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BT 15.000 718.042 Td /F2 21.0 Tf  [(Identification of Influenza Cases During the H1N1 Pandemic in )] TJ ET
BT 15.000 693.094 Td /F2 21.0 Tf  [(Massachusetts Using Population-Based Hospital Discharge Data)] TJ ET
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BT 15.000 675.088 Td /F3 9.8 Tf  [(August 17, 2011)] TJ ET
BT 26.250 663.247 Td /F1 9.8 Tf  [(, )] TJ ET
BT 31.671 663.247 Td /F1 9.8 Tf  [(, )] TJ ET
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BT 37.092 663.247 Td /F1 9.8 Tf  [(Hilary Placzek)] TJ ET
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BT 98.849 663.247 Td /F1 9.8 Tf  [(, )] TJ ET
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BT 104.270 663.247 Td /F1 9.8 Tf  [(Larry Madoff)] TJ ET
0.271 0.267 0.267 rg
BT 26.250 651.342 Td /F1 9.8 Tf  [(Placzek H, Madoff L. Identification of Influenza Cases During the H1N1 Pandemic in Massachusetts Using Population-Based )] TJ ET
BT 26.250 639.438 Td /F1 9.8 Tf  [(Hospital Discharge Data. PLOS Currents Influenza. 2011 Aug 17 . Edition 1. doi: 10.1371/currents.RRN1256.)] TJ ET
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BT 26.250 610.335 Td /F4 12.0 Tf  [(Abstract)] TJ ET
BT 26.250 590.381 Td /F1 9.8 Tf  [(Objectives)] TJ ET
BT 26.250 578.476 Td /F1 9.8 Tf  [(\(1\) To characterize the epidemiology of H1N1-related hospitalizations in Massachusetts; and \(2\) to compare characteristics of )] TJ ET
BT 26.250 566.571 Td /F1 9.8 Tf  [(those hospitalized during periods of seasonal influenza activity and during the H1N1 pandemic.)] TJ ET
BT 26.250 554.667 Td /F1 9.8 Tf  [(Methods)] TJ ET
BT 26.250 542.762 Td /F1 9.8 Tf  [(Authors applied maximum and minimum criteria to the Massachusetts Hospital Discharge Database to identify H1N1-related )] TJ ET
BT 26.250 530.857 Td /F1 9.8 Tf  [(hospitalizations. They constructed annual line graphs describing mean frequencies of influenza-like illness\(ILI\)-related )] TJ ET
BT 26.250 518.952 Td /F1 9.8 Tf  [(discharges between 2005-2008, and compared these rates to early waves of H1N1 in 2009.)] TJ ET
BT 26.250 507.048 Td /F1 9.8 Tf  [(Results)] TJ ET
BT 26.250 495.143 Td /F1 9.8 Tf  [(During spring and summer 2009, there were significantly higher rates of ILI-related hospital discharges in Massachusetts )] TJ ET
BT 26.250 483.238 Td /F1 9.8 Tf  [(compared to 2005-2008. Out of 359,344 total discharges between April 26-September 30,2009, H1N1-related hospitalizations )] TJ ET
BT 26.250 471.333 Td /F1 9.8 Tf  [(ranged from 601 to 10,967 cases. Minimum criteria confirmed that H1N1 affected a younger population \(50% were <18 years\), )] TJ ET
BT 26.250 459.429 Td /F1 9.8 Tf  [(with higher rates among African-Americans \(18%\) and Hispanics \(23%\) and higher rates of ICU admission \(21%\) compared to )] TJ ET
BT 26.250 447.524 Td /F1 9.8 Tf  [(seasonal influenza \(39%, 10%, 14%, and 17% respectively\).)] TJ ET
BT 26.250 435.619 Td /F1 9.8 Tf  [(Conclusions)] TJ ET
BT 26.250 423.714 Td /F1 9.8 Tf  [(This is the first population-based assessment of epidemiological characteristics of hospitalized H1N1 cases in Massachusetts, )] TJ ET
BT 26.250 411.810 Td /F1 9.8 Tf  [(and it is the first to include all possible hospitalized cases in the analysis. The authors confirm that large administrative data sets )] TJ ET
BT 26.250 399.905 Td /F1 9.8 Tf  [(can detect hospitalizations for influenza during a pandemic, but estimated case counts vary widely depending on selection )] TJ ET
BT 26.250 388.000 Td /F1 9.8 Tf  [(criteria used. Maximum criteria overestimated H1N1 activity, and those meeting minimum criteria resemble published accounts )] TJ ET
BT 26.250 376.095 Td /F1 9.8 Tf  [(of H1N1-related hospitalizations closely.)] TJ ET
BT 26.250 339.493 Td /F4 12.0 Tf  [(BACKGROUND)] TJ ET
BT 26.250 319.539 Td /F1 9.8 Tf  [(The emergence and spread of the novel influenza A \(H1N1\) virus resulted in extraordinary influenza activity across the United )] TJ ET
BT 26.250 307.634 Td /F1 9.8 Tf  [(States throughout the spring, summer and fall of 2009 )] TJ ET
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BT 261.459 307.634 Td /F1 9.8 Tf  [([1])] TJ ET
0.271 0.267 0.267 rg
BT 272.301 307.634 Td /F1 9.8 Tf  [( . Previous studies assessed fatality rates and rates of healthcare )] TJ ET
BT 26.250 295.729 Td /F1 9.8 Tf  [(utilization due to H1N1 influenza )] TJ ET
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BT 168.775 295.729 Td /F1 9.8 Tf  [([2])] TJ ET
BT 179.618 295.729 Td /F1 9.8 Tf  [([3])] TJ ET
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BT 190.460 295.729 Td /F1 9.8 Tf  [( . However, accuracy and severity of in-hospital H1N1 case ascertainment are difficult to )] TJ ET
BT 26.250 283.824 Td /F1 9.8 Tf  [(determine )] TJ ET
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BT 72.309 283.824 Td /F1 9.8 Tf  [([4])] TJ ET
0.271 0.267 0.267 rg
BT 83.151 283.824 Td /F1 9.8 Tf  [( , and the impact of influenza-related hospitalizations and mortality are poorly quantified as a result of limitations )] TJ ET
BT 26.250 271.920 Td /F1 9.8 Tf  [(and methodological challenges related to influenza reporting, diagnosis, and surveillance. Serological samples are considered )] TJ ET
BT 26.250 260.015 Td /F1 9.8 Tf  [(the gold standard for influenza case identification )] TJ ET
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BT 240.321 260.015 Td /F1 9.8 Tf  [([5])] TJ ET
0.271 0.267 0.267 rg
BT 251.163 260.015 Td /F1 9.8 Tf  [( , but they are rarely done during routine practice, and more importantly, )] TJ ET
BT 26.250 248.110 Td /F1 9.8 Tf  [(reliable measures of confirmed influenza in population-based data sources have not been described. Under-reporting of )] TJ ET
BT 26.250 236.205 Td /F1 9.8 Tf  [(hospitalizations and deaths occurs as well since not all patients undergo virologic testing. Thus, there is an inability to identify, )] TJ ET
BT 26.250 224.301 Td /F1 9.8 Tf  [(test, confirm, and report many cases.)] TJ ET
BT 26.250 204.896 Td /F1 9.8 Tf  [(Current statewide data describing hospitalized H1N1 cases in Massachusetts cannot be assessed for accuracy or )] TJ ET
BT 26.250 192.991 Td /F1 9.8 Tf  [(completeness. Most hospitalizations and about 90% of deaths attributable to seasonal influenza are categorized as respiratory )] TJ ET
BT 26.250 181.086 Td /F1 9.8 Tf  [(or circulatory \(i.e., due to heart attack or stroke and not including the more specific diagnoses of pneumonia and influenza\) but )] TJ ET
BT 26.250 169.182 Td /F1 9.8 Tf  [(are nonetheless likely initially caused by influenza infection )] TJ ET
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BT 282.568 169.182 Td /F1 9.8 Tf  [([6])] TJ ET
0.271 0.267 0.267 rg
BT 293.410 169.182 Td /F1 9.8 Tf  [( . Mandated by CDC during the H1N1 pandemic, all hospitalized )] TJ ET
BT 26.250 157.277 Td /F1 9.8 Tf  [(confirmed H1N1 cases are reportable to state health departments. Although all hospitalized cases with H1N1 should have been )] TJ ET
BT 26.250 145.372 Td /F1 9.8 Tf  [(reported to the Massachusetts Department of Public Health \(MDPH\), this reporting is considered under-representative of the )] TJ ET
BT 26.250 133.467 Td /F1 9.8 Tf  [(actual number of cases, and many \(if not most\) case reports contain incomplete information. One study confirmed the )] TJ ET
BT 26.250 121.563 Td /F1 9.8 Tf  [(�undercount� theory by using data from laboratory-confirmed cases reported to the CDC to estimate the prevalence of H1N1 )] TJ ET
BT 26.250 109.658 Td /F1 9.8 Tf  [(cases. Correcting for under-ascertainment, the study estimated that every confirmed case of 2009 H1N1 reported from April � )] TJ ET
BT 26.250 97.753 Td /F1 9.8 Tf  [(July represented 79 actual cases, and every hospitalized case reported may have represented an average of 2.7 total )] TJ ET
BT 26.250 85.848 Td /F1 9.8 Tf  [(hospitalized people )] TJ ET
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BT 112.421 85.848 Td /F1 9.8 Tf  [([7])] TJ ET
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BT 123.263 85.848 Td /F1 9.8 Tf  [( .)] TJ ET
BT 26.250 66.444 Td /F1 9.8 Tf  [(Reliable estimates of influenza cases are important to better understand the impact of the virus on the population, how providers )] TJ ET
BT 26.250 54.539 Td /F1 9.8 Tf  [(and healthcare facilities were affected by the epidemic, and to know costs associated with treatments and diagnoses. Many )] TJ ET
BT 26.250 42.634 Td /F1 9.8 Tf  [(researchers turn to large administrative databases to calculate population-based measures of severity of influenza. These data )] TJ ET
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BT 15.000 718.042 Td /F2 21.0 Tf  [(Identification of Influenza Cases During the H1N1 Pandemic in )] TJ ET
BT 15.000 693.094 Td /F2 21.0 Tf  [(Massachusetts Using Population-Based Hospital Discharge Data)] TJ ET
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0.271 0.267 0.267 rg
BT 15.000 675.088 Td /F3 9.8 Tf  [(August 17, 2011)] TJ ET
BT 26.250 663.247 Td /F1 9.8 Tf  [(, )] TJ ET
BT 31.671 663.247 Td /F1 9.8 Tf  [(, )] TJ ET
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BT 37.092 663.247 Td /F1 9.8 Tf  [(Hilary Placzek)] TJ ET
0.271 0.267 0.267 rg
BT 98.849 663.247 Td /F1 9.8 Tf  [(, )] TJ ET
0.267 0.267 0.267 rg
BT 104.270 663.247 Td /F1 9.8 Tf  [(Larry Madoff)] TJ ET
0.271 0.267 0.267 rg
BT 26.250 651.342 Td /F1 9.8 Tf  [(Placzek H, Madoff L. Identification of Influenza Cases During the H1N1 Pandemic in Massachusetts Using Population-Based )] TJ ET
BT 26.250 639.438 Td /F1 9.8 Tf  [(Hospital Discharge Data. PLOS Currents Influenza. 2011 Aug 17 . Edition 1. doi: 10.1371/currents.RRN1256.)] TJ ET
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0.271 0.267 0.267 rg
BT 26.250 610.335 Td /F4 12.0 Tf  [(Abstract)] TJ ET
BT 26.250 590.381 Td /F1 9.8 Tf  [(Objectives)] TJ ET
BT 26.250 578.476 Td /F1 9.8 Tf  [(\(1\) To characterize the epidemiology of H1N1-related hospitalizations in Massachusetts; and \(2\) to compare characteristics of )] TJ ET
BT 26.250 566.571 Td /F1 9.8 Tf  [(those hospitalized during periods of seasonal influenza activity and during the H1N1 pandemic.)] TJ ET
BT 26.250 554.667 Td /F1 9.8 Tf  [(Methods)] TJ ET
BT 26.250 542.762 Td /F1 9.8 Tf  [(Authors applied maximum and minimum criteria to the Massachusetts Hospital Discharge Database to identify H1N1-related )] TJ ET
BT 26.250 530.857 Td /F1 9.8 Tf  [(hospitalizations. They constructed annual line graphs describing mean frequencies of influenza-like illness\(ILI\)-related )] TJ ET
BT 26.250 518.952 Td /F1 9.8 Tf  [(discharges between 2005-2008, and compared these rates to early waves of H1N1 in 2009.)] TJ ET
BT 26.250 507.048 Td /F1 9.8 Tf  [(Results)] TJ ET
BT 26.250 495.143 Td /F1 9.8 Tf  [(During spring and summer 2009, there were significantly higher rates of ILI-related hospital discharges in Massachusetts )] TJ ET
BT 26.250 483.238 Td /F1 9.8 Tf  [(compared to 2005-2008. Out of 359,344 total discharges between April 26-September 30,2009, H1N1-related hospitalizations )] TJ ET
BT 26.250 471.333 Td /F1 9.8 Tf  [(ranged from 601 to 10,967 cases. Minimum criteria confirmed that H1N1 affected a younger population \(50% were <18 years\), )] TJ ET
BT 26.250 459.429 Td /F1 9.8 Tf  [(with higher rates among African-Americans \(18%\) and Hispanics \(23%\) and higher rates of ICU admission \(21%\) compared to )] TJ ET
BT 26.250 447.524 Td /F1 9.8 Tf  [(seasonal influenza \(39%, 10%, 14%, and 17% respectively\).)] TJ ET
BT 26.250 435.619 Td /F1 9.8 Tf  [(Conclusions)] TJ ET
BT 26.250 423.714 Td /F1 9.8 Tf  [(This is the first population-based assessment of epidemiological characteristics of hospitalized H1N1 cases in Massachusetts, )] TJ ET
BT 26.250 411.810 Td /F1 9.8 Tf  [(and it is the first to include all possible hospitalized cases in the analysis. The authors confirm that large administrative data sets )] TJ ET
BT 26.250 399.905 Td /F1 9.8 Tf  [(can detect hospitalizations for influenza during a pandemic, but estimated case counts vary widely depending on selection )] TJ ET
BT 26.250 388.000 Td /F1 9.8 Tf  [(criteria used. Maximum criteria overestimated H1N1 activity, and those meeting minimum criteria resemble published accounts )] TJ ET
BT 26.250 376.095 Td /F1 9.8 Tf  [(of H1N1-related hospitalizations closely.)] TJ ET
BT 26.250 339.493 Td /F4 12.0 Tf  [(BACKGROUND)] TJ ET
BT 26.250 319.539 Td /F1 9.8 Tf  [(The emergence and spread of the novel influenza A \(H1N1\) virus resulted in extraordinary influenza activity across the United )] TJ ET
BT 26.250 307.634 Td /F1 9.8 Tf  [(States throughout the spring, summer and fall of 2009 )] TJ ET
0.267 0.267 0.267 rg
BT 261.459 307.634 Td /F1 9.8 Tf  [([1])] TJ ET
0.271 0.267 0.267 rg
BT 272.301 307.634 Td /F1 9.8 Tf  [( . Previous studies assessed fatality rates and rates of healthcare )] TJ ET
BT 26.250 295.729 Td /F1 9.8 Tf  [(utilization due to H1N1 influenza )] TJ ET
0.267 0.267 0.267 rg
BT 168.775 295.729 Td /F1 9.8 Tf  [([2])] TJ ET
BT 179.618 295.729 Td /F1 9.8 Tf  [([3])] TJ ET
0.271 0.267 0.267 rg
BT 190.460 295.729 Td /F1 9.8 Tf  [( . However, accuracy and severity of in-hospital H1N1 case ascertainment are difficult to )] TJ ET
BT 26.250 283.824 Td /F1 9.8 Tf  [(determine )] TJ ET
0.267 0.267 0.267 rg
BT 72.309 283.824 Td /F1 9.8 Tf  [([4])] TJ ET
0.271 0.267 0.267 rg
BT 83.151 283.824 Td /F1 9.8 Tf  [( , and the impact of influenza-related hospitalizations and mortality are poorly quantified as a result of limitations )] TJ ET
BT 26.250 271.920 Td /F1 9.8 Tf  [(and methodological challenges related to influenza reporting, diagnosis, and surveillance. Serological samples are considered )] TJ ET
BT 26.250 260.015 Td /F1 9.8 Tf  [(the gold standard for influenza case identification )] TJ ET
0.267 0.267 0.267 rg
BT 240.321 260.015 Td /F1 9.8 Tf  [([5])] TJ ET
0.271 0.267 0.267 rg
BT 251.163 260.015 Td /F1 9.8 Tf  [( , but they are rarely done during routine practice, and more importantly, )] TJ ET
BT 26.250 248.110 Td /F1 9.8 Tf  [(reliable measures of confirmed influenza in population-based data sources have not been described. Under-reporting of )] TJ ET
BT 26.250 236.205 Td /F1 9.8 Tf  [(hospitalizations and deaths occurs as well since not all patients undergo virologic testing. Thus, there is an inability to identify, )] TJ ET
BT 26.250 224.301 Td /F1 9.8 Tf  [(test, confirm, and report many cases.)] TJ ET
BT 26.250 204.896 Td /F1 9.8 Tf  [(Current statewide data describing hospitalized H1N1 cases in Massachusetts cannot be assessed for accuracy or )] TJ ET
BT 26.250 192.991 Td /F1 9.8 Tf  [(completeness. Most hospitalizations and about 90% of deaths attributable to seasonal influenza are categorized as respiratory )] TJ ET
BT 26.250 181.086 Td /F1 9.8 Tf  [(or circulatory \(i.e., due to heart attack or stroke and not including the more specific diagnoses of pneumonia and influenza\) but )] TJ ET
BT 26.250 169.182 Td /F1 9.8 Tf  [(are nonetheless likely initially caused by influenza infection )] TJ ET
0.267 0.267 0.267 rg
BT 282.568 169.182 Td /F1 9.8 Tf  [([6])] TJ ET
0.271 0.267 0.267 rg
BT 293.410 169.182 Td /F1 9.8 Tf  [( . Mandated by CDC during the H1N1 pandemic, all hospitalized )] TJ ET
BT 26.250 157.277 Td /F1 9.8 Tf  [(confirmed H1N1 cases are reportable to state health departments. Although all hospitalized cases with H1N1 should have been )] TJ ET
BT 26.250 145.372 Td /F1 9.8 Tf  [(reported to the Massachusetts Department of Public Health \(MDPH\), this reporting is considered under-representative of the )] TJ ET
BT 26.250 133.467 Td /F1 9.8 Tf  [(actual number of cases, and many \(if not most\) case reports contain incomplete information. One study confirmed the )] TJ ET
BT 26.250 121.563 Td /F1 9.8 Tf  [(�undercount� theory by using data from laboratory-confirmed cases reported to the CDC to estimate the prevalence of H1N1 )] TJ ET
