 0 obj << /Length 3718 >> stream 0.267 0.267 0.267 rg q 15.000 648.667 577.500 128.333 re W n 0.271 0.267 0.267 rg BT 26.250 759.976 Td /F1 9.8 Tf [(10.)] TJ ET BT 43.553 759.976 Td /F1 9.8 Tf [(Woo, P.C., et al., Cost-effectiveness of rapid diagnosis of viral respiratory tract infections in pediatric patients. J Clin )] TJ ET BT 26.250 748.071 Td /F1 9.8 Tf [(Microbiol, 1997. 35\(6\): p. 1579-81.)] TJ ET BT 26.250 728.667 Td /F1 9.8 Tf [(11.)] TJ ET BT 43.553 728.667 Td /F1 9.8 Tf [(Ninove, L., et al., Impact of diagnostic procedures on patient management and hospitalisation cost during the 2000 and )] TJ ET BT 26.250 716.762 Td /F1 9.8 Tf [(2005 enterovirus epidemics in Marseilles, France. Clin Microbiol Infect., in press.)] TJ ET BT 26.250 697.357 Td /F1 9.8 Tf [(12.)] TJ ET BT 43.553 697.357 Td /F1 9.8 Tf [(Morens, D.M., G.K. Folkers, and A.S. Fauci, The challenge of emerging and re-emerging infectious diseases. Nature, 2004. )] TJ ET BT 26.250 685.452 Td /F1 9.8 Tf [(430\(6996\): p. 242-9.)] TJ ET BT 26.250 666.048 Td /F1 9.8 Tf [(13.)] TJ ET BT 43.553 666.048 Td /F1 9.8 Tf [(Enserink, M., Global health. Some neglected diseases are more neglected than others. Science, 2009. 323\(5915\): p. 700.)] TJ ET Q q 15.000 648.667 577.500 128.333 re W n 0.271 0.267 0.267 rg BT 26.250 759.976 Td /F1 9.8 Tf [(10.)] TJ ET BT 43.553 759.976 Td /F1 9.8 Tf [(Woo, P.C., et al., Cost-effectiveness of rapid diagnosis of viral respiratory tract infections in pediatric patients. J Clin )] TJ ET BT 26.250 748.071 Td /F1 9.8 Tf [(Microbiol, 1997. 35\(6\): p. 1579-81.)] TJ ET BT 26.250 728.667 Td /F1 9.8 Tf [(11.)] TJ ET BT 43.553 728.667 Td /F1 9.8 Tf [(Ninove, L., et al., Impact of diagnostic procedures on patient management and hospitalisation cost during the 2000 and )] TJ ET BT 26.250 716.762 Td /F1 9.8 Tf [(2005 enterovirus epidemics in Marseilles, France. Clin Microbiol Infect., in press.)] TJ ET BT 26.250 697.357 Td /F1 9.8 Tf [(12.)] TJ ET BT 43.553 697.357 Td /F1 9.8 Tf [(Morens, D.M., G.K. Folkers, and A.S. Fauci, The challenge of emerging and re-emerging infectious diseases. Nature, 2004. )] TJ ET BT 26.250 685.452 Td /F1 9.8 Tf [(430\(6996\): p. 242-9.)] TJ ET BT 26.250 666.048 Td /F1 9.8 Tf [(13.)] TJ ET BT 43.553 666.048 Td /F1 9.8 Tf [(Enserink, M., Global health. Some neglected diseases are more neglected than others. Science, 2009. 323\(5915\): p. 700.)] TJ ET Q q 15.000 648.667 577.500 128.333 re W n 0.271 0.267 0.267 rg BT 26.250 759.976 Td /F1 9.8 Tf [(10.)] TJ ET BT 43.553 759.976 Td /F1 9.8 Tf [(Woo, P.C., et al., Cost-effectiveness of rapid diagnosis of viral respiratory tract infections in pediatric patients. J Clin )] TJ ET BT 26.250 748.071 Td /F1 9.8 Tf [(Microbiol, 1997. 35\(6\): p. 1579-81.)] TJ ET BT 26.250 728.667 Td /F1 9.8 Tf [(11.)] TJ ET BT 43.553 728.667 Td /F1 9.8 Tf [(Ninove, L., et al., Impact of diagnostic procedures on patient management and hospitalisation cost during the 2000 and )] TJ ET BT 26.250 716.762 Td /F1 9.8 Tf [(2005 enterovirus epidemics in Marseilles, France. Clin Microbiol Infect., in press.)] TJ ET BT 26.250 697.357 Td /F1 9.8 Tf [(12.)] TJ ET BT 43.553 697.357 Td /F1 9.8 Tf [(Morens, D.M., G.K. Folkers, and A.S. Fauci, The challenge of emerging and re-emerging infectious diseases. Nature, 2004. )] TJ ET BT 26.250 685.452 Td /F1 9.8 Tf [(430\(6996\): p. 242-9.)] TJ ET BT 26.250 666.048 Td /F1 9.8 Tf [(13.)] TJ ET BT 43.553 666.048 Td /F1 9.8 Tf [(Enserink, M., Global health. Some neglected diseases are more neglected than others. 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