BT 26.250 109.658 Td /F1 9.8 Tf  [(cases. Correcting for under-ascertainment, the study estimated that every confirmed case of 2009 H1N1 reported from April � )] TJ ET
BT 26.250 97.753 Td /F1 9.8 Tf  [(July represented 79 actual cases, and every hospitalized case reported may have represented an average of 2.7 total )] TJ ET
BT 26.250 85.848 Td /F1 9.8 Tf  [(hospitalized people )] TJ ET
0.267 0.267 0.267 rg
BT 112.421 85.848 Td /F1 9.8 Tf  [([7])] TJ ET
0.271 0.267 0.267 rg
BT 123.263 85.848 Td /F1 9.8 Tf  [( .)] TJ ET
BT 26.250 66.444 Td /F1 9.8 Tf  [(Reliable estimates of influenza cases are important to better understand the impact of the virus on the population, how providers )] TJ ET
BT 26.250 54.539 Td /F1 9.8 Tf  [(and healthcare facilities were affected by the epidemic, and to know costs associated with treatments and diagnoses. Many )] TJ ET
BT 26.250 42.634 Td /F1 9.8 Tf  [(researchers turn to large administrative databases to calculate population-based measures of severity of influenza. These data )] TJ ET
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15.000 684.354 577.500 53.646 re W n
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BT 15.000 718.042 Td /F2 21.0 Tf  [(Identification of Influenza Cases During the H1N1 Pandemic in )] TJ ET
BT 15.000 693.094 Td /F2 21.0 Tf  [(Massachusetts Using Population-Based Hospital Discharge Data)] TJ ET
Q
0.271 0.267 0.267 rg
BT 15.000 675.088 Td /F3 9.8 Tf  [(August 17, 2011)] TJ ET
BT 26.250 663.247 Td /F1 9.8 Tf  [(, )] TJ ET
BT 31.671 663.247 Td /F1 9.8 Tf  [(, )] TJ ET
0.267 0.267 0.267 rg
BT 37.092 663.247 Td /F1 9.8 Tf  [(Hilary Placzek)] TJ ET
0.271 0.267 0.267 rg
BT 98.849 663.247 Td /F1 9.8 Tf  [(, )] TJ ET
0.267 0.267 0.267 rg
BT 104.270 663.247 Td /F1 9.8 Tf  [(Larry Madoff)] TJ ET
0.271 0.267 0.267 rg
BT 26.250 651.342 Td /F1 9.8 Tf  [(Placzek H, Madoff L. Identification of Influenza Cases During the H1N1 Pandemic in Massachusetts Using Population-Based )] TJ ET
BT 26.250 639.438 Td /F1 9.8 Tf  [(Hospital Discharge Data. PLOS Currents Influenza. 2011 Aug 17 . Edition 1. doi: 10.1371/currents.RRN1256.)] TJ ET
q
15.000 28.348 577.500 608.708 re W n
0.271 0.267 0.267 rg
BT 26.250 610.335 Td /F4 12.0 Tf  [(Abstract)] TJ ET
BT 26.250 590.381 Td /F1 9.8 Tf  [(Objectives)] TJ ET
BT 26.250 578.476 Td /F1 9.8 Tf  [(\(1\) To characterize the epidemiology of H1N1-related hospitalizations in Massachusetts; and \(2\) to compare characteristics of )] TJ ET
BT 26.250 566.571 Td /F1 9.8 Tf  [(those hospitalized during periods of seasonal influenza activity and during the H1N1 pandemic.)] TJ ET
BT 26.250 554.667 Td /F1 9.8 Tf  [(Methods)] TJ ET
BT 26.250 542.762 Td /F1 9.8 Tf  [(Authors applied maximum and minimum criteria to the Massachusetts Hospital Discharge Database to identify H1N1-related )] TJ ET
BT 26.250 530.857 Td /F1 9.8 Tf  [(hospitalizations. They constructed annual line graphs describing mean frequencies of influenza-like illness\(ILI\)-related )] TJ ET
BT 26.250 518.952 Td /F1 9.8 Tf  [(discharges between 2005-2008, and compared these rates to early waves of H1N1 in 2009.)] TJ ET
BT 26.250 507.048 Td /F1 9.8 Tf  [(Results)] TJ ET
BT 26.250 495.143 Td /F1 9.8 Tf  [(During spring and summer 2009, there were significantly higher rates of ILI-related hospital discharges in Massachusetts )] TJ ET
BT 26.250 483.238 Td /F1 9.8 Tf  [(compared to 2005-2008. Out of 359,344 total discharges between April 26-September 30,2009, H1N1-related hospitalizations )] TJ ET
BT 26.250 471.333 Td /F1 9.8 Tf  [(ranged from 601 to 10,967 cases. Minimum criteria confirmed that H1N1 affected a younger population \(50% were <18 years\), )] TJ ET
BT 26.250 459.429 Td /F1 9.8 Tf  [(with higher rates among African-Americans \(18%\) and Hispanics \(23%\) and higher rates of ICU admission \(21%\) compared to )] TJ ET
BT 26.250 447.524 Td /F1 9.8 Tf  [(seasonal influenza \(39%, 10%, 14%, and 17% respectively\).)] TJ ET
BT 26.250 435.619 Td /F1 9.8 Tf  [(Conclusions)] TJ ET
BT 26.250 423.714 Td /F1 9.8 Tf  [(This is the first population-based assessment of epidemiological characteristics of hospitalized H1N1 cases in Massachusetts, )] TJ ET
BT 26.250 411.810 Td /F1 9.8 Tf  [(and it is the first to include all possible hospitalized cases in the analysis. The authors confirm that large administrative data sets )] TJ ET
BT 26.250 399.905 Td /F1 9.8 Tf  [(can detect hospitalizations for influenza during a pandemic, but estimated case counts vary widely depending on selection )] TJ ET
BT 26.250 388.000 Td /F1 9.8 Tf  [(criteria used. Maximum criteria overestimated H1N1 activity, and those meeting minimum criteria resemble published accounts )] TJ ET
BT 26.250 376.095 Td /F1 9.8 Tf  [(of H1N1-related hospitalizations closely.)] TJ ET
BT 26.250 339.493 Td /F4 12.0 Tf  [(BACKGROUND)] TJ ET
BT 26.250 319.539 Td /F1 9.8 Tf  [(The emergence and spread of the novel influenza A \(H1N1\) virus resulted in extraordinary influenza activity across the United )] TJ ET
BT 26.250 307.634 Td /F1 9.8 Tf  [(States throughout the spring, summer and fall of 2009 )] TJ ET
0.267 0.267 0.267 rg
BT 261.459 307.634 Td /F1 9.8 Tf  [([1])] TJ ET
0.271 0.267 0.267 rg
BT 272.301 307.634 Td /F1 9.8 Tf  [( . Previous studies assessed fatality rates and rates of healthcare )] TJ ET
BT 26.250 295.729 Td /F1 9.8 Tf  [(utilization due to H1N1 influenza )] TJ ET
0.267 0.267 0.267 rg
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BT 26.250 767.476 Td /F1 9.8 Tf  [(sources characterize hospital encounter information through billing, diagnostic codes, and/or ICD-9 codes. Attempts to identify )] TJ ET
BT 26.250 755.571 Td /F1 9.8 Tf  [(influenza cases in administrative datasets have been described in the literature )] TJ ET
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BT 369.284 755.571 Td /F1 9.8 Tf  [([8])] TJ ET
BT 380.126 755.571 Td /F1 9.8 Tf  [([9])] TJ ET
BT 390.968 755.571 Td /F1 9.8 Tf  [([10])] TJ ET
BT 407.231 755.571 Td /F1 9.8 Tf  [([11])] TJ ET
BT 423.494 755.571 Td /F1 9.8 Tf  [([12])] TJ ET
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BT 439.757 755.571 Td /F1 9.8 Tf  [( , but more information is )] TJ ET
BT 26.250 743.667 Td /F1 9.8 Tf  [(required about accurate case identification methods since currently no �gold standard� influenza case selection criteria exists.)] TJ ET
BT 26.250 724.262 Td /F1 9.8 Tf  [(Epidemiological assessments have compared severity of disease between patients hospitalized with seasonal influenza and )] TJ ET
BT 26.250 712.357 Td /F1 9.8 Tf  [(H1N1. One study in a pediatric cohort found that H1N1 was associated with more severe respiratory disease than seasonal )] TJ ET
BT 26.250 700.452 Td /F1 9.8 Tf  [(influenza )] TJ ET
0.267 0.267 0.267 rg
BT 67.980 700.452 Td /F1 9.8 Tf  [([13])] TJ ET
0.271 0.267 0.267 rg
BT 84.243 700.452 Td /F1 9.8 Tf  [( . Many of these studies were limited to single-center or regional assessments, however, and there are no )] TJ ET
BT 26.250 688.548 Td /F1 9.8 Tf  [(population-based studies assessing this relationship, although reviews have described H1N1 activity in the Northern )] TJ ET
BT 26.250 676.643 Td /F1 9.8 Tf  [(Hemisphere )] TJ ET
0.267 0.267 0.267 rg
BT 81.513 676.643 Td /F1 9.8 Tf  [([14])] TJ ET
0.271 0.267 0.267 rg
BT 97.776 676.643 Td /F1 9.8 Tf  [( and Southern Hemisphere )] TJ ET
0.267 0.267 0.267 rg
BT 216.999 676.643 Td /F1 9.8 Tf  [([15])] TJ ET
0.271 0.267 0.267 rg
BT 233.262 676.643 Td /F1 9.8 Tf  [( .)] TJ ET
BT 26.250 657.238 Td /F1 9.8 Tf  [(There are also confirmed diagnosis data suggesting that specific communities and populations, racial and ethnic groups )] TJ ET
0.267 0.267 0.267 rg
BT 544.862 657.238 Td /F1 9.8 Tf  [([16])] TJ ET
0.271 0.267 0.267 rg
BT 26.250 645.333 Td /F1 9.8 Tf  [(and specific age groups in particular, may be at increased risk of developing severe infection from H1N1, but this has not been )] TJ ET
BT 26.250 633.429 Td /F1 9.8 Tf  [(examined in population-based studies using hospitalization discharge data from Massachusetts.)] TJ ET
BT 26.250 614.024 Td /F1 9.8 Tf  [(This study used the Hospital Discharge Database \(HDD\), which is a patient-linked listing of all hospital discharges in )] TJ ET
BT 26.250 602.119 Td /F1 9.8 Tf  [(Massachusetts and includes up to 15 ICD-9-coded discharge diagnoses for each patient. We evaluated ICD-9 codes that )] TJ ET
BT 26.250 590.214 Td /F1 9.8 Tf  [(correspond with common and relatively serious respiratory infections and influenza using two influenza case selection criteria to )] TJ ET
BT 26.250 578.310 Td /F1 9.8 Tf  [(identify those hospitalized with influenza during the first wave of the H1N1 pandemic.)] TJ ET
BT 26.250 558.905 Td /F1 9.8 Tf  [(Taking into account the data and limitations addressed above, the main objectives for this study include: \(1\) to characterize the )] TJ ET
BT 26.250 547.000 Td /F1 9.8 Tf  [(epidemiology of H1N1-related hospitalizations in Massachusetts; and \(2\) to compare characteristics of those hospitalized in )] TJ ET
BT 26.250 535.095 Td /F1 9.8 Tf  [(Massachusetts during periods of seasonal influenza activity and during the H1N1 pandemic period.)] TJ ET
BT 26.250 498.493 Td /F4 12.0 Tf  [(MATERIALS AND METHODS)] TJ ET
BT 26.250 478.539 Td /F4 9.8 Tf  [(Data source)] TJ ET
BT 26.250 459.134 Td /F1 9.8 Tf  [(The HDD contains discharge data for all inpatients discharged from all 76 acute care hospitals in Massachusetts. This data )] TJ ET
BT 26.250 447.229 Td /F1 9.8 Tf  [(source contains comprehensive information including socio-demographic data, clinical data, and charge data, with a total of 377 )] TJ ET
BT 26.250 435.324 Td /F1 9.8 Tf  [(variables )] TJ ET
0.267 0.267 0.267 rg
BT 67.970 435.324 Td /F1 9.8 Tf  [([17])] TJ ET
0.271 0.267 0.267 rg
BT 84.233 435.324 Td /F1 9.8 Tf  [( . Data included all 351 cities and towns. For this study, patients met the following inclusion criteria: 1\) discharge )] TJ ET
BT 26.250 423.420 Td /F1 9.8 Tf  [(from any acute care hospital in Massachusetts in the time period October 1, 2004-Sept 30, 2010; and 2\) assigned one or more )] TJ ET
BT 26.250 411.515 Td /F1 9.8 Tf  [(diagnosis codes corresponding to a grouping of ICD-9 codes used to identify ILI.)] TJ ET
BT 26.250 392.110 Td /F4 9.8 Tf  [(Time period selection)] TJ ET
BT 26.250 372.705 Td /F1 9.8 Tf  [(Confirmed-case laboratory specimen data from the Massachusetts State Laboratory indicated that between April 19-October 1, )] TJ ET
BT 26.250 360.801 Td /F1 9.8 Tf  [(2009, 99% of influenza virus isolates were H1N1. In addition, 34% of all submitted specimens were positive for H1N1 )] TJ ET
0.267 0.267 0.267 rg
BT 532.918 360.801 Td /F1 9.8 Tf  [([18])] TJ ET
0.271 0.267 0.267 rg
BT 549.182 360.801 Td /F1 9.8 Tf  [( . This )] TJ ET
BT 26.250 348.896 Td /F1 9.8 Tf  [(time interval occurred before H1N1 vaccine was released, therefore it is a unique time to study the impact of the virus prior to )] TJ ET
BT 26.250 336.991 Td /F1 9.8 Tf  [(the availability of immunization. Prior to April 26, 2009, seasonal influenza activity was common in Massachusetts: April 26 )] TJ ET
BT 26.250 325.086 Td /F1 9.8 Tf  [(marks the first date that H1N1 was detected, and September 30 marks the end of non-influenza season. For comparison )] TJ ET
BT 26.250 313.182 Td /F1 9.8 Tf  [(purposes, we applied the same selection criteria for influenza-like illness to the five prior influenza seasons between October 1, )] TJ ET
BT 26.250 301.277 Td /F1 9.8 Tf  [(2004-April 25, 2009.)] TJ ET
BT 26.250 281.872 Td /F4 9.8 Tf  [(Study population identification)] TJ ET
BT 26.250 262.467 Td /F1 9.8 Tf  [(Patients assigned one or more ICD-9 diagnosis codes corresponding to specific case selection criteria were included in the )] TJ ET
BT 26.250 250.563 Td /F1 9.8 Tf  [(analysis. Nationwide U.S. data indicated that only 7% of H1N1-related hospitalizations occurred in those =65 )] TJ ET
0.267 0.267 0.267 rg
BT 496.902 250.563 Td /F1 9.8 Tf  [([19])] TJ ET
0.271 0.267 0.267 rg
BT 513.165 250.563 Td /F1 9.8 Tf  [( , so those =65 )] TJ ET
BT 26.250 238.658 Td /F1 9.8 Tf  [(years of age were excluded from the study population to minimize misclassification bias introduced by non-influenza cases. We )] TJ ET
BT 26.250 226.753 Td /F1 9.8 Tf  [(created a �maximum-minimum� approach to describe influenza for case selection in this study and provide an interval within )] TJ ET
BT 26.250 214.848 Td /F1 9.8 Tf  [(which the true frequency of cases is found. This approach includes two sets of selection criteria to characterize influenza and )] TJ ET
BT 26.250 202.944 Td /F1 9.8 Tf  [(select cases using ICD-9 codes: \(1\) the � )] TJ ET
BT 203.983 202.944 Td /F4 9.8 Tf  [(maximum�)] TJ ET
BT 252.206 202.944 Td /F1 9.8 Tf  [( criterion applied the broadest definition of influenza. This list of codes has )] TJ ET
BT 26.250 191.039 Td /F1 9.8 Tf  [(been validated against virologic results in a study evaluating code-based syndromic surveillance for ILI which found that 14 )] TJ ET
BT 26.250 179.134 Td /F1 9.8 Tf  [(codes correlated highly with positive viral specimens )] TJ ET
0.267 0.267 0.267 rg
BT 254.907 179.134 Td /F1 9.8 Tf  [([20])] TJ ET
0.271 0.267 0.267 rg
BT 271.170 179.134 Td /F1 9.8 Tf  [( . These ICD-9 codes include codes for influenza, fever, and other )] TJ ET
BT 26.250 167.229 Td /F1 9.8 Tf  [(respiratory illnesses \(Table 1\), and is currently in use in other H1N1 surveillance work using administrative data )] TJ ET
0.267 0.267 0.267 rg
BT 507.949 167.229 Td /F1 9.8 Tf  [([21])] TJ ET
0.271 0.267 0.267 rg
BT 524.212 167.229 Td /F1 9.8 Tf  [( . \(2\) The � )] TJ ET
BT 26.250 155.325 Td /F4 9.8 Tf  [(minimum�)] TJ ET
BT 72.299 155.325 Td /F1 9.8 Tf  [( criterion is the narrowest definition for influenza and included those patients who were assigned codes )] TJ ET
BT 26.250 143.420 Td /F1 9.8 Tf  [(corresponding to influenza- specific diagnoses \(Table 1\). Prior studies identifying influenza cases in administrative datasets )] TJ ET
BT 26.250 131.515 Td /F1 9.8 Tf  [(have used influenza-only diagnoses in addition to pneumonia codes )] TJ ET
0.267 0.267 0.267 rg
BT 321.616 131.515 Td /F1 9.8 Tf  [([22])] TJ ET
0.271 0.267 0.267 rg
BT 337.879 131.515 Td /F1 9.8 Tf  [( .)] TJ ET
BT 26.250 112.110 Td /F4 9.8 Tf  [(Table 1: Specific ICD-9 Codes Included in Case Selection Criteria)] TJ ET
1.000 1.000 1.000 rg
30.850 56.217 550.400 46.013 re f
31.100 100.979 231.005 1.000 re f
31.100 84.848 1.000 17.131 re f
0.271 0.267 0.267 rg
BT 37.500 91.124 Td /F4 9.8 Tf  [(ICD-9 Code)] TJ ET
261.105 100.979 160.448 1.000 re f
261.105 84.848 1.000 17.131 re f
BT 267.005 91.124 Td /F4 9.8 Tf  [(Maximum Selection Criteria)] TJ ET
420.552 100.979 160.448 1.000 re f
420.552 84.848 1.000 17.131 re f
580.000 84.848 1.000 17.131 re f
BT 426.452 91.124 Td /F4 9.8 Tf  [(Minimum Selection Criteria)] TJ ET
31.100 84.848 231.005 1.000 re f
31.100 69.217 231.005 1.000 re f
31.100 69.217 1.000 16.631 re f
BT 37.500 75.493 Td /F4 9.8 Tf  [(79.99 Viral infection NOS)] TJ ET
261.105 84.848 160.448 1.000 re f
261.105 69.217 160.448 1.000 re f
261.105 69.217 1.000 16.631 re f
BT 267.005 75.493 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 84.848 160.448 1.000 re f
420.552 69.217 160.448 1.000 re f
420.552 69.217 1.000 16.631 re f
580.000 69.217 1.000 16.631 re f
Q
q
15.000 56.217 577.500 720.783 re W n
0.271 0.267 0.267 rg
BT 26.250 767.476 Td /F1 9.8 Tf  [(sources characterize hospital encounter information through billing, diagnostic codes, and/or ICD-9 codes. Attempts to identify )] TJ ET
BT 26.250 755.571 Td /F1 9.8 Tf  [(influenza cases in administrative datasets have been described in the literature )] TJ ET
0.267 0.267 0.267 rg
BT 369.284 755.571 Td /F1 9.8 Tf  [([8])] TJ ET
BT 380.126 755.571 Td /F1 9.8 Tf  [([9])] TJ ET
BT 390.968 755.571 Td /F1 9.8 Tf  [([10])] TJ ET
BT 407.231 755.571 Td /F1 9.8 Tf  [([11])] TJ ET
BT 423.494 755.571 Td /F1 9.8 Tf  [([12])] TJ ET
0.271 0.267 0.267 rg
BT 439.757 755.571 Td /F1 9.8 Tf  [( , but more information is )] TJ ET
BT 26.250 743.667 Td /F1 9.8 Tf  [(required about accurate case identification methods since currently no �gold standard� influenza case selection criteria exists.)] TJ ET
BT 26.250 724.262 Td /F1 9.8 Tf  [(Epidemiological assessments have compared severity of disease between patients hospitalized with seasonal influenza and )] TJ ET
BT 26.250 712.357 Td /F1 9.8 Tf  [(H1N1. One study in a pediatric cohort found that H1N1 was associated with more severe respiratory disease than seasonal )] TJ ET
BT 26.250 700.452 Td /F1 9.8 Tf  [(influenza )] TJ ET
0.267 0.267 0.267 rg
BT 67.980 700.452 Td /F1 9.8 Tf  [([13])] TJ ET
0.271 0.267 0.267 rg
BT 84.243 700.452 Td /F1 9.8 Tf  [( . Many of these studies were limited to single-center or regional assessments, however, and there are no )] TJ ET
BT 26.250 688.548 Td /F1 9.8 Tf  [(population-based studies assessing this relationship, although reviews have described H1N1 activity in the Northern )] TJ ET
BT 26.250 676.643 Td /F1 9.8 Tf  [(Hemisphere )] TJ ET
0.267 0.267 0.267 rg
BT 81.513 676.643 Td /F1 9.8 Tf  [([14])] TJ ET
0.271 0.267 0.267 rg
BT 97.776 676.643 Td /F1 9.8 Tf  [( and Southern Hemisphere )] TJ ET
0.267 0.267 0.267 rg
BT 216.999 676.643 Td /F1 9.8 Tf  [([15])] TJ ET
0.271 0.267 0.267 rg
BT 233.262 676.643 Td /F1 9.8 Tf  [( .)] TJ ET
BT 26.250 657.238 Td /F1 9.8 Tf  [(There are also confirmed diagnosis data suggesting that specific communities and populations, racial and ethnic groups )] TJ ET
0.267 0.267 0.267 rg
BT 544.862 657.238 Td /F1 9.8 Tf  [([16])] TJ ET
0.271 0.267 0.267 rg
BT 26.250 645.333 Td /F1 9.8 Tf  [(and specific age groups in particular, may be at increased risk of developing severe infection from H1N1, but this has not been )] TJ ET
BT 26.250 633.429 Td /F1 9.8 Tf  [(examined in population-based studies using hospitalization discharge data from Massachusetts.)] TJ ET
BT 26.250 614.024 Td /F1 9.8 Tf  [(This study used the Hospital Discharge Database \(HDD\), which is a patient-linked listing of all hospital discharges in )] TJ ET
BT 26.250 602.119 Td /F1 9.8 Tf  [(Massachusetts and includes up to 15 ICD-9-coded discharge diagnoses for each patient. We evaluated ICD-9 codes that )] TJ ET
BT 26.250 590.214 Td /F1 9.8 Tf  [(correspond with common and relatively serious respiratory infections and influenza using two influenza case selection criteria to )] TJ ET
BT 26.250 578.310 Td /F1 9.8 Tf  [(identify those hospitalized with influenza during the first wave of the H1N1 pandemic.)] TJ ET
BT 26.250 558.905 Td /F1 9.8 Tf  [(Taking into account the data and limitations addressed above, the main objectives for this study include: \(1\) to characterize the )] TJ ET
BT 26.250 547.000 Td /F1 9.8 Tf  [(epidemiology of H1N1-related hospitalizations in Massachusetts; and \(2\) to compare characteristics of those hospitalized in )] TJ ET
BT 26.250 535.095 Td /F1 9.8 Tf  [(Massachusetts during periods of seasonal influenza activity and during the H1N1 pandemic period.)] TJ ET
BT 26.250 498.493 Td /F4 12.0 Tf  [(MATERIALS AND METHODS)] TJ ET
BT 26.250 478.539 Td /F4 9.8 Tf  [(Data source)] TJ ET
BT 26.250 459.134 Td /F1 9.8 Tf  [(The HDD contains discharge data for all inpatients discharged from all 76 acute care hospitals in Massachusetts. This data )] TJ ET
BT 26.250 447.229 Td /F1 9.8 Tf  [(source contains comprehensive information including socio-demographic data, clinical data, and charge data, with a total of 377 )] TJ ET
BT 26.250 435.324 Td /F1 9.8 Tf  [(variables )] TJ ET
0.267 0.267 0.267 rg
BT 67.970 435.324 Td /F1 9.8 Tf  [([17])] TJ ET
0.271 0.267 0.267 rg
BT 84.233 435.324 Td /F1 9.8 Tf  [( . Data included all 351 cities and towns. For this study, patients met the following inclusion criteria: 1\) discharge )] TJ ET
BT 26.250 423.420 Td /F1 9.8 Tf  [(from any acute care hospital in Massachusetts in the time period October 1, 2004-Sept 30, 2010; and 2\) assigned one or more )] TJ ET
BT 26.250 411.515 Td /F1 9.8 Tf  [(diagnosis codes corresponding to a grouping of ICD-9 codes used to identify ILI.)] TJ ET
BT 26.250 392.110 Td /F4 9.8 Tf  [(Time period selection)] TJ ET
BT 26.250 372.705 Td /F1 9.8 Tf  [(Confirmed-case laboratory specimen data from the Massachusetts State Laboratory indicated that between April 19-October 1, )] TJ ET
BT 26.250 360.801 Td /F1 9.8 Tf  [(2009, 99% of influenza virus isolates were H1N1. In addition, 34% of all submitted specimens were positive for H1N1 )] TJ ET
0.267 0.267 0.267 rg
BT 532.918 360.801 Td /F1 9.8 Tf  [([18])] TJ ET
0.271 0.267 0.267 rg
BT 549.182 360.801 Td /F1 9.8 Tf  [( . This )] TJ ET
BT 26.250 348.896 Td /F1 9.8 Tf  [(time interval occurred before H1N1 vaccine was released, therefore it is a unique time to study the impact of the virus prior to )] TJ ET
BT 26.250 336.991 Td /F1 9.8 Tf  [(the availability of immunization. Prior to April 26, 2009, seasonal influenza activity was common in Massachusetts: April 26 )] TJ ET
BT 26.250 325.086 Td /F1 9.8 Tf  [(marks the first date that H1N1 was detected, and September 30 marks the end of non-influenza season. For comparison )] TJ ET
BT 26.250 313.182 Td /F1 9.8 Tf  [(purposes, we applied the same selection criteria for influenza-like illness to the five prior influenza seasons between October 1, )] TJ ET
BT 26.250 301.277 Td /F1 9.8 Tf  [(2004-April 25, 2009.)] TJ ET
BT 26.250 281.872 Td /F4 9.8 Tf  [(Study population identification)] TJ ET
BT 26.250 262.467 Td /F1 9.8 Tf  [(Patients assigned one or more ICD-9 diagnosis codes corresponding to specific case selection criteria were included in the )] TJ ET
BT 26.250 250.563 Td /F1 9.8 Tf  [(analysis. Nationwide U.S. data indicated that only 7% of H1N1-related hospitalizations occurred in those =65 )] TJ ET
0.267 0.267 0.267 rg
BT 496.902 250.563 Td /F1 9.8 Tf  [([19])] TJ ET
0.271 0.267 0.267 rg
BT 513.165 250.563 Td /F1 9.8 Tf  [( , so those =65 )] TJ ET
BT 26.250 238.658 Td /F1 9.8 Tf  [(years of age were excluded from the study population to minimize misclassification bias introduced by non-influenza cases. We )] TJ ET
BT 26.250 226.753 Td /F1 9.8 Tf  [(created a �maximum-minimum� approach to describe influenza for case selection in this study and provide an interval within )] TJ ET
BT 26.250 214.848 Td /F1 9.8 Tf  [(which the true frequency of cases is found. This approach includes two sets of selection criteria to characterize influenza and )] TJ ET
BT 26.250 202.944 Td /F1 9.8 Tf  [(select cases using ICD-9 codes: \(1\) the � )] TJ ET
BT 203.983 202.944 Td /F4 9.8 Tf  [(maximum�)] TJ ET
BT 252.206 202.944 Td /F1 9.8 Tf  [( criterion applied the broadest definition of influenza. This list of codes has )] TJ ET
BT 26.250 191.039 Td /F1 9.8 Tf  [(been validated against virologic results in a study evaluating code-based syndromic surveillance for ILI which found that 14 )] TJ ET
BT 26.250 179.134 Td /F1 9.8 Tf  [(codes correlated highly with positive viral specimens )] TJ ET
0.267 0.267 0.267 rg
BT 254.907 179.134 Td /F1 9.8 Tf  [([20])] TJ ET
0.271 0.267 0.267 rg
BT 271.170 179.134 Td /F1 9.8 Tf  [( . These ICD-9 codes include codes for influenza, fever, and other )] TJ ET
BT 26.250 167.229 Td /F1 9.8 Tf  [(respiratory illnesses \(Table 1\), and is currently in use in other H1N1 surveillance work using administrative data )] TJ ET
0.267 0.267 0.267 rg
BT 507.949 167.229 Td /F1 9.8 Tf  [([21])] TJ ET
0.271 0.267 0.267 rg
BT 524.212 167.229 Td /F1 9.8 Tf  [( . \(2\) The � )] TJ ET
BT 26.250 155.325 Td /F4 9.8 Tf  [(minimum�)] TJ ET
BT 72.299 155.325 Td /F1 9.8 Tf  [( criterion is the narrowest definition for influenza and included those patients who were assigned codes )] TJ ET
BT 26.250 143.420 Td /F1 9.8 Tf  [(corresponding to influenza- specific diagnoses \(Table 1\). Prior studies identifying influenza cases in administrative datasets )] TJ ET
BT 26.250 131.515 Td /F1 9.8 Tf  [(have used influenza-only diagnoses in addition to pneumonia codes )] TJ ET
0.267 0.267 0.267 rg
BT 321.616 131.515 Td /F1 9.8 Tf  [([22])] TJ ET
0.271 0.267 0.267 rg
BT 337.879 131.515 Td /F1 9.8 Tf  [( .)] TJ ET
BT 26.250 112.110 Td /F4 9.8 Tf  [(Table 1: Specific ICD-9 Codes Included in Case Selection Criteria)] TJ ET
1.000 1.000 1.000 rg
30.850 56.217 550.400 46.013 re f
31.100 100.979 231.005 1.000 re f
31.100 84.848 1.000 17.131 re f
0.271 0.267 0.267 rg
BT 37.500 91.124 Td /F4 9.8 Tf  [(ICD-9 Code)] TJ ET
261.105 100.979 160.448 1.000 re f
261.105 84.848 1.000 17.131 re f
BT 267.005 91.124 Td /F4 9.8 Tf  [(Maximum Selection Criteria)] TJ ET
420.552 100.979 160.448 1.000 re f
420.552 84.848 1.000 17.131 re f
580.000 84.848 1.000 17.131 re f
BT 426.452 91.124 Td /F4 9.8 Tf  [(Minimum Selection Criteria)] TJ ET
31.100 84.848 231.005 1.000 re f
31.100 69.217 231.005 1.000 re f
31.100 69.217 1.000 16.631 re f
BT 37.500 75.493 Td /F4 9.8 Tf  [(79.99 Viral infection NOS)] TJ ET
261.105 84.848 160.448 1.000 re f
261.105 69.217 160.448 1.000 re f
261.105 69.217 1.000 16.631 re f
BT 267.005 75.493 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 84.848 160.448 1.000 re f
420.552 69.217 160.448 1.000 re f
420.552 69.217 1.000 16.631 re f
580.000 69.217 1.000 16.631 re f
Q
q
15.000 56.217 577.500 720.783 re W n
0.271 0.267 0.267 rg
BT 26.250 767.476 Td /F1 9.8 Tf  [(sources characterize hospital encounter information through billing, diagnostic codes, and/or ICD-9 codes. Attempts to identify )] TJ ET
BT 26.250 755.571 Td /F1 9.8 Tf  [(influenza cases in administrative datasets have been described in the literature )] TJ ET
0.267 0.267 0.267 rg
BT 369.284 755.571 Td /F1 9.8 Tf  [([8])] TJ ET
BT 380.126 755.571 Td /F1 9.8 Tf  [([9])] TJ ET
BT 390.968 755.571 Td /F1 9.8 Tf  [([10])] TJ ET
BT 407.231 755.571 Td /F1 9.8 Tf  [([11])] TJ ET
BT 423.494 755.571 Td /F1 9.8 Tf  [([12])] TJ ET
0.271 0.267 0.267 rg
BT 439.757 755.571 Td /F1 9.8 Tf  [( , but more information is )] TJ ET
BT 26.250 743.667 Td /F1 9.8 Tf  [(required about accurate case identification methods since currently no �gold standard� influenza case selection criteria exists.)] TJ ET
BT 26.250 724.262 Td /F1 9.8 Tf  [(Epidemiological assessments have compared severity of disease between patients hospitalized with seasonal influenza and )] TJ ET
BT 26.250 712.357 Td /F1 9.8 Tf  [(H1N1. One study in a pediatric cohort found that H1N1 was associated with more severe respiratory disease than seasonal )] TJ ET
BT 26.250 700.452 Td /F1 9.8 Tf  [(influenza )] TJ ET
0.267 0.267 0.267 rg
BT 67.980 700.452 Td /F1 9.8 Tf  [([13])] TJ ET
0.271 0.267 0.267 rg
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BT 233.262 676.643 Td /F1 9.8 Tf  [( .)] TJ ET
BT 26.250 657.238 Td /F1 9.8 Tf  [(There are also confirmed diagnosis data suggesting that specific communities and populations, racial and ethnic groups )] TJ ET
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BT 26.250 578.310 Td /F1 9.8 Tf  [(identify those hospitalized with influenza during the first wave of the H1N1 pandemic.)] TJ ET
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BT 26.250 498.493 Td /F4 12.0 Tf  [(MATERIALS AND METHODS)] TJ ET
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BT 267.005 705.251 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 714.606 160.448 1.000 re f
420.552 690.106 1.000 25.500 re f
580.000 690.106 1.000 25.500 re f
31.100 690.106 231.005 1.000 re f
31.100 665.606 1.000 25.500 re f
BT 37.500 680.751 Td /F4 9.8 Tf  [(461.9 Acute sinusitis, unspecified)] TJ ET
261.105 690.106 160.448 1.000 re f
261.105 665.606 1.000 25.500 re f
BT 267.005 680.751 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 690.106 160.448 1.000 re f
420.552 665.606 1.000 25.500 re f
580.000 665.606 1.000 25.500 re f
31.100 665.606 231.005 1.000 re f
31.100 649.975 1.000 16.631 re f
BT 37.500 656.251 Td /F4 9.8 Tf  [(382.9 Otitis media NOS)] TJ ET
261.105 665.606 160.448 1.000 re f
261.105 649.975 1.000 16.631 re f
BT 267.005 656.251 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 665.606 160.448 1.000 re f
420.552 649.975 1.000 16.631 re f
580.000 649.975 1.000 16.631 re f
31.100 649.975 231.005 1.000 re f
31.100 634.344 1.000 16.631 re f
BT 37.500 640.620 Td /F4 9.8 Tf  [(460 Nasopharyngitis, acute)] TJ ET
261.105 649.975 160.448 1.000 re f
261.105 634.344 1.000 16.631 re f
BT 267.005 640.620 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 649.975 160.448 1.000 re f
420.552 634.344 1.000 16.631 re f
580.000 634.344 1.000 16.631 re f
31.100 634.344 231.005 1.000 re f
31.100 618.712 1.000 16.631 re f
BT 37.500 624.989 Td /F4 9.8 Tf  [(490 Bronchitis NOS)] TJ ET
261.105 634.344 160.448 1.000 re f
261.105 618.712 1.000 16.631 re f
BT 267.005 624.989 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 634.344 160.448 1.000 re f
420.552 618.712 1.000 16.631 re f
580.000 618.712 1.000 16.631 re f
31.100 618.712 231.005 1.000 re f
31.100 603.081 1.000 16.631 re f
BT 37.500 609.358 Td /F4 9.8 Tf  [(786.2 Cough)] TJ ET
261.105 618.712 160.448 1.000 re f
261.105 603.081 1.000 16.631 re f
BT 267.005 609.358 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 618.712 160.448 1.000 re f
420.552 603.081 1.000 16.631 re f
580.000 603.081 1.000 16.631 re f
31.100 603.081 231.005 1.000 re f
31.100 582.831 1.000 21.250 re f
BT 37.500 593.726 Td /F4 9.8 Tf  [(487.1 Influenza with resp manif)] TJ ET
261.105 603.081 160.448 1.000 re f
261.105 582.831 1.000 21.250 re f
BT 267.005 593.726 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 603.081 160.448 1.000 re f
420.552 582.831 1.000 21.250 re f
580.000 582.831 1.000 21.250 re f
BT 426.452 593.726 Td /F4 9.8 Tf  [(?)] TJ ET
31.100 582.831 231.005 1.000 re f
31.100 567.200 1.000 16.631 re f
BT 37.500 573.476 Td /F4 9.8 Tf  [(487.8 Influenza with manif NEC)] TJ ET
261.105 582.831 160.448 1.000 re f
261.105 567.200 1.000 16.631 re f
BT 267.005 573.476 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 582.831 160.448 1.000 re f
420.552 567.200 1.000 16.631 re f
580.000 567.200 1.000 16.631 re f
BT 426.452 573.476 Td /F4 9.8 Tf  [(?)] TJ ET
31.100 567.200 231.005 1.000 re f
31.100 551.569 1.000 16.631 re f
BT 37.500 557.845 Td /F4 9.8 Tf  [(487 Influenza)] TJ ET
261.105 567.200 160.448 1.000 re f
261.105 551.569 1.000 16.631 re f
BT 267.005 557.845 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 567.200 160.448 1.000 re f
420.552 551.569 1.000 16.631 re f
580.000 551.569 1.000 16.631 re f
BT 426.452 557.845 Td /F4 9.8 Tf  [(?)] TJ ET
31.100 551.569 231.005 1.000 re f
31.100 527.069 1.000 25.500 re f
BT 37.500 542.214 Td /F4 9.8 Tf  [(465.8 Infectious upper resp, mult sites)] TJ ET
261.105 551.569 160.448 1.000 re f
261.105 527.069 1.000 25.500 re f
BT 267.005 542.214 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 551.569 160.448 1.000 re f
420.552 527.069 1.000 25.500 re f
580.000 527.069 1.000 25.500 re f
BT 426.452 542.214 Td /F4 9.8 Tf  [(?)] TJ ET
31.100 527.069 231.005 1.000 re f
31.100 511.438 231.005 1.000 re f
31.100 511.438 1.000 16.631 re f
BT 37.500 517.714 Td /F4 9.8 Tf  [(488.1 H1N1 Influenza)] TJ ET
261.105 527.069 160.448 1.000 re f
261.105 511.438 160.448 1.000 re f
261.105 511.438 1.000 16.631 re f
BT 267.005 517.714 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 527.069 160.448 1.000 re f
420.552 511.438 160.448 1.000 re f
420.552 511.438 1.000 16.631 re f
580.000 511.438 1.000 16.631 re f
BT 426.452 517.714 Td /F4 9.8 Tf  [(?)] TJ ET
BT 26.250 464.164 Td /F4 9.8 Tf  [(Statistical analyses)] TJ ET
BT 26.250 444.759 Td /F1 9.8 Tf  [(We constructed line graphs describing weekly ILI discharge rates, and calculated mean frequencies of ILI discharges )] TJ ET
BT 26.250 432.854 Td /F1 9.8 Tf  [(corresponding to the fiscal year: MMWR Week 40 \(10/1\) through week 39 \(9/30\) to describe annual trends. To describe )] TJ ET
BT 26.250 420.949 Td /F1 9.8 Tf  [(variability related to ILI discharges prior to the H1N1 pandemic, we calculated mean weekly frequencies of ILI-related )] TJ ET
BT 26.250 409.045 Td /F1 9.8 Tf  [(discharges for the period October 1, 2004-April 25, 2009, and 95% confidence intervals \(CIs\). We used SAS v.9.2 to conduct all )] TJ ET
BT 26.250 397.140 Td /F1 9.8 Tf  [(analyses.)] TJ ET
BT 26.250 377.735 Td /F1 9.8 Tf  [(To determine how and if the H1N1 population differed from the seasonal influenza population we compared periods of H1N1-)] TJ ET
BT 26.250 365.830 Td /F1 9.8 Tf  [(specific influenza activity \(April-Sept 2009\) to those of seasonal influenza. To do this, we analyzed frequencies of ILI discharges )] TJ ET
BT 26.250 353.926 Td /F1 9.8 Tf  [(from 2004-2009, described characteristics of patients with H1N1 and seasonal influenza, and used chi-square tests of )] TJ ET
BT 26.250 342.021 Td /F1 9.8 Tf  [(proportions between groups to determine significance \(Table 2\).Those with )] TJ ET
BT 351.929 342.021 Td /F5 9.8 Tf  [(P)] TJ ET
BT 358.433 342.021 Td /F1 9.8 Tf  [( <0.05 indicate that proportions of the seasonal )] TJ ET
BT 26.250 330.116 Td /F1 9.8 Tf  [(influenza and H1N1 influenza groups represent statistically different distributions.)] TJ ET
BT 26.250 293.514 Td /F4 12.0 Tf  [(RESULTS)] TJ ET
BT 26.250 273.559 Td /F4 9.8 Tf  [(Characterization of H1N1-related hospitalizations in Massachusetts)] TJ ET
BT 26.250 254.155 Td /F1 9.8 Tf  [(For fiscal year 2009 \(October 1, 2008 -September 30, 2009\) there were 853,446 total discharges. Out of 359,344 total )] TJ ET
BT 26.250 242.250 Td /F1 9.8 Tf  [(discharges between April 26-September 30, 2009, there were 10,976 individuals discharged from an acute care hospital in )] TJ ET
BT 26.250 230.345 Td /F1 9.8 Tf  [(Massachusetts meeting the maximum selection criteria \(Table 2\) during the H1N1 pandemic. Between October 1, 2004-April 25, )] TJ ET
BT 26.250 218.440 Td /F1 9.8 Tf  [(2009, there were 109,084 individuals discharged with an ILI diagnosis code corresponding to influenza. According to the )] TJ ET
BT 26.250 206.536 Td /F1 9.8 Tf  [(minimum criteria, there were 601 individuals discharged during the H1N1 pandemic \(Table 2\), and 2,715 patients discharged )] TJ ET
BT 26.250 194.631 Td /F1 9.8 Tf  [(from a Massachusetts hospital between October 1, 2004-April 25, 2009.)] TJ ET
0.965 0.965 0.965 rg
26.250 -5.000 555.000 189.750 re f
0.267 0.267 0.267 rg
0.267 0.267 0.267 RG
26.250 184.750 m 581.250 184.750 l 581.250 184.000 l 26.250 184.000 l  f
q
225.000 0 0 174.000 35.250 1.000 cm /I3 Do
Q 
q
35.250 -5.000 537.000 0.000 re W n
Q
Q
q
15.000 -5.000 577.500 782.000 re W n
1.000 1.000 1.000 rg
30.850 511.188 550.400 265.812 re f
31.100 745.869 1.000 31.131 re f
0.271 0.267 0.267 rg
BT 37.500 767.145 Td /F4 9.8 Tf  [(780.6 Fever)] TJ ET
261.105 745.869 1.000 31.131 re f
BT 267.005 767.145 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 745.869 1.000 31.131 re f
580.000 745.869 1.000 31.131 re f
31.100 745.869 231.005 1.000 re f
31.100 730.237 1.000 16.631 re f
BT 37.500 736.514 Td /F4 9.8 Tf  [(466 Laryngopharyngitis, acute)] TJ ET
261.105 745.869 160.448 1.000 re f
261.105 730.237 1.000 16.631 re f
BT 267.005 736.514 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 745.869 160.448 1.000 re f
420.552 730.237 1.000 16.631 re f
580.000 730.237 1.000 16.631 re f
31.100 730.237 231.005 1.000 re f
31.100 714.606 1.000 16.631 re f
BT 37.500 720.883 Td /F4 9.8 Tf  [(486 Pneumonia, organism NOS)] TJ ET
261.105 730.237 160.448 1.000 re f
261.105 714.606 1.000 16.631 re f
BT 267.005 720.883 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 730.237 160.448 1.000 re f
420.552 714.606 1.000 16.631 re f
580.000 714.606 1.000 16.631 re f
31.100 714.606 231.005 1.000 re f
31.100 690.106 1.000 25.500 re f
BT 37.500 705.251 Td /F4 9.8 Tf  [(465.9 Infectious upper resp, mult sites)] TJ ET
261.105 714.606 160.448 1.000 re f
261.105 690.106 1.000 25.500 re f
BT 267.005 705.251 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 714.606 160.448 1.000 re f
420.552 690.106 1.000 25.500 re f
580.000 690.106 1.000 25.500 re f
31.100 690.106 231.005 1.000 re f
31.100 665.606 1.000 25.500 re f
BT 37.500 680.751 Td /F4 9.8 Tf  [(461.9 Acute sinusitis, unspecified)] TJ ET
261.105 690.106 160.448 1.000 re f
261.105 665.606 1.000 25.500 re f
BT 267.005 680.751 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 690.106 160.448 1.000 re f
420.552 665.606 1.000 25.500 re f
580.000 665.606 1.000 25.500 re f
31.100 665.606 231.005 1.000 re f
31.100 649.975 1.000 16.631 re f
BT 37.500 656.251 Td /F4 9.8 Tf  [(382.9 Otitis media NOS)] TJ ET
261.105 665.606 160.448 1.000 re f
261.105 649.975 1.000 16.631 re f
BT 267.005 656.251 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 665.606 160.448 1.000 re f
420.552 649.975 1.000 16.631 re f
580.000 649.975 1.000 16.631 re f
31.100 649.975 231.005 1.000 re f
31.100 634.344 1.000 16.631 re f
BT 37.500 640.620 Td /F4 9.8 Tf  [(460 Nasopharyngitis, acute)] TJ ET
261.105 649.975 160.448 1.000 re f
261.105 634.344 1.000 16.631 re f
BT 267.005 640.620 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 649.975 160.448 1.000 re f
420.552 634.344 1.000 16.631 re f
580.000 634.344 1.000 16.631 re f
31.100 634.344 231.005 1.000 re f
31.100 618.712 1.000 16.631 re f
BT 37.500 624.989 Td /F4 9.8 Tf  [(490 Bronchitis NOS)] TJ ET
261.105 634.344 160.448 1.000 re f
261.105 618.712 1.000 16.631 re f
BT 267.005 624.989 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 634.344 160.448 1.000 re f
420.552 618.712 1.000 16.631 re f
580.000 618.712 1.000 16.631 re f
31.100 618.712 231.005 1.000 re f
31.100 603.081 1.000 16.631 re f
BT 37.500 609.358 Td /F4 9.8 Tf  [(786.2 Cough)] TJ ET
261.105 618.712 160.448 1.000 re f
261.105 603.081 1.000 16.631 re f
BT 267.005 609.358 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 618.712 160.448 1.000 re f
420.552 603.081 1.000 16.631 re f
580.000 603.081 1.000 16.631 re f
31.100 603.081 231.005 1.000 re f
31.100 582.831 1.000 21.250 re f
BT 37.500 593.726 Td /F4 9.8 Tf  [(487.1 Influenza with resp manif)] TJ ET
261.105 603.081 160.448 1.000 re f
261.105 582.831 1.000 21.250 re f
BT 267.005 593.726 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 603.081 160.448 1.000 re f
420.552 582.831 1.000 21.250 re f
580.000 582.831 1.000 21.250 re f
BT 426.452 593.726 Td /F4 9.8 Tf  [(?)] TJ ET
31.100 582.831 231.005 1.000 re f
31.100 567.200 1.000 16.631 re f
BT 37.500 573.476 Td /F4 9.8 Tf  [(487.8 Influenza with manif NEC)] TJ ET
261.105 582.831 160.448 1.000 re f
261.105 567.200 1.000 16.631 re f
BT 267.005 573.476 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 582.831 160.448 1.000 re f
420.552 567.200 1.000 16.631 re f
580.000 567.200 1.000 16.631 re f
BT 426.452 573.476 Td /F4 9.8 Tf  [(?)] TJ ET
31.100 567.200 231.005 1.000 re f
31.100 551.569 1.000 16.631 re f
BT 37.500 557.845 Td /F4 9.8 Tf  [(487 Influenza)] TJ ET
261.105 567.200 160.448 1.000 re f
261.105 551.569 1.000 16.631 re f
BT 267.005 557.845 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 567.200 160.448 1.000 re f
420.552 551.569 1.000 16.631 re f
580.000 551.569 1.000 16.631 re f
BT 426.452 557.845 Td /F4 9.8 Tf  [(?)] TJ ET
31.100 551.569 231.005 1.000 re f
31.100 527.069 1.000 25.500 re f
BT 37.500 542.214 Td /F4 9.8 Tf  [(465.8 Infectious upper resp, mult sites)] TJ ET
261.105 551.569 160.448 1.000 re f
261.105 527.069 1.000 25.500 re f
BT 267.005 542.214 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 551.569 160.448 1.000 re f
420.552 527.069 1.000 25.500 re f
580.000 527.069 1.000 25.500 re f
BT 426.452 542.214 Td /F4 9.8 Tf  [(?)] TJ ET
31.100 527.069 231.005 1.000 re f
31.100 511.438 231.005 1.000 re f
31.100 511.438 1.000 16.631 re f
BT 37.500 517.714 Td /F4 9.8 Tf  [(488.1 H1N1 Influenza)] TJ ET
261.105 527.069 160.448 1.000 re f
261.105 511.438 160.448 1.000 re f
261.105 511.438 1.000 16.631 re f
BT 267.005 517.714 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 527.069 160.448 1.000 re f
420.552 511.438 160.448 1.000 re f
420.552 511.438 1.000 16.631 re f
580.000 511.438 1.000 16.631 re f
BT 426.452 517.714 Td /F4 9.8 Tf  [(?)] TJ ET
BT 26.250 464.164 Td /F4 9.8 Tf  [(Statistical analyses)] TJ ET
BT 26.250 444.759 Td /F1 9.8 Tf  [(We constructed line graphs describing weekly ILI discharge rates, and calculated mean frequencies of ILI discharges )] TJ ET
BT 26.250 432.854 Td /F1 9.8 Tf  [(corresponding to the fiscal year: MMWR Week 40 \(10/1\) through week 39 \(9/30\) to describe annual trends. To describe )] TJ ET
BT 26.250 420.949 Td /F1 9.8 Tf  [(variability related to ILI discharges prior to the H1N1 pandemic, we calculated mean weekly frequencies of ILI-related )] TJ ET
BT 26.250 409.045 Td /F1 9.8 Tf  [(discharges for the period October 1, 2004-April 25, 2009, and 95% confidence intervals \(CIs\). We used SAS v.9.2 to conduct all )] TJ ET
BT 26.250 397.140 Td /F1 9.8 Tf  [(analyses.)] TJ ET
BT 26.250 377.735 Td /F1 9.8 Tf  [(To determine how and if the H1N1 population differed from the seasonal influenza population we compared periods of H1N1-)] TJ ET
BT 26.250 365.830 Td /F1 9.8 Tf  [(specific influenza activity \(April-Sept 2009\) to those of seasonal influenza. To do this, we analyzed frequencies of ILI discharges )] TJ ET
BT 26.250 353.926 Td /F1 9.8 Tf  [(from 2004-2009, described characteristics of patients with H1N1 and seasonal influenza, and used chi-square tests of )] TJ ET
BT 26.250 342.021 Td /F1 9.8 Tf  [(proportions between groups to determine significance \(Table 2\).Those with )] TJ ET
BT 351.929 342.021 Td /F5 9.8 Tf  [(P)] TJ ET
BT 358.433 342.021 Td /F1 9.8 Tf  [( <0.05 indicate that proportions of the seasonal )] TJ ET
BT 26.250 330.116 Td /F1 9.8 Tf  [(influenza and H1N1 influenza groups represent statistically different distributions.)] TJ ET
BT 26.250 293.514 Td /F4 12.0 Tf  [(RESULTS)] TJ ET
BT 26.250 273.559 Td /F4 9.8 Tf  [(Characterization of H1N1-related hospitalizations in Massachusetts)] TJ ET
BT 26.250 254.155 Td /F1 9.8 Tf  [(For fiscal year 2009 \(October 1, 2008 -September 30, 2009\) there were 853,446 total discharges. Out of 359,344 total )] TJ ET
BT 26.250 242.250 Td /F1 9.8 Tf  [(discharges between April 26-September 30, 2009, there were 10,976 individuals discharged from an acute care hospital in )] TJ ET
BT 26.250 230.345 Td /F1 9.8 Tf  [(Massachusetts meeting the maximum selection criteria \(Table 2\) during the H1N1 pandemic. Between October 1, 2004-April 25, )] TJ ET
BT 26.250 218.440 Td /F1 9.8 Tf  [(2009, there were 109,084 individuals discharged with an ILI diagnosis code corresponding to influenza. According to the )] TJ ET
BT 26.250 206.536 Td /F1 9.8 Tf  [(minimum criteria, there were 601 individuals discharged during the H1N1 pandemic \(Table 2\), and 2,715 patients discharged )] TJ ET
BT 26.250 194.631 Td /F1 9.8 Tf  [(from a Massachusetts hospital between October 1, 2004-April 25, 2009.)] TJ ET
0.965 0.965 0.965 rg
26.250 -5.000 555.000 189.750 re f
0.267 0.267 0.267 rg
0.267 0.267 0.267 RG
26.250 184.750 m 581.250 184.750 l 581.250 184.000 l 26.250 184.000 l  f
q
225.000 0 0 174.000 35.250 1.000 cm /I3 Do
Q 
q
35.250 -5.000 537.000 0.000 re W n
Q
Q
q
15.000 -5.000 577.500 782.000 re W n
1.000 1.000 1.000 rg
30.850 511.188 550.400 265.812 re f
31.100 745.869 1.000 31.131 re f
0.271 0.267 0.267 rg
BT 37.500 767.145 Td /F4 9.8 Tf  [(780.6 Fever)] TJ ET
261.105 745.869 1.000 31.131 re f
BT 267.005 767.145 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 745.869 1.000 31.131 re f
580.000 745.869 1.000 31.131 re f
31.100 745.869 231.005 1.000 re f
31.100 730.237 1.000 16.631 re f
BT 37.500 736.514 Td /F4 9.8 Tf  [(466 Laryngopharyngitis, acute)] TJ ET
261.105 745.869 160.448 1.000 re f
261.105 730.237 1.000 16.631 re f
BT 267.005 736.514 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 745.869 160.448 1.000 re f
420.552 730.237 1.000 16.631 re f
580.000 730.237 1.000 16.631 re f
31.100 730.237 231.005 1.000 re f
31.100 714.606 1.000 16.631 re f
BT 37.500 720.883 Td /F4 9.8 Tf  [(486 Pneumonia, organism NOS)] TJ ET
261.105 730.237 160.448 1.000 re f
261.105 714.606 1.000 16.631 re f
BT 267.005 720.883 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 730.237 160.448 1.000 re f
420.552 714.606 1.000 16.631 re f
580.000 714.606 1.000 16.631 re f
31.100 714.606 231.005 1.000 re f
31.100 690.106 1.000 25.500 re f
BT 37.500 705.251 Td /F4 9.8 Tf  [(465.9 Infectious upper resp, mult sites)] TJ ET
261.105 714.606 160.448 1.000 re f
261.105 690.106 1.000 25.500 re f
BT 267.005 705.251 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 714.606 160.448 1.000 re f
420.552 690.106 1.000 25.500 re f
580.000 690.106 1.000 25.500 re f
31.100 690.106 231.005 1.000 re f
31.100 665.606 1.000 25.500 re f
BT 37.500 680.751 Td /F4 9.8 Tf  [(461.9 Acute sinusitis, unspecified)] TJ ET
261.105 690.106 160.448 1.000 re f
261.105 665.606 1.000 25.500 re f
BT 267.005 680.751 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 690.106 160.448 1.000 re f
420.552 665.606 1.000 25.500 re f
580.000 665.606 1.000 25.500 re f
31.100 665.606 231.005 1.000 re f
31.100 649.975 1.000 16.631 re f
BT 37.500 656.251 Td /F4 9.8 Tf  [(382.9 Otitis media NOS)] TJ ET
261.105 665.606 160.448 1.000 re f
261.105 649.975 1.000 16.631 re f
BT 267.005 656.251 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 665.606 160.448 1.000 re f
420.552 649.975 1.000 16.631 re f
580.000 649.975 1.000 16.631 re f
31.100 649.975 231.005 1.000 re f
31.100 634.344 1.000 16.631 re f
BT 37.500 640.620 Td /F4 9.8 Tf  [(460 Nasopharyngitis, acute)] TJ ET
261.105 649.975 160.448 1.000 re f
261.105 634.344 1.000 16.631 re f
BT 267.005 640.620 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 649.975 160.448 1.000 re f
420.552 634.344 1.000 16.631 re f
580.000 634.344 1.000 16.631 re f
31.100 634.344 231.005 1.000 re f
31.100 618.712 1.000 16.631 re f
BT 37.500 624.989 Td /F4 9.8 Tf  [(490 Bronchitis NOS)] TJ ET
261.105 634.344 160.448 1.000 re f
261.105 618.712 1.000 16.631 re f
BT 267.005 624.989 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 634.344 160.448 1.000 re f
420.552 618.712 1.000 16.631 re f
580.000 618.712 1.000 16.631 re f
31.100 618.712 231.005 1.000 re f
31.100 603.081 1.000 16.631 re f
BT 37.500 609.358 Td /F4 9.8 Tf  [(786.2 Cough)] TJ ET
261.105 618.712 160.448 1.000 re f
261.105 603.081 1.000 16.631 re f
BT 267.005 609.358 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 618.712 160.448 1.000 re f
420.552 603.081 1.000 16.631 re f
580.000 603.081 1.000 16.631 re f
31.100 603.081 231.005 1.000 re f
31.100 582.831 1.000 21.250 re f
BT 37.500 593.726 Td /F4 9.8 Tf  [(487.1 Influenza with resp manif)] TJ ET
261.105 603.081 160.448 1.000 re f
261.105 582.831 1.000 21.250 re f
BT 267.005 593.726 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 603.081 160.448 1.000 re f
420.552 582.831 1.000 21.250 re f
580.000 582.831 1.000 21.250 re f
BT 426.452 593.726 Td /F4 9.8 Tf  [(?)] TJ ET
31.100 582.831 231.005 1.000 re f
31.100 567.200 1.000 16.631 re f
BT 37.500 573.476 Td /F4 9.8 Tf  [(487.8 Influenza with manif NEC)] TJ ET
261.105 582.831 160.448 1.000 re f
261.105 567.200 1.000 16.631 re f
BT 267.005 573.476 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 582.831 160.448 1.000 re f
420.552 567.200 1.000 16.631 re f
580.000 567.200 1.000 16.631 re f
BT 426.452 573.476 Td /F4 9.8 Tf  [(?)] TJ ET
31.100 567.200 231.005 1.000 re f
31.100 551.569 1.000 16.631 re f
BT 37.500 557.845 Td /F4 9.8 Tf  [(487 Influenza)] TJ ET
261.105 567.200 160.448 1.000 re f
261.105 551.569 1.000 16.631 re f
BT 267.005 557.845 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 567.200 160.448 1.000 re f
420.552 551.569 1.000 16.631 re f
580.000 551.569 1.000 16.631 re f
BT 426.452 557.845 Td /F4 9.8 Tf  [(?)] TJ ET
31.100 551.569 231.005 1.000 re f
31.100 527.069 1.000 25.500 re f
BT 37.500 542.214 Td /F4 9.8 Tf  [(465.8 Infectious upper resp, mult sites)] TJ ET
261.105 551.569 160.448 1.000 re f
261.105 527.069 1.000 25.500 re f
BT 267.005 542.214 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 551.569 160.448 1.000 re f
420.552 527.069 1.000 25.500 re f
580.000 527.069 1.000 25.500 re f
BT 426.452 542.214 Td /F4 9.8 Tf  [(?)] TJ ET
31.100 527.069 231.005 1.000 re f
31.100 511.438 231.005 1.000 re f
31.100 511.438 1.000 16.631 re f
BT 37.500 517.714 Td /F4 9.8 Tf  [(488.1 H1N1 Influenza)] TJ ET
261.105 527.069 160.448 1.000 re f
261.105 511.438 160.448 1.000 re f
261.105 511.438 1.000 16.631 re f
BT 267.005 517.714 Td /F4 9.8 Tf  [(?)] TJ ET
420.552 527.069 160.448 1.000 re f
420.552 511.438 160.448 1.000 re f
420.552 511.438 1.000 16.631 re f
580.000 511.438 1.000 16.631 re f
BT 426.452 517.714 Td /F4 9.8 Tf  [(?)] TJ ET
BT 26.250 464.164 Td /F4 9.8 Tf  [(Statistical analyses)] TJ ET
BT 26.250 444.759 Td /F1 9.8 Tf  [(We constructed line graphs describing weekly ILI discharge rates, and calculated mean frequencies of ILI discharges )] TJ ET
BT 26.250 432.854 Td /F1 9.8 Tf  [(corresponding to the fiscal year: MMWR Week 40 \(10/1\) through week 39 \(9/30\) to describe annual trends. To describe )] TJ ET
BT 26.250 420.949 Td /F1 9.8 Tf  [(variability related to ILI discharges prior to the H1N1 pandemic, we calculated mean weekly frequencies of ILI-related )] TJ ET
BT 26.250 409.045 Td /F1 9.8 Tf  [(discharges for the period October 1, 2004-April 25, 2009, and 95% confidence intervals \(CIs\). We used SAS v.9.2 to conduct all )] TJ ET
BT 26.250 397.140 Td /F1 9.8 Tf  [(analyses.)] TJ ET
BT 26.250 377.735 Td /F1 9.8 Tf  [(To determine how and if the H1N1 population differed from the seasonal influenza population we compared periods of H1N1-)] TJ ET
BT 26.250 365.830 Td /F1 9.8 Tf  [(specific influenza activity \(April-Sept 2009\) to those of seasonal influenza. To do this, we analyzed frequencies of ILI discharges )] TJ ET
BT 26.250 353.926 Td /F1 9.8 Tf  [(from 2004-2009, described characteristics of patients with H1N1 and seasonal influenza, and used chi-square tests of )] TJ ET
BT 26.250 342.021 Td /F1 9.8 Tf  [(proportions between groups to determine significance \(Table 2\).Those with )] TJ ET
BT 351.929 342.021 Td /F5 9.8 Tf  [(P)] TJ ET
BT 358.433 342.021 Td /F1 9.8 Tf  [( <0.05 indicate that proportions of the seasonal )] TJ ET
BT 26.250 330.116 Td /F1 9.8 Tf  [(influenza and H1N1 influenza groups represent statistically different distributions.)] TJ ET
BT 26.250 293.514 Td /F4 12.0 Tf  [(RESULTS)] TJ ET
BT 26.250 273.559 Td /F4 9.8 Tf  [(Characterization of H1N1-related hospitalizations in Massachusetts)] TJ ET
BT 26.250 254.155 Td /F1 9.8 Tf  [(For fiscal year 2009 \(October 1, 2008 -September 30, 2009\) there were 853,446 total discharges. Out of 359,344 total )] TJ ET
BT 26.250 242.250 Td /F1 9.8 Tf  [(discharges between April 26-September 30, 2009, there were 10,976 individuals discharged from an acute care hospital in )] TJ ET
BT 26.250 230.345 Td /F1 9.8 Tf  [(Massachusetts meeting the maximum selection criteria \(Table 2\) during the H1N1 pandemic. Between October 1, 2004-April 25, )] TJ ET
BT 26.250 218.440 Td /F1 9.8 Tf  [(2009, there were 109,084 individuals discharged with an ILI diagnosis code corresponding to influenza. According to the )] TJ ET
BT 26.250 206.536 Td /F1 9.8 Tf  [(minimum criteria, there were 601 individuals discharged during the H1N1 pandemic \(Table 2\), and 2,715 patients discharged )] TJ ET
BT 26.250 194.631 Td /F1 9.8 Tf  [(from a Massachusetts hospital between October 1, 2004-April 25, 2009.)] TJ ET
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BT 26.250 767.476 Td /F1 9.8 Tf  [(In general, there were more narrow confidence intervals during periods of relatively low ILI activity \(Weeks 40-46, or 21-27\) )] TJ ET
BT 26.250 755.571 Td /F1 9.8 Tf  [(\(Figure 1\).)] TJ ET
0.965 0.965 0.965 rg
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0.267 0.267 0.267 RG
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35.250 587.204 537.000 21.236 re W n
0.271 0.267 0.267 rg
BT 35.250 597.451 Td /F1 9.8 Tf  [(Frequency Meeting Maximum Criteria in Massachusetts by MMWR Week, FY2005-200)] TJ ET
Q
BT 26.250 558.930 Td /F1 9.8 Tf  [(Legend: Figures 1 and 2 show the mean frequency of ILI discharges by MMWR week for fiscal years 2005-2008 \(blue\) and )] TJ ET
BT 26.250 547.026 Td /F1 9.8 Tf  [(2009 \(red\) with 95% CI�s.)] TJ ET
BT 26.250 527.621 Td /F1 9.8 Tf  [(Except for Week 9, ILI discharges in 2009 fell within the 95% CI for 2005-2008 until Week 17. Starting at Week 17, however, )] TJ ET
BT 26.250 515.716 Td /F1 9.8 Tf  [(there was an unusual increase in frequency of ILI discharges corresponding to the H1N1 pandemic. During weeks with low )] TJ ET
BT 26.250 503.811 Td /F1 9.8 Tf  [(activity during fiscal years 2005-2008, there was a baseline of 400-500 discharges, with peaks at approximately 700 cases )] TJ ET
BT 26.250 491.907 Td /F1 9.8 Tf  [(during Weeks 3 and 9. Activity during 2009 peaked at Week 10 with 800 discharges and then at week 25 with approximately )] TJ ET
BT 26.250 480.002 Td /F1 9.8 Tf  [(650 cases, compared to approximately 425 for 2005-2008. This comparison indicates typical ILI activity during fall 2008 and )] TJ ET
BT 26.250 468.097 Td /F1 9.8 Tf  [(winter 2009, but unusually high frequency of ILI discharges during spring and summer 2009.)] TJ ET
BT 26.250 448.692 Td /F1 9.8 Tf  [(Influenza-specific codes are rarely used in summer months identifying approximately zero cases except for Summer 2009 )] TJ ET
BT 26.250 436.788 Td /F1 9.8 Tf  [(\(Figure 2\).)] TJ ET
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BT 35.250 265.168 Td /F1 9.8 Tf  [(Frequency Meeting Minimum Criteria in Massachusetts by MMWR Week, FY2005-2009)] TJ ET
Q
BT 26.250 226.647 Td /F1 9.8 Tf  [(The mean frequency of ILI discharges from 2005-2008 are shown in blue with 95% CIs. Similar to Figure 1, ILI discharges in )] TJ ET
BT 26.250 214.742 Td /F1 9.8 Tf  [(2009 fell within the CIs of 2005-2008 until week 17. In 2005-2008, the frequency of discharges with influenza-specific diagnoses )] TJ ET
BT 26.250 202.837 Td /F1 9.8 Tf  [(declined to approximately zero per week between Weeks 22-39, but we saw a peak of discharges with influenza-specific )] TJ ET
BT 26.250 190.932 Td /F1 9.8 Tf  [(diagnoses at Week 26 \(n=58\) during 2009 corresponding to the H1N1 pandemic. This comparison indicates that influenza )] TJ ET
BT 26.250 179.028 Td /F1 9.8 Tf  [(diagnoses were not common during Weeks 22-39 in years 2005-2008 which is typically non-influenza season, but in the spring )] TJ ET
BT 26.250 167.123 Td /F1 9.8 Tf  [(and summer of 2009 there was a comparatively large number of discharges with influenza diagnoses from hospitals in )] TJ ET
BT 26.250 155.218 Td /F1 9.8 Tf  [(Massachusetts. Results in Figure 2 also correspond closely with statewide sentinel site surveillance data from Massachusetts )] TJ ET
BT 26.250 143.313 Td /F1 9.8 Tf  [(providers reporting percentage of ILI visits )] TJ ET
0.267 0.267 0.267 rg
BT 210.496 143.313 Td /F1 9.8 Tf  [([18])] TJ ET
0.271 0.267 0.267 rg
BT 226.759 143.313 Td /F1 9.8 Tf  [( .)] TJ ET
BT 26.250 123.909 Td /F1 9.8 Tf  [(To address possible misclassification of non-influenza cases included as influenza cases, the breakdown and trends of each )] TJ ET
BT 26.250 112.004 Td /F1 9.8 Tf  [(code included in the maximum \(broad\) criteria were analyzed. The H1N1-specific ICD-9 code \(488.1\) introduced in June 2009 )] TJ ET
BT 26.250 100.099 Td /F1 9.8 Tf  [(was not used to diagnose any individuals discharged from a hospital in Massachusetts. Among those meeting the maximum )] TJ ET
BT 26.250 88.194 Td /F1 9.8 Tf  [(criteria, 64% had a discharge code corresponding to pneumonia \(486\), and 10% had the corresponding discharge code for )] TJ ET
BT 26.250 76.290 Td /F1 9.8 Tf  [(fever \(780.6\).)] TJ ET
BT 26.250 56.885 Td /F4 9.8 Tf  [(Comparing characteristics of H1N1 and seasonal influenza populations)] TJ ET
BT 26.250 37.480 Td /F1 9.8 Tf  [(Comparing the H1N1 and seasonal influenza groups among the maximum criteria, there were higher proportions of Black, non-)] TJ ET
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q
15.000 23.194 577.500 753.806 re W n
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35.250 777.000 537.000 0.000 re W n
Q
0.271 0.267 0.267 rg
BT 26.250 767.476 Td /F1 9.8 Tf  [(In general, there were more narrow confidence intervals during periods of relatively low ILI activity \(Weeks 40-46, or 21-27\) )] TJ ET
BT 26.250 755.571 Td /F1 9.8 Tf  [(\(Figure 1\).)] TJ ET
0.965 0.965 0.965 rg
26.250 575.954 555.000 169.736 re f
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0.267 0.267 0.267 RG
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BT 35.250 597.451 Td /F1 9.8 Tf  [(Frequency Meeting Maximum Criteria in Massachusetts by MMWR Week, FY2005-200)] TJ ET
Q
BT 26.250 558.930 Td /F1 9.8 Tf  [(Legend: Figures 1 and 2 show the mean frequency of ILI discharges by MMWR week for fiscal years 2005-2008 \(blue\) and )] TJ ET
BT 26.250 547.026 Td /F1 9.8 Tf  [(2009 \(red\) with 95% CI�s.)] TJ ET
BT 26.250 527.621 Td /F1 9.8 Tf  [(Except for Week 9, ILI discharges in 2009 fell within the 95% CI for 2005-2008 until Week 17. Starting at Week 17, however, )] TJ ET
BT 26.250 515.716 Td /F1 9.8 Tf  [(there was an unusual increase in frequency of ILI discharges corresponding to the H1N1 pandemic. During weeks with low )] TJ ET
BT 26.250 503.811 Td /F1 9.8 Tf  [(activity during fiscal years 2005-2008, there was a baseline of 400-500 discharges, with peaks at approximately 700 cases )] TJ ET
BT 26.250 491.907 Td /F1 9.8 Tf  [(during Weeks 3 and 9. Activity during 2009 peaked at Week 10 with 800 discharges and then at week 25 with approximately )] TJ ET
BT 26.250 480.002 Td /F1 9.8 Tf  [(650 cases, compared to approximately 425 for 2005-2008. This comparison indicates typical ILI activity during fall 2008 and )] TJ ET
BT 26.250 468.097 Td /F1 9.8 Tf  [(winter 2009, but unusually high frequency of ILI discharges during spring and summer 2009.)] TJ ET
BT 26.250 448.692 Td /F1 9.8 Tf  [(Influenza-specific codes are rarely used in summer months identifying approximately zero cases except for Summer 2009 )] TJ ET
BT 26.250 436.788 Td /F1 9.8 Tf  [(\(Figure 2\).)] TJ ET
0.965 0.965 0.965 rg
26.250 243.670 555.000 183.236 re f
0.267 0.267 0.267 rg
0.267 0.267 0.267 RG
26.250 426.907 m 581.250 426.907 l 581.250 426.157 l 26.250 426.157 l  f
26.250 243.670 m 581.250 243.670 l 581.250 244.420 l 26.250 244.420 l  f
q
225.000 0 0 135.000 35.250 282.157 cm /I5 Do
Q 
q
35.250 254.920 537.000 21.236 re W n
0.271 0.267 0.267 rg
BT 35.250 265.168 Td /F1 9.8 Tf  [(Frequency Meeting Minimum Criteria in Massachusetts by MMWR Week, FY2005-2009)] TJ ET
Q
BT 26.250 226.647 Td /F1 9.8 Tf  [(The mean frequency of ILI discharges from 2005-2008 are shown in blue with 95% CIs. Similar to Figure 1, ILI discharges in )] TJ ET
BT 26.250 214.742 Td /F1 9.8 Tf  [(2009 fell within the CIs of 2005-2008 until week 17. In 2005-2008, the frequency of discharges with influenza-specific diagnoses )] TJ ET
BT 26.250 202.837 Td /F1 9.8 Tf  [(declined to approximately zero per week between Weeks 22-39, but we saw a peak of discharges with influenza-specific )] TJ ET
BT 26.250 190.932 Td /F1 9.8 Tf  [(diagnoses at Week 26 \(n=58\) during 2009 corresponding to the H1N1 pandemic. This comparison indicates that influenza )] TJ ET
BT 26.250 179.028 Td /F1 9.8 Tf  [(diagnoses were not common during Weeks 22-39 in years 2005-2008 which is typically non-influenza season, but in the spring )] TJ ET
BT 26.250 167.123 Td /F1 9.8 Tf  [(and summer of 2009 there was a comparatively large number of discharges with influenza diagnoses from hospitals in )] TJ ET
BT 26.250 155.218 Td /F1 9.8 Tf  [(Massachusetts. Results in Figure 2 also correspond closely with statewide sentinel site surveillance data from Massachusetts )] TJ ET
BT 26.250 143.313 Td /F1 9.8 Tf  [(providers reporting percentage of ILI visits )] TJ ET
0.267 0.267 0.267 rg
BT 210.496 143.313 Td /F1 9.8 Tf  [([18])] TJ ET
0.271 0.267 0.267 rg
BT 226.759 143.313 Td /F1 9.8 Tf  [( .)] TJ ET
BT 26.250 123.909 Td /F1 9.8 Tf  [(To address possible misclassification of non-influenza cases included as influenza cases, the breakdown and trends of each )] TJ ET
BT 26.250 112.004 Td /F1 9.8 Tf  [(code included in the maximum \(broad\) criteria were analyzed. The H1N1-specific ICD-9 code \(488.1\) introduced in June 2009 )] TJ ET
BT 26.250 100.099 Td /F1 9.8 Tf  [(was not used to diagnose any individuals discharged from a hospital in Massachusetts. Among those meeting the maximum )] TJ ET
BT 26.250 88.194 Td /F1 9.8 Tf  [(criteria, 64% had a discharge code corresponding to pneumonia \(486\), and 10% had the corresponding discharge code for )] TJ ET
BT 26.250 76.290 Td /F1 9.8 Tf  [(fever \(780.6\).)] TJ ET
BT 26.250 56.885 Td /F4 9.8 Tf  [(Comparing characteristics of H1N1 and seasonal influenza populations)] TJ ET
BT 26.250 37.480 Td /F1 9.8 Tf  [(Comparing the H1N1 and seasonal influenza groups among the maximum criteria, there were higher proportions of Black, non-)] TJ ET
Q
q
15.000 23.194 577.500 753.806 re W n
0.965 0.965 0.965 rg
26.250 777.000 555.000 0.000 re f
0.267 0.267 0.267 rg
0.267 0.267 0.267 RG
26.250 777.000 m 581.250 777.000 l 581.250 777.750 l 26.250 777.750 l  f
q
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Q
0.271 0.267 0.267 rg
BT 26.250 767.476 Td /F1 9.8 Tf  [(In general, there were more narrow confidence intervals during periods of relatively low ILI activity \(Weeks 40-46, or 21-27\) )] TJ ET
BT 26.250 755.571 Td /F1 9.8 Tf  [(\(Figure 1\).)] TJ ET
0.965 0.965 0.965 rg
26.250 575.954 555.000 169.736 re f
0.267 0.267 0.267 rg
0.267 0.267 0.267 RG
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35.250 587.204 537.000 21.236 re W n
0.271 0.267 0.267 rg
BT 35.250 597.451 Td /F1 9.8 Tf  [(Frequency Meeting Maximum Criteria in Massachusetts by MMWR Week, FY2005-200)] TJ ET
Q
BT 26.250 558.930 Td /F1 9.8 Tf  [(Legend: Figures 1 and 2 show the mean frequency of ILI discharges by MMWR week for fiscal years 2005-2008 \(blue\) and )] TJ ET
BT 26.250 547.026 Td /F1 9.8 Tf  [(2009 \(red\) with 95% CI�s.)] TJ ET
BT 26.250 527.621 Td /F1 9.8 Tf  [(Except for Week 9, ILI discharges in 2009 fell within the 95% CI for 2005-2008 until Week 17. Starting at Week 17, however, )] TJ ET
BT 26.250 515.716 Td /F1 9.8 Tf  [(there was an unusual increase in frequency of ILI discharges corresponding to the H1N1 pandemic. During weeks with low )] TJ ET
BT 26.250 503.811 Td /F1 9.8 Tf  [(activity during fiscal years 2005-2008, there was a baseline of 400-500 discharges, with peaks at approximately 700 cases )] TJ ET
BT 26.250 491.907 Td /F1 9.8 Tf  [(during Weeks 3 and 9. Activity during 2009 peaked at Week 10 with 800 discharges and then at week 25 with approximately )] TJ ET
BT 26.250 480.002 Td /F1 9.8 Tf  [(650 cases, compared to approximately 425 for 2005-2008. This comparison indicates typical ILI activity during fall 2008 and )] TJ ET
BT 26.250 468.097 Td /F1 9.8 Tf  [(winter 2009, but unusually high frequency of ILI discharges during spring and summer 2009.)] TJ ET
BT 26.250 448.692 Td /F1 9.8 Tf  [(Influenza-specific codes are rarely used in summer months identifying approximately zero cases except for Summer 2009 )] TJ ET
BT 26.250 436.788 Td /F1 9.8 Tf  [(\(Figure 2\).)] TJ ET
0.965 0.965 0.965 rg
26.250 243.670 555.000 183.236 re f
0.267 0.267 0.267 rg
0.267 0.267 0.267 RG
26.250 426.907 m 581.250 426.907 l 581.250 426.157 l 26.250 426.157 l  f
26.250 243.670 m 581.250 243.670 l 581.250 244.420 l 26.250 244.420 l  f
q
225.000 0 0 135.000 35.250 282.157 cm /I5 Do
Q 
q
35.250 254.920 537.000 21.236 re W n
0.271 0.267 0.267 rg
BT 35.250 265.168 Td /F1 9.8 Tf  [(Frequency Meeting Minimum Criteria in Massachusetts by MMWR Week, FY2005-2009)] TJ ET
Q
BT 26.250 226.647 Td /F1 9.8 Tf  [(The mean frequency of ILI discharges from 2005-2008 are shown in blue with 95% CIs. Similar to Figure 1, ILI discharges in )] TJ ET
BT 26.250 214.742 Td /F1 9.8 Tf  [(2009 fell within the CIs of 2005-2008 until week 17. In 2005-2008, the frequency of discharges with influenza-specific diagnoses )] TJ ET
BT 26.250 202.837 Td /F1 9.8 Tf  [(declined to approximately zero per week between Weeks 22-39, but we saw a peak of discharges with influenza-specific )] TJ ET
BT 26.250 190.932 Td /F1 9.8 Tf  [(diagnoses at Week 26 \(n=58\) during 2009 corresponding to the H1N1 pandemic. This comparison indicates that influenza )] TJ ET
BT 26.250 179.028 Td /F1 9.8 Tf  [(diagnoses were not common during Weeks 22-39 in years 2005-2008 which is typically non-influenza season, but in the spring )] TJ ET
BT 26.250 167.123 Td /F1 9.8 Tf  [(and summer of 2009 there was a comparatively large number of discharges with influenza diagnoses from hospitals in )] TJ ET
BT 26.250 155.218 Td /F1 9.8 Tf  [(Massachusetts. Results in Figure 2 also correspond closely with statewide sentinel site surveillance data from Massachusetts )] TJ ET
BT 26.250 143.313 Td /F1 9.8 Tf  [(providers reporting percentage of ILI visits )] TJ ET
0.267 0.267 0.267 rg
BT 210.496 143.313 Td /F1 9.8 Tf  [([18])] TJ ET
0.271 0.267 0.267 rg
BT 226.759 143.313 Td /F1 9.8 Tf  [( .)] TJ ET
BT 26.250 123.909 Td /F1 9.8 Tf  [(To address possible misclassification of non-influenza cases included as influenza cases, the breakdown and trends of each )] TJ ET
BT 26.250 112.004 Td /F1 9.8 Tf  [(code included in the maximum \(broad\) criteria were analyzed. The H1N1-specific ICD-9 code \(488.1\) introduced in June 2009 )] TJ ET
BT 26.250 100.099 Td /F1 9.8 Tf  [(was not used to diagnose any individuals discharged from a hospital in Massachusetts. Among those meeting the maximum )] TJ ET
BT 26.250 88.194 Td /F1 9.8 Tf  [(criteria, 64% had a discharge code corresponding to pneumonia \(486\), and 10% had the corresponding discharge code for )] TJ ET
BT 26.250 76.290 Td /F1 9.8 Tf  [(fever \(780.6\).)] TJ ET
BT 26.250 56.885 Td /F4 9.8 Tf  [(Comparing characteristics of H1N1 and seasonal influenza populations)] TJ ET
BT 26.250 37.480 Td /F1 9.8 Tf  [(Comparing the H1N1 and seasonal influenza groups among the maximum criteria, there were higher proportions of Black, non-)] TJ ET
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BT 26.250 767.476 Td /F1 9.8 Tf  [(Hispanic individuals with H1N1 compared to seasonal influenza \(11% versus 9%\), as well as Hispanics \(12% compared to )] TJ ET
BT 26.250 755.571 Td /F1 9.8 Tf  [(10%\). There was also a higher ICU admission rate among those with H1N1 \(18% compared to 16%\), and statistically significant )] TJ ET
BT 26.250 743.667 Td /F1 9.8 Tf  [(differences among proportions relating to gender, race/ethnicity, age groups, ICU admission, and ED admission \(Table 2\).)] TJ ET
BT 26.250 724.262 Td /F1 9.8 Tf  [(Some of these population differences are more dramatic in the minimum criteria. Compared to seasonal influenza, ILI )] TJ ET
BT 26.250 712.357 Td /F1 9.8 Tf  [(discharges during the H1N1 pandemic had higher proportions of Black, non-Hispanics \(18% compared to 10%\), as well as )] TJ ET
BT 26.250 700.452 Td /F1 9.8 Tf  [(Hispanics \(23% compared to 14%\). Those with H1N1 were also younger: there were significantly higher proportions of those )] TJ ET
BT 26.250 688.548 Td /F1 9.8 Tf  [(<18 years with H1N1 compared to seasonal influenza \(50% compared to 39%\). Other variables with significantly different )] TJ ET
BT 26.250 676.643 Td /F1 9.8 Tf  [(proportions between H1N1 and seasonal influenza are ICU admission rates, percentage of those admitted to the hospital )] TJ ET
BT 26.250 664.738 Td /F1 9.8 Tf  [(through the ED, and those admitted through the outpatient department \(Table 2\).)] TJ ET
BT 26.250 628.136 Td /F4 12.0 Tf  [(DISCUSSION)] TJ ET
BT 26.250 608.181 Td /F4 9.8 Tf  [(Characterization of H1N1-related hospitalizations in Massachusetts)] TJ ET
BT 26.250 588.777 Td /F1 9.8 Tf  [(We examined influenza cases in Massachusetts using population-based hospital discharge data from HDD. We applied two )] TJ ET
BT 26.250 576.872 Td /F1 9.8 Tf  [(selection criteria to identify and compare influenza cases. The two study populations are not mutually exclusive since the )] TJ ET
BT 26.250 564.967 Td /F1 9.8 Tf  [(influenza-specific codes are a subset of the maximum criteria. Nearly two-thirds \(64%\) of those meeting the maximum criteria )] TJ ET
BT 26.250 553.062 Td /F1 9.8 Tf  [(had a discharge code corresponding to pneumonia. However, studies have found that pneumonia occurred in only 2.5% of )] TJ ET
BT 26.250 541.158 Td /F1 9.8 Tf  [(those with confirmed H1N1 )] TJ ET
0.267 0.267 0.267 rg
BT 146.000 541.158 Td /F1 9.8 Tf  [([23])] TJ ET
0.271 0.267 0.267 rg
BT 162.262 541.158 Td /F1 9.8 Tf  [( . One study in particular conducted computed tomography \(CT\) scans on patients with )] TJ ET
BT 26.250 529.253 Td /F1 9.8 Tf  [(confirmed H1N1 infection, and discovered that 7.5% \(40 of 584 confirmed infections\) had chest abnormalities consistent with )] TJ ET
BT 26.250 517.348 Td /F1 9.8 Tf  [(pneumonia )] TJ ET
0.267 0.267 0.267 rg
BT 77.194 517.348 Td /F1 9.8 Tf  [([24])] TJ ET
0.271 0.267 0.267 rg
BT 93.457 517.348 Td /F1 9.8 Tf  [( . Since these, and other related assessments, indicate that most of those with H1N1-related symptoms did not )] TJ ET
BT 26.250 505.443 Td /F1 9.8 Tf  [(have pneumonia during the pandemic, one way to reduce misclassification of those with H1N1 \(and possibly other emerging )] TJ ET
BT 26.250 493.539 Td /F1 9.8 Tf  [(influenza strains\) may be to exclude pneumonia from the selection criteria altogether. Including the code for �pneumonia� )] TJ ET
BT 26.250 481.634 Td /F1 9.8 Tf  [(contributes a large number of cases who may not have confirmed influenza, and with these points in mind, we cannot )] TJ ET
BT 26.250 469.729 Td /F1 9.8 Tf  [(recommend applying the maximum criteria within an administrative dataset to calculate total influenza caseloads or describe )] TJ ET
BT 26.250 457.824 Td /F1 9.8 Tf  [(those hospitalized with influenza during a pandemic.)] TJ ET
BT 26.250 438.420 Td /F1 9.8 Tf  [(Based on hospital report data between April 25-September 30, 2009, there were 177 people hospitalized in Massachusetts with )] TJ ET
BT 26.250 426.515 Td /F1 9.8 Tf  [(confirmed H1N1 infection. If we apply the �undercount� calculations )] TJ ET
0.267 0.267 0.267 rg
BT 316.166 426.515 Td /F1 9.8 Tf  [([7])] TJ ET
0.271 0.267 0.267 rg
BT 327.008 426.515 Td /F1 9.8 Tf  [(, this number represents approximately 478 actual )] TJ ET
BT 26.250 414.610 Td /F1 9.8 Tf  [(hospitalized cases and is closer to the totals found using the minimum criteria \(n=601\) compared to the maximum criteria )] TJ ET
BT 26.250 402.705 Td /F1 9.8 Tf  [(\(n=10,967\). For comparison, we cannot determine precisely how many influenza-related hospitalizations occurred during the )] TJ ET
BT 26.250 390.801 Td /F1 9.8 Tf  [(same time period in prior years between April and September since influenza-related hospitalizations have no standard )] TJ ET
BT 26.250 378.896 Td /F1 9.8 Tf  [(reporting protocol, and prior estimates do not exist. Without a population-based data source with reliable estimates of confirmed )] TJ ET
BT 26.250 366.991 Td /F1 9.8 Tf  [(influenza infection, the estimates provided in this assessment describe a range of possible H1N1-related hospitalizations based )] TJ ET
BT 26.250 355.086 Td /F1 9.8 Tf  [(on published evidence and methodology.)] TJ ET
BT 26.250 335.682 Td /F1 9.8 Tf  [(Specific to the H1N1 pandemic, hospital discharge coding practice could have changed throughout the duration of the epidemic )] TJ ET
BT 26.250 323.777 Td /F1 9.8 Tf  [(since increased coverage of the epidemic in the media could influence provider perception, and could influence their diagnoses )] TJ ET
BT 26.250 311.872 Td /F1 9.8 Tf  [(assigned to patients. To address this, we analyzed individual codes in our maximum selection criteria to discover which were )] TJ ET
BT 26.250 299.967 Td /F1 9.8 Tf  [(used to flag ILI between April 26- July 15 and July 16-September 30, 2009. Between April 26-July 15, 2009 there were 7,050 )] TJ ET
BT 26.250 288.063 Td /F1 9.8 Tf  [(total codes used to flag ILI, and 439 \(6.2%\) were influenza-specific codes. Between July 16-September 30, there were 4,570 )] TJ ET
BT 26.250 276.158 Td /F1 9.8 Tf  [(total codes used to flag ILI, and 114 influenza-specific codes \(2.5%\) indicating that the overall use of ILI and influenza-specific )] TJ ET
BT 26.250 264.253 Td /F1 9.8 Tf  [(codes were used more often in the first time period of the epidemic compared to the second time period. These findings are )] TJ ET
BT 26.250 252.348 Td /F1 9.8 Tf  [(consistent with another study that reported ILI coding trends during the 2009 H1N1 pandemic )] TJ ET
0.267 0.267 0.267 rg
BT 430.543 252.348 Td /F1 9.8 Tf  [([25])] TJ ET
0.271 0.267 0.267 rg
BT 446.806 252.348 Td /F1 9.8 Tf  [( , also indicating that influenza-)] TJ ET
BT 26.250 240.444 Td /F1 9.8 Tf  [(specific diagnosis codes were also more likely to be used in the beginning of the pandemic compared to the end, and codes )] TJ ET
BT 26.250 228.539 Td /F1 9.8 Tf  [(indicating influenza symptoms \(such as cough, fever and pneumonia\) were used to identify influenza cases more often later in )] TJ ET
BT 26.250 216.634 Td /F1 9.8 Tf  [(the pandemic.)] TJ ET
BT 26.250 197.229 Td /F1 9.8 Tf  [(Physicians� perceptions of influenza incidence could have been influenced by media coverage of the magnitude of the epidemic, )] TJ ET
BT 26.250 185.325 Td /F1 9.8 Tf  [(and could have increased the frequency of diagnoses assigned to patients. However, it is difficult to determine if consistent )] TJ ET
BT 26.250 173.420 Td /F1 9.8 Tf  [(coding practice occurred throughout the duration of the epidemic. Since influenza-specific codes are the most specific indicator )] TJ ET
BT 26.250 161.515 Td /F1 9.8 Tf  [(of influenza in administrative data sources using ICD-9 codes, and if they�re going to continue to be used as an accurate )] TJ ET
BT 26.250 149.610 Td /F1 9.8 Tf  [(indicator of influenza, coding practice should encourage the consistent use of these codes.)] TJ ET
BT 26.250 130.206 Td /F4 9.8 Tf  [(Comparing characteristics of H1N1 and seasonal influenza populations)] TJ ET
BT 26.250 110.801 Td /F1 9.8 Tf  [(One could argue that the smaller, influenza-specific population could be a more accurate and realistic picture of actual influenza )] TJ ET
BT 26.250 98.896 Td /F1 9.8 Tf  [(activity. Most epidemiological reports described in the literature rely on confirmed hospital case report data to describe H1N1 )] TJ ET
BT 26.250 86.991 Td /F1 9.8 Tf  [(cases. We have used two selection criteria to describe patients hospitalized with influenza and ILI. Although the methodology of )] TJ ET
BT 26.250 75.087 Td /F1 9.8 Tf  [(case identification in our study is different than hospital case reporting, we have shown consistent results between published )] TJ ET
BT 26.250 63.182 Td /F1 9.8 Tf  [(reports and the minimum selection criteria. We found that those who received influenza-specific diagnosis codes )] TJ ET
BT 26.250 51.277 Td /F1 9.8 Tf  [(overrepresented non-White minority groups, were younger in age, more likely to be male, and had higher rates of ICU )] TJ ET
BT 26.250 39.372 Td /F1 9.8 Tf  [(admission compared to those who met the more broad criteria. Other characteristics of the influenza-specific group suggest )] TJ ET
Q
q
15.000 25.087 577.500 751.913 re W n
0.271 0.267 0.267 rg
BT 26.250 767.476 Td /F1 9.8 Tf  [(Hispanic individuals with H1N1 compared to seasonal influenza \(11% versus 9%\), as well as Hispanics \(12% compared to )] TJ ET
BT 26.250 755.571 Td /F1 9.8 Tf  [(10%\). There was also a higher ICU admission rate among those with H1N1 \(18% compared to 16%\), and statistically significant )] TJ ET
BT 26.250 743.667 Td /F1 9.8 Tf  [(differences among proportions relating to gender, race/ethnicity, age groups, ICU admission, and ED admission \(Table 2\).)] TJ ET
BT 26.250 724.262 Td /F1 9.8 Tf  [(Some of these population differences are more dramatic in the minimum criteria. Compared to seasonal influenza, ILI )] TJ ET
BT 26.250 712.357 Td /F1 9.8 Tf  [(discharges during the H1N1 pandemic had higher proportions of Black, non-Hispanics \(18% compared to 10%\), as well as )] TJ ET
BT 26.250 700.452 Td /F1 9.8 Tf  [(Hispanics \(23% compared to 14%\). Those with H1N1 were also younger: there were significantly higher proportions of those )] TJ ET
BT 26.250 688.548 Td /F1 9.8 Tf  [(<18 years with H1N1 compared to seasonal influenza \(50% compared to 39%\). Other variables with significantly different )] TJ ET
BT 26.250 676.643 Td /F1 9.8 Tf  [(proportions between H1N1 and seasonal influenza are ICU admission rates, percentage of those admitted to the hospital )] TJ ET
BT 26.250 664.738 Td /F1 9.8 Tf  [(through the ED, and those admitted through the outpatient department \(Table 2\).)] TJ ET
BT 26.250 628.136 Td /F4 12.0 Tf  [(DISCUSSION)] TJ ET
BT 26.250 608.181 Td /F4 9.8 Tf  [(Characterization of H1N1-related hospitalizations in Massachusetts)] TJ ET
BT 26.250 588.777 Td /F1 9.8 Tf  [(We examined influenza cases in Massachusetts using population-based hospital discharge data from HDD. We applied two )] TJ ET
BT 26.250 576.872 Td /F1 9.8 Tf  [(selection criteria to identify and compare influenza cases. The two study populations are not mutually exclusive since the )] TJ ET
BT 26.250 564.967 Td /F1 9.8 Tf  [(influenza-specific codes are a subset of the maximum criteria. Nearly two-thirds \(64%\) of those meeting the maximum criteria )] TJ ET
BT 26.250 553.062 Td /F1 9.8 Tf  [(had a discharge code corresponding to pneumonia. However, studies have found that pneumonia occurred in only 2.5% of )] TJ ET
BT 26.250 541.158 Td /F1 9.8 Tf  [(those with confirmed H1N1 )] TJ ET
0.267 0.267 0.267 rg
BT 146.000 541.158 Td /F1 9.8 Tf  [([23])] TJ ET
0.271 0.267 0.267 rg
BT 162.262 541.158 Td /F1 9.8 Tf  [( . One study in particular conducted computed tomography \(CT\) scans on patients with )] TJ ET
BT 26.250 529.253 Td /F1 9.8 Tf  [(confirmed H1N1 infection, and discovered that 7.5% \(40 of 584 confirmed infections\) had chest abnormalities consistent with )] TJ ET
BT 26.250 517.348 Td /F1 9.8 Tf  [(pneumonia )] TJ ET
0.267 0.267 0.267 rg
BT 77.194 517.348 Td /F1 9.8 Tf  [([24])] TJ ET
0.271 0.267 0.267 rg
BT 93.457 517.348 Td /F1 9.8 Tf  [( . Since these, and other related assessments, indicate that most of those with H1N1-related symptoms did not )] TJ ET
BT 26.250 505.443 Td /F1 9.8 Tf  [(have pneumonia during the pandemic, one way to reduce misclassification of those with H1N1 \(and possibly other emerging )] TJ ET
BT 26.250 493.539 Td /F1 9.8 Tf  [(influenza strains\) may be to exclude pneumonia from the selection criteria altogether. Including the code for �pneumonia� )] TJ ET
BT 26.250 481.634 Td /F1 9.8 Tf  [(contributes a large number of cases who may not have confirmed influenza, and with these points in mind, we cannot )] TJ ET
BT 26.250 469.729 Td /F1 9.8 Tf  [(recommend applying the maximum criteria within an administrative dataset to calculate total influenza caseloads or describe )] TJ ET
BT 26.250 457.824 Td /F1 9.8 Tf  [(those hospitalized with influenza during a pandemic.)] TJ ET
BT 26.250 438.420 Td /F1 9.8 Tf  [(Based on hospital report data between April 25-September 30, 2009, there were 177 people hospitalized in Massachusetts with )] TJ ET
BT 26.250 426.515 Td /F1 9.8 Tf  [(confirmed H1N1 infection. If we apply the �undercount� calculations )] TJ ET
0.267 0.267 0.267 rg
BT 316.166 426.515 Td /F1 9.8 Tf  [([7])] TJ ET
0.271 0.267 0.267 rg
BT 327.008 426.515 Td /F1 9.8 Tf  [(, this number represents approximately 478 actual )] TJ ET
BT 26.250 414.610 Td /F1 9.8 Tf  [(hospitalized cases and is closer to the totals found using the minimum criteria \(n=601\) compared to the maximum criteria )] TJ ET
BT 26.250 402.705 Td /F1 9.8 Tf  [(\(n=10,967\). For comparison, we cannot determine precisely how many influenza-related hospitalizations occurred during the )] TJ ET
BT 26.250 390.801 Td /F1 9.8 Tf  [(same time period in prior years between April and September since influenza-related hospitalizations have no standard )] TJ ET
BT 26.250 378.896 Td /F1 9.8 Tf  [(reporting protocol, and prior estimates do not exist. Without a population-based data source with reliable estimates of confirmed )] TJ ET
BT 26.250 366.991 Td /F1 9.8 Tf  [(influenza infection, the estimates provided in this assessment describe a range of possible H1N1-related hospitalizations based )] TJ ET
BT 26.250 355.086 Td /F1 9.8 Tf  [(on published evidence and methodology.)] TJ ET
BT 26.250 335.682 Td /F1 9.8 Tf  [(Specific to the H1N1 pandemic, hospital discharge coding practice could have changed throughout the duration of the epidemic )] TJ ET
BT 26.250 323.777 Td /F1 9.8 Tf  [(since increased coverage of the epidemic in the media could influence provider perception, and could influence their diagnoses )] TJ ET
BT 26.250 311.872 Td /F1 9.8 Tf  [(assigned to patients. To address this, we analyzed individual codes in our maximum selection criteria to discover which were )] TJ ET
BT 26.250 299.967 Td /F1 9.8 Tf  [(used to flag ILI between April 26- July 15 and July 16-September 30, 2009. Between April 26-July 15, 2009 there were 7,050 )] TJ ET
BT 26.250 288.063 Td /F1 9.8 Tf  [(total codes used to flag ILI, and 439 \(6.2%\) were influenza-specific codes. Between July 16-September 30, there were 4,570 )] TJ ET
BT 26.250 276.158 Td /F1 9.8 Tf  [(total codes used to flag ILI, and 114 influenza-specific codes \(2.5%\) indicating that the overall use of ILI and influenza-specific )] TJ ET
BT 26.250 264.253 Td /F1 9.8 Tf  [(codes were used more often in the first time period of the epidemic compared to the second time period. These findings are )] TJ ET
BT 26.250 252.348 Td /F1 9.8 Tf  [(consistent with another study that reported ILI coding trends during the 2009 H1N1 pandemic )] TJ ET
0.267 0.267 0.267 rg
BT 430.543 252.348 Td /F1 9.8 Tf  [([25])] TJ ET
0.271 0.267 0.267 rg
BT 446.806 252.348 Td /F1 9.8 Tf  [( , also indicating that influenza-)] TJ ET
BT 26.250 240.444 Td /F1 9.8 Tf  [(specific diagnosis codes were also more likely to be used in the beginning of the pandemic compared to the end, and codes )] TJ ET
BT 26.250 228.539 Td /F1 9.8 Tf  [(indicating influenza symptoms \(such as cough, fever and pneumonia\) were used to identify influenza cases more often later in )] TJ ET
BT 26.250 216.634 Td /F1 9.8 Tf  [(the pandemic.)] TJ ET
BT 26.250 197.229 Td /F1 9.8 Tf  [(Physicians� perceptions of influenza incidence could have been influenced by media coverage of the magnitude of the epidemic, )] TJ ET
BT 26.250 185.325 Td /F1 9.8 Tf  [(and could have increased the frequency of diagnoses assigned to patients. However, it is difficult to determine if consistent )] TJ ET
BT 26.250 173.420 Td /F1 9.8 Tf  [(coding practice occurred throughout the duration of the epidemic. Since influenza-specific codes are the most specific indicator )] TJ ET
BT 26.250 161.515 Td /F1 9.8 Tf  [(of influenza in administrative data sources using ICD-9 codes, and if they�re going to continue to be used as an accurate )] TJ ET
BT 26.250 149.610 Td /F1 9.8 Tf  [(indicator of influenza, coding practice should encourage the consistent use of these codes.)] TJ ET
BT 26.250 130.206 Td /F4 9.8 Tf  [(Comparing characteristics of H1N1 and seasonal influenza populations)] TJ ET
BT 26.250 110.801 Td /F1 9.8 Tf  [(One could argue that the smaller, influenza-specific population could be a more accurate and realistic picture of actual influenza )] TJ ET
BT 26.250 98.896 Td /F1 9.8 Tf  [(activity. Most epidemiological reports described in the literature rely on confirmed hospital case report data to describe H1N1 )] TJ ET
BT 26.250 86.991 Td /F1 9.8 Tf  [(cases. We have used two selection criteria to describe patients hospitalized with influenza and ILI. Although the methodology of )] TJ ET
BT 26.250 75.087 Td /F1 9.8 Tf  [(case identification in our study is different than hospital case reporting, we have shown consistent results between published )] TJ ET
BT 26.250 63.182 Td /F1 9.8 Tf  [(reports and the minimum selection criteria. We found that those who received influenza-specific diagnosis codes )] TJ ET
BT 26.250 51.277 Td /F1 9.8 Tf  [(overrepresented non-White minority groups, were younger in age, more likely to be male, and had higher rates of ICU )] TJ ET
BT 26.250 39.372 Td /F1 9.8 Tf  [(admission compared to those who met the more broad criteria. Other characteristics of the influenza-specific group suggest )] TJ ET
Q
q
15.000 25.087 577.500 751.913 re W n
0.271 0.267 0.267 rg
BT 26.250 767.476 Td /F1 9.8 Tf  [(Hispanic individuals with H1N1 compared to seasonal influenza \(11% versus 9%\), as well as Hispanics \(12% compared to )] TJ ET
BT 26.250 755.571 Td /F1 9.8 Tf  [(10%\). There was also a higher ICU admission rate among those with H1N1 \(18% compared to 16%\), and statistically significant )] TJ ET
BT 26.250 743.667 Td /F1 9.8 Tf  [(differences among proportions relating to gender, race/ethnicity, age groups, ICU admission, and ED admission \(Table 2\).)] TJ ET
BT 26.250 724.262 Td /F1 9.8 Tf  [(Some of these population differences are more dramatic in the minimum criteria. Compared to seasonal influenza, ILI )] TJ ET
BT 26.250 712.357 Td /F1 9.8 Tf  [(discharges during the H1N1 pandemic had higher proportions of Black, non-Hispanics \(18% compared to 10%\), as well as )] TJ ET
BT 26.250 700.452 Td /F1 9.8 Tf  [(Hispanics \(23% compared to 14%\). Those with H1N1 were also younger: there were significantly higher proportions of those )] TJ ET
BT 26.250 688.548 Td /F1 9.8 Tf  [(<18 years with H1N1 compared to seasonal influenza \(50% compared to 39%\). Other variables with significantly different )] TJ ET
BT 26.250 676.643 Td /F1 9.8 Tf  [(proportions between H1N1 and seasonal influenza are ICU admission rates, percentage of those admitted to the hospital )] TJ ET
BT 26.250 664.738 Td /F1 9.8 Tf  [(through the ED, and those admitted through the outpatient department \(Table 2\).)] TJ ET
BT 26.250 628.136 Td /F4 12.0 Tf  [(DISCUSSION)] TJ ET
BT 26.250 608.181 Td /F4 9.8 Tf  [(Characterization of H1N1-related hospitalizations in Massachusetts)] TJ ET
BT 26.250 588.777 Td /F1 9.8 Tf  [(We examined influenza cases in Massachusetts using population-based hospital discharge data from HDD. We applied two )] TJ ET
BT 26.250 576.872 Td /F1 9.8 Tf  [(selection criteria to identify and compare influenza cases. The two study populations are not mutually exclusive since the )] TJ ET
BT 26.250 564.967 Td /F1 9.8 Tf  [(influenza-specific codes are a subset of the maximum criteria. Nearly two-thirds \(64%\) of those meeting the maximum criteria )] TJ ET
BT 26.250 553.062 Td /F1 9.8 Tf  [(had a discharge code corresponding to pneumonia. However, studies have found that pneumonia occurred in only 2.5% of )] TJ ET
BT 26.250 541.158 Td /F1 9.8 Tf  [(those with confirmed H1N1 )] TJ ET
0.267 0.267 0.267 rg
BT 146.000 541.158 Td /F1 9.8 Tf  [([23])] TJ ET
0.271 0.267 0.267 rg
BT 162.262 541.158 Td /F1 9.8 Tf  [( . One study in particular conducted computed tomography \(CT\) scans on patients with )] TJ ET
BT 26.250 529.253 Td /F1 9.8 Tf  [(confirmed H1N1 infection, and discovered that 7.5% \(40 of 584 confirmed infections\) had chest abnormalities consistent with )] TJ ET
BT 26.250 517.348 Td /F1 9.8 Tf  [(pneumonia )] TJ ET
0.267 0.267 0.267 rg
BT 77.194 517.348 Td /F1 9.8 Tf  [([24])] TJ ET
0.271 0.267 0.267 rg
BT 93.457 517.348 Td /F1 9.8 Tf  [( . Since these, and other related assessments, indicate that most of those with H1N1-related symptoms did not )] TJ ET
BT 26.250 505.443 Td /F1 9.8 Tf  [(have pneumonia during the pandemic, one way to reduce misclassification of those with H1N1 \(and possibly other emerging )] TJ ET
BT 26.250 493.539 Td /F1 9.8 Tf  [(influenza strains\) may be to exclude pneumonia from the selection criteria altogether. Including the code for �pneumonia� )] TJ ET
BT 26.250 481.634 Td /F1 9.8 Tf  [(contributes a large number of cases who may not have confirmed influenza, and with these points in mind, we cannot )] TJ ET
BT 26.250 469.729 Td /F1 9.8 Tf  [(recommend applying the maximum criteria within an administrative dataset to calculate total influenza caseloads or describe )] TJ ET
BT 26.250 457.824 Td /F1 9.8 Tf  [(those hospitalized with influenza during a pandemic.)] TJ ET
BT 26.250 438.420 Td /F1 9.8 Tf  [(Based on hospital report data between April 25-September 30, 2009, there were 177 people hospitalized in Massachusetts with )] TJ ET
BT 26.250 426.515 Td /F1 9.8 Tf  [(confirmed H1N1 infection. If we apply the �undercount� calculations )] TJ ET
0.267 0.267 0.267 rg
BT 316.166 426.515 Td /F1 9.8 Tf  [([7])] TJ ET
0.271 0.267 0.267 rg
BT 327.008 426.515 Td /F1 9.8 Tf  [(, this number represents approximately 478 actual )] TJ ET
BT 26.250 414.610 Td /F1 9.8 Tf  [(hospitalized cases and is closer to the totals found using the minimum criteria \(n=601\) compared to the maximum criteria )] TJ ET
BT 26.250 402.705 Td /F1 9.8 Tf  [(\(n=10,967\). For comparison, we cannot determine precisely how many influenza-related hospitalizations occurred during the )] TJ ET
BT 26.250 390.801 Td /F1 9.8 Tf  [(same time period in prior years between April and September since influenza-related hospitalizations have no standard )] TJ ET
BT 26.250 378.896 Td /F1 9.8 Tf  [(reporting protocol, and prior estimates do not exist. Without a population-based data source with reliable estimates of confirmed )] TJ ET
BT 26.250 366.991 Td /F1 9.8 Tf  [(influenza infection, the estimates provided in this assessment describe a range of possible H1N1-related hospitalizations based )] TJ ET
BT 26.250 355.086 Td /F1 9.8 Tf  [(on published evidence and methodology.)] TJ ET
BT 26.250 335.682 Td /F1 9.8 Tf  [(Specific to the H1N1 pandemic, hospital discharge coding practice could have changed throughout the duration of the epidemic )] TJ ET
BT 26.250 323.777 Td /F1 9.8 Tf  [(since increased coverage of the epidemic in the media could influence provider perception, and could influence their diagnoses )] TJ ET
BT 26.250 311.872 Td /F1 9.8 Tf  [(assigned to patients. To address this, we analyzed individual codes in our maximum selection criteria to discover which were )] TJ ET
BT 26.250 299.967 Td /F1 9.8 Tf  [(used to flag ILI between April 26- July 15 and July 16-September 30, 2009. Between April 26-July 15, 2009 there were 7,050 )] TJ ET
BT 26.250 288.063 Td /F1 9.8 Tf  [(total codes used to flag ILI, and 439 \(6.2%\) were influenza-specific codes. Between July 16-September 30, there were 4,570 )] TJ ET
BT 26.250 276.158 Td /F1 9.8 Tf  [(total codes used to flag ILI, and 114 influenza-specific codes \(2.5%\) indicating that the overall use of ILI and influenza-specific )] TJ ET
BT 26.250 264.253 Td /F1 9.8 Tf  [(codes were used more often in the first time period of the epidemic compared to the second time period. These findings are )] TJ ET
BT 26.250 252.348 Td /F1 9.8 Tf  [(consistent with another study that reported ILI coding trends during the 2009 H1N1 pandemic )] TJ ET
0.267 0.267 0.267 rg
BT 430.543 252.348 Td /F1 9.8 Tf  [([25])] TJ ET
0.271 0.267 0.267 rg
BT 446.806 252.348 Td /F1 9.8 Tf  [( , also indicating that influenza-)] TJ ET
BT 26.250 240.444 Td /F1 9.8 Tf  [(specific diagnosis codes were also more likely to be used in the beginning of the pandemic compared to the end, and codes )] TJ ET
BT 26.250 228.539 Td /F1 9.8 Tf  [(indicating influenza symptoms \(such as cough, fever and pneumonia\) were used to identify influenza cases more often later in )] TJ ET
BT 26.250 216.634 Td /F1 9.8 Tf  [(the pandemic.)] TJ ET
BT 26.250 197.229 Td /F1 9.8 Tf  [(Physicians� perceptions of influenza incidence could have been influenced by media coverage of the magnitude of the epidemic, )] TJ ET
BT 26.250 185.325 Td /F1 9.8 Tf  [(and could have increased the frequency of diagnoses assigned to patients. However, it is difficult to determine if consistent )] TJ ET
BT 26.250 173.420 Td /F1 9.8 Tf  [(coding practice occurred throughout the duration of the epidemic. Since influenza-specific codes are the most specific indicator )] TJ ET
BT 26.250 161.515 Td /F1 9.8 Tf  [(of influenza in administrative data sources using ICD-9 codes, and if they�re going to continue to be used as an accurate )] TJ ET
BT 26.250 149.610 Td /F1 9.8 Tf  [(indicator of influenza, coding practice should encourage the consistent use of these codes.)] TJ ET
BT 26.250 130.206 Td /F4 9.8 Tf  [(Comparing characteristics of H1N1 and seasonal influenza populations)] TJ ET
BT 26.250 110.801 Td /F1 9.8 Tf  [(One could argue that the smaller, influenza-specific population could be a more accurate and realistic picture of actual influenza )] TJ ET
BT 26.250 98.896 Td /F1 9.8 Tf  [(activity. Most epidemiological reports described in the literature rely on confirmed hospital case report data to describe H1N1 )] TJ ET
BT 26.250 86.991 Td /F1 9.8 Tf  [(cases. We have used two selection criteria to describe patients hospitalized with influenza and ILI. Although the methodology of )] TJ ET
BT 26.250 75.087 Td /F1 9.8 Tf  [(case identification in our study is different than hospital case reporting, we have shown consistent results between published )] TJ ET
BT 26.250 63.182 Td /F1 9.8 Tf  [(reports and the minimum selection criteria. We found that those who received influenza-specific diagnosis codes )] TJ ET
BT 26.250 51.277 Td /F1 9.8 Tf  [(overrepresented non-White minority groups, were younger in age, more likely to be male, and had higher rates of ICU )] TJ ET
BT 26.250 39.372 Td /F1 9.8 Tf  [(admission compared to those who met the more broad criteria. Other characteristics of the influenza-specific group suggest )] 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

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q
15.000 28.182 577.500 748.818 re W n
0.271 0.267 0.267 rg
BT 26.250 767.476 Td /F1 9.8 Tf  [(that, of the two criteria used, this group may be a more accurate estimate of actual influenza activity. Those with H1N1 had )] TJ ET
BT 26.250 755.571 Td /F1 9.8 Tf  [(higher rates of ICU admission compared to those with seasonal influenza. This is consistent with another published assessment )] TJ ET
BT 26.250 743.667 Td /F1 9.8 Tf  [(restricted to a metropolitan area in the United States )] TJ ET
0.267 0.267 0.267 rg
BT 254.400 743.667 Td /F1 9.8 Tf  [([13])] TJ ET
0.271 0.267 0.267 rg
BT 270.663 743.667 Td /F1 9.8 Tf  [( . Also shown in the literature, H1N1 affected all age groups, but )] TJ ET
BT 26.250 731.762 Td /F1 9.8 Tf  [(frequently occurred in previously healthy, young adults with a wide range of socio-demographic characteristics and clinical )] TJ ET
BT 26.250 719.857 Td /F1 9.8 Tf  [(presentations )] TJ ET
0.267 0.267 0.267 rg
BT 87.490 719.857 Td /F1 9.8 Tf  [([26])] TJ ET
0.271 0.267 0.267 rg
BT 103.753 719.857 Td /F1 9.8 Tf  [( . In the Northern Hemisphere, hospitalized patients with confirmed or probable H1N1 infection ranged in age )] TJ ET
BT 26.250 707.952 Td /F1 9.8 Tf  [(from 21 days to 86 years, but 45% of hospitalized cases were under the age of 18 years, and only 5% of cases were 65 years of )] TJ ET
BT 26.250 696.048 Td /F1 9.8 Tf  [(age or older )] TJ ET
0.267 0.267 0.267 rg
BT 80.987 696.048 Td /F1 9.8 Tf  [([27])] TJ ET
0.271 0.267 0.267 rg
BT 97.249 696.048 Td /F1 9.8 Tf  [( . State reports based on laboratory-confirmed H1N1 data indicate that 45% were <19 years, 33% 19-49 years, )] TJ ET
BT 26.250 684.143 Td /F1 9.8 Tf  [(15% 50-64 years, and 7% =65 years )] TJ ET
0.267 0.267 0.267 rg
BT 186.940 684.143 Td /F1 9.8 Tf  [([19])] TJ ET
0.271 0.267 0.267 rg
BT 203.203 684.143 Td /F1 9.8 Tf  [( . This is consistent with what we found in the minimum criteria \(50% were <18 years\), )] TJ ET
BT 26.250 672.238 Td /F1 9.8 Tf  [(but not the maximum \(23% were <18 years, and 51% were aged 45-64 years\). In fact, the maximum criteria showed a greater )] TJ ET
BT 26.250 660.333 Td /F1 9.8 Tf  [(distribution of 45-64 year olds during the H1N1 pandemic compared to prior seasonal influenza seasons.)] TJ ET
BT 26.250 640.929 Td /F1 9.8 Tf  [(Similar trends existed in relation to race/ethnic group characteristics. Unpublished statewide 2009 H1N1 epidemiological data )] TJ ET
BT 26.250 629.024 Td /F1 9.8 Tf  [(suggests that there have been disproportionate numbers of laboratory-confirmed and hospitalized H1N1 cases among certain )] TJ ET
BT 26.250 617.119 Td /F1 9.8 Tf  [(racial/ethnic groups in Massachusetts. The Massachusetts DPH found that rates of lab-confirmed H1N1-related hospitalization )] TJ ET
BT 26.250 605.214 Td /F1 9.8 Tf  [(were three to four times higher in Black and Hispanic populations compared to White, non-Hispanic populations \(Alfred )] TJ ET
BT 26.250 593.310 Td /F1 9.8 Tf  [(DeMaria, MDPH, personal communication, 2010\). Furthermore, the CDC reports greater proportions of hospitalizations and )] TJ ET
BT 26.250 581.405 Td /F1 9.8 Tf  [(deaths among particular ethnic groups in Chicago )] TJ ET
0.267 0.267 0.267 rg
BT 243.558 581.405 Td /F1 9.8 Tf  [([28])] TJ ET
0.271 0.267 0.267 rg
BT 259.821 581.405 Td /F1 9.8 Tf  [( and among American Indian/Alaskan Natives compared to other racial )] TJ ET
BT 26.250 569.500 Td /F1 9.8 Tf  [(groups )] TJ ET
0.267 0.267 0.267 rg
BT 58.766 569.500 Td /F1 9.8 Tf  [([29])] TJ ET
0.271 0.267 0.267 rg
BT 75.029 569.500 Td /F1 9.8 Tf  [( . From our analyses, we can see that both H1N1 selection criteria have higher proportions of Black and Hispanic )] TJ ET
BT 26.250 557.595 Td /F1 9.8 Tf  [(groups compared to seasonal influenza. However, proportions of non-White race/ethnic groups among those in the narrow )] TJ ET
BT 26.250 545.691 Td /F1 9.8 Tf  [(criteria \(47% White, non-Hispanic\) correspond more closely to rates in published epidemiological reports compared to broad )] TJ ET
BT 26.250 533.786 Td /F1 9.8 Tf  [(criteria \(70% White, non-Hispanic\).)] TJ ET
BT 26.250 514.381 Td /F1 9.8 Tf  [(From the results described, it becomes clear that although the maximum criteria have been used to describe influenza activity )] TJ ET
BT 26.250 502.476 Td /F1 9.8 Tf  [(and have correlated with confirmed influenza in prior studies )] TJ ET
0.267 0.267 0.267 rg
BT 288.525 502.476 Td /F1 9.8 Tf  [([20])] TJ ET
BT 304.788 502.476 Td /F1 9.8 Tf  [([25])] TJ ET
0.271 0.267 0.267 rg
BT 321.051 502.476 Td /F1 9.8 Tf  [( , these selection criteria may be too non-specific for the )] TJ ET
BT 26.250 490.572 Td /F1 9.8 Tf  [(purposes of influenza case detection among those hospitalized with H1N1. The maximum criteria utilized in this study display )] TJ ET
BT 26.250 478.667 Td /F1 9.8 Tf  [(high frequencies of ILI-related discharges � even during summer months, which is typically outside of the influenza season )] TJ ET
BT 26.250 466.762 Td /F1 9.8 Tf  [(\(Figure 1\). Furthermore, those included in the maximum criteria do not correspond with epidemiological descriptions presented )] TJ ET
BT 26.250 454.857 Td /F1 9.8 Tf  [(in the literature, the total caseload between Apr-Sept 2009 \(n=10,976\) could be a gross overrepresentation of actual )] TJ ET
BT 26.250 442.953 Td /F1 9.8 Tf  [(hospitalized cases, and since additional respiratory syndromes are included in the maximum selection criteria, misclassification )] TJ ET
BT 26.250 431.048 Td /F1 9.8 Tf  [(due to non-influenza is not a possibility � it is a certainty. These results correspond with another recent assessment which found )] TJ ET
BT 26.250 419.143 Td /F1 9.8 Tf  [(that these same criteria did not sufficiently monitor/detect the H1N1 outbreak, had inadequate sensitivity, and poor positive )] TJ ET
BT 26.250 407.238 Td /F1 9.8 Tf  [(predictive value for identifying ILI cases )] TJ ET
0.267 0.267 0.267 rg
BT 199.118 407.238 Td /F1 9.8 Tf  [([30])] TJ ET
0.271 0.267 0.267 rg
BT 215.381 407.238 Td /F1 9.8 Tf  [( .)] TJ ET
BT 26.250 387.834 Td /F1 9.8 Tf  [(However, there are major limitations to using the minimum criteria as an indicator for disease activity. Assigning influenza-)] TJ ET
BT 26.250 375.929 Td /F1 9.8 Tf  [(specific codes to patients in administrative data sources is not dependent on confirmed influenza test results, and there is no )] TJ ET
BT 26.250 364.024 Td /F1 9.8 Tf  [(way, other than manual chart review, to confirm if someone who received an influenza diagnosis actually had the disease. We )] TJ ET
BT 26.250 352.119 Td /F1 9.8 Tf  [(were authorized to use this dataset only in a de-identified way, and manual chart review was therefore not feasible. Studies )] TJ ET
BT 26.250 340.215 Td /F1 9.8 Tf  [(investigating the use of ICD-9 codes to identify influenza cases have found that confirmed-positive pandemic 2009 H1N1 cases )] TJ ET
BT 26.250 328.310 Td /F1 9.8 Tf  [(were not uniformly coded as influenza, and nearly 10% of confirmed cases were not even captured in a syndromic surveillance )] TJ ET
BT 26.250 316.405 Td /F1 9.8 Tf  [(ILI algorithm )] TJ ET
0.267 0.267 0.267 rg
BT 82.605 316.405 Td /F1 9.8 Tf  [([25])] TJ ET
0.271 0.267 0.267 rg
BT 98.868 316.405 Td /F1 9.8 Tf  [( further suggesting that there are many difficulties detecting and tracking confirmed influenza cases using )] TJ ET
BT 26.250 304.500 Td /F1 9.8 Tf  [(administrative data sources. Finally, there is a lack of standard clinical protocol for coding influenza diagnoses, and it is difficult )] TJ ET
BT 26.250 292.596 Td /F1 9.8 Tf  [(to understand the process of clinical decision-making related to influenza diagnoses by analyzing ICD-9 codes.)] TJ ET
BT 26.250 273.191 Td /F4 9.8 Tf  [(Limitations)] TJ ET
BT 26.250 253.786 Td /F1 9.8 Tf  [(Data from correctional facilities and veteran�s hospitals in Massachusetts are not included in the HDD, and there is also limited )] TJ ET
BT 26.250 241.881 Td /F1 9.8 Tf  [(information related to treatments and diagnoses in emergency departments. Reports of those with self-reported ILI symptoms )] TJ ET
BT 26.250 229.977 Td /F1 9.8 Tf  [(during the H1N1 pandemic in the U.S. indicate that 40% of adults and 56% of children sought health care )] TJ ET
0.267 0.267 0.267 rg
BT 482.033 229.977 Td /F1 9.8 Tf  [([31])] TJ ET
0.271 0.267 0.267 rg
BT 498.296 229.977 Td /F1 9.8 Tf  [( . Because the )] TJ ET
BT 26.250 218.072 Td /F1 9.8 Tf  [(HDD only includes those hospitalized with H1N1, we were not able to compare this hospitalized population to non-hospitalized )] TJ ET
BT 26.250 206.167 Td /F1 9.8 Tf  [(H1N1 cases to see differences in demographics, diagnoses, or outcomes.)] TJ ET
BT 26.250 177.065 Td /F4 12.0 Tf  [(Conclusions)] TJ ET
Q
q
15.000 28.182 577.500 748.818 re W n
0.271 0.267 0.267 rg
BT 26.250 767.476 Td /F1 9.8 Tf  [(that, of the two criteria used, this group may be a more accurate estimate of actual influenza activity. Those with H1N1 had )] TJ ET
BT 26.250 755.571 Td /F1 9.8 Tf  [(higher rates of ICU admission compared to those with seasonal influenza. This is consistent with another published assessment )] TJ ET
BT 26.250 743.667 Td /F1 9.8 Tf  [(restricted to a metropolitan area in the United States )] TJ ET
0.267 0.267 0.267 rg
BT 254.400 743.667 Td /F1 9.8 Tf  [([13])] TJ ET
0.271 0.267 0.267 rg
BT 270.663 743.667 Td /F1 9.8 Tf  [( . Also shown in the literature, H1N1 affected all age groups, but )] TJ ET
BT 26.250 731.762 Td /F1 9.8 Tf  [(frequently occurred in previously healthy, young adults with a wide range of socio-demographic characteristics and clinical )] TJ ET
BT 26.250 719.857 Td /F1 9.8 Tf  [(presentations )] TJ ET
0.267 0.267 0.267 rg
BT 87.490 719.857 Td /F1 9.8 Tf  [([26])] TJ ET
0.271 0.267 0.267 rg
BT 103.753 719.857 Td /F1 9.8 Tf  [( . In the Northern Hemisphere, hospitalized patients with confirmed or probable H1N1 infection ranged in age )] TJ ET
BT 26.250 707.952 Td /F1 9.8 Tf  [(from 21 days to 86 years, but 45% of hospitalized cases were under the age of 18 years, and only 5% of cases were 65 years of )] TJ ET
BT 26.250 696.048 Td /F1 9.8 Tf  [(age or older )] TJ ET
0.267 0.267 0.267 rg
BT 80.987 696.048 Td /F1 9.8 Tf  [([27])] TJ ET
0.271 0.267 0.267 rg
BT 97.249 696.048 Td /F1 9.8 Tf  [( . State reports based on laboratory-confirmed H1N1 data indicate that 45% were <19 years, 33% 19-49 years, )] TJ ET
BT 26.250 684.143 Td /F1 9.8 Tf  [(15% 50-64 years, and 7% =65 years )] TJ ET
0.267 0.267 0.267 rg
BT 186.940 684.143 Td /F1 9.8 Tf  [([19])] TJ ET
0.271 0.267 0.267 rg
BT 203.203 684.143 Td /F1 9.8 Tf  [( . This is consistent with what we found in the minimum criteria \(50% were <18 years\), )] TJ ET
BT 26.250 672.238 Td /F1 9.8 Tf  [(but not the maximum \(23% were <18 years, and 51% were aged 45-64 years\). In fact, the maximum criteria showed a greater )] TJ ET
BT 26.250 660.333 Td /F1 9.8 Tf  [(distribution of 45-64 year olds during the H1N1 pandemic compared to prior seasonal influenza seasons.)] TJ ET
BT 26.250 640.929 Td /F1 9.8 Tf  [(Similar trends existed in relation to race/ethnic group characteristics. Unpublished statewide 2009 H1N1 epidemiological data )] TJ ET
BT 26.250 629.024 Td /F1 9.8 Tf  [(suggests that there have been disproportionate numbers of laboratory-confirmed and hospitalized H1N1 cases among certain )] TJ ET
BT 26.250 617.119 Td /F1 9.8 Tf  [(racial/ethnic groups in Massachusetts. The Massachusetts DPH found that rates of lab-confirmed H1N1-related hospitalization )] TJ ET
BT 26.250 605.214 Td /F1 9.8 Tf  [(were three to four times higher in Black and Hispanic populations compared to White, non-Hispanic populations \(Alfred )] TJ ET
BT 26.250 593.310 Td /F1 9.8 Tf  [(DeMaria, MDPH, personal communication, 2010\). Furthermore, the CDC reports greater proportions of hospitalizations and )] TJ ET
BT 26.250 581.405 Td /F1 9.8 Tf  [(deaths among particular ethnic groups in Chicago )] TJ ET
0.267 0.267 0.267 rg
BT 243.558 581.405 Td /F1 9.8 Tf  [([28])] TJ ET
0.271 0.267 0.267 rg
BT 259.821 581.405 Td /F1 9.8 Tf  [( and among American Indian/Alaskan Natives compared to other racial )] TJ ET
BT 26.250 569.500 Td /F1 9.8 Tf  [(groups )] TJ ET
0.267 0.267 0.267 rg
BT 58.766 569.500 Td /F1 9.8 Tf  [([29])] TJ ET
0.271 0.267 0.267 rg
BT 75.029 569.500 Td /F1 9.8 Tf  [( . From our analyses, we can see that both H1N1 selection criteria have higher proportions of Black and Hispanic )] TJ ET
BT 26.250 557.595 Td /F1 9.8 Tf  [(groups compared to seasonal influenza. However, proportions of non-White race/ethnic groups among those in the narrow )] TJ ET
BT 26.250 545.691 Td /F1 9.8 Tf  [(criteria \(47% White, non-Hispanic\) correspond more closely to rates in published epidemiological reports compared to broad )] TJ ET
BT 26.250 533.786 Td /F1 9.8 Tf  [(criteria \(70% White, non-Hispanic\).)] TJ ET
BT 26.250 514.381 Td /F1 9.8 Tf  [(From the results described, it becomes clear that although the maximum criteria have been used to describe influenza activity )] TJ ET
BT 26.250 502.476 Td /F1 9.8 Tf  [(and have correlated with confirmed influenza in prior studies )] TJ ET
0.267 0.267 0.267 rg
BT 288.525 502.476 Td /F1 9.8 Tf  [([20])] TJ ET
BT 304.788 502.476 Td /F1 9.8 Tf  [([25])] TJ ET
0.271 0.267 0.267 rg
BT 321.051 502.476 Td /F1 9.8 Tf  [( , these selection criteria may be too non-specific for the )] TJ ET
BT 26.250 490.572 Td /F1 9.8 Tf  [(purposes of influenza case detection among those hospitalized with H1N1. The maximum criteria utilized in this study display )] TJ ET
BT 26.250 478.667 Td /F1 9.8 Tf  [(high frequencies of ILI-related discharges � even during summer months, which is typically outside of the influenza season )] TJ ET
BT 26.250 466.762 Td /F1 9.8 Tf  [(\(Figure 1\). Furthermore, those included in the maximum criteria do not correspond with epidemiological descriptions presented )] TJ ET
BT 26.250 454.857 Td /F1 9.8 Tf  [(in the literature, the total caseload between Apr-Sept 2009 \(n=10,976\) could be a gross overrepresentation of actual )] TJ ET
BT 26.250 442.953 Td /F1 9.8 Tf  [(hospitalized cases, and since additional respiratory syndromes are included in the maximum selection criteria, misclassification )] TJ ET
BT 26.250 431.048 Td /F1 9.8 Tf  [(due to non-influenza is not a possibility � it is a certainty. These results correspond with another recent assessment which found )] TJ ET
BT 26.250 419.143 Td /F1 9.8 Tf  [(that these same criteria did not sufficiently monitor/detect the H1N1 outbreak, had inadequate sensitivity, and poor positive )] TJ ET
BT 26.250 407.238 Td /F1 9.8 Tf  [(predictive value for identifying ILI cases )] TJ ET
0.267 0.267 0.267 rg
BT 199.118 407.238 Td /F1 9.8 Tf  [([30])] TJ ET
0.271 0.267 0.267 rg
BT 215.381 407.238 Td /F1 9.8 Tf  [( .)] TJ ET
BT 26.250 387.834 Td /F1 9.8 Tf  [(However, there are major limitations to using the minimum criteria as an indicator for disease activity. Assigning influenza-)] TJ ET
BT 26.250 375.929 Td /F1 9.8 Tf  [(specific codes to patients in administrative data sources is not dependent on confirmed influenza test results, and there is no )] TJ ET
BT 26.250 364.024 Td /F1 9.8 Tf  [(way, other than manual chart review, to confirm if someone who received an influenza diagnosis actually had the disease. We )] TJ ET
BT 26.250 352.119 Td /F1 9.8 Tf  [(were authorized to use this dataset only in a de-identified way, and manual chart review was therefore not feasible. Studies )] TJ ET
BT 26.250 340.215 Td /F1 9.8 Tf  [(investigating the use of ICD-9 codes to identify influenza cases have found that confirmed-positive pandemic 2009 H1N1 cases )] TJ ET
BT 26.250 328.310 Td /F1 9.8 Tf  [(were not uniformly coded as influenza, and nearly 10% of confirmed cases were not even captured in a syndromic surveillance )] TJ ET
BT 26.250 316.405 Td /F1 9.8 Tf  [(ILI algorithm )] TJ ET
0.267 0.267 0.267 rg
BT 82.605 316.405 Td /F1 9.8 Tf  [([25])] TJ ET
0.271 0.267 0.267 rg
BT 98.868 316.405 Td /F1 9.8 Tf  [( further suggesting that there are many difficulties detecting and tracking confirmed influenza cases using )] TJ ET
BT 26.250 304.500 Td /F1 9.8 Tf  [(administrative data sources. Finally, there is a lack of standard clinical protocol for coding influenza diagnoses, and it is difficult )] TJ ET
BT 26.250 292.596 Td /F1 9.8 Tf  [(to understand the process of clinical decision-making related to influenza diagnoses by analyzing ICD-9 codes.)] TJ ET
BT 26.250 273.191 Td /F4 9.8 Tf  [(Limitations)] TJ ET
BT 26.250 253.786 Td /F1 9.8 Tf  [(Data from correctional facilities and veteran�s hospitals in Massachusetts are not included in the HDD, and there is also limited )] TJ ET
BT 26.250 241.881 Td /F1 9.8 Tf  [(information related to treatments and diagnoses in emergency departments. Reports of those with self-reported ILI symptoms )] TJ ET
BT 26.250 229.977 Td /F1 9.8 Tf  [(during the H1N1 pandemic in the U.S. indicate that 40% of adults and 56% of children sought health care )] TJ ET
0.267 0.267 0.267 rg
BT 482.033 229.977 Td /F1 9.8 Tf  [([31])] TJ ET
0.271 0.267 0.267 rg
BT 498.296 229.977 Td /F1 9.8 Tf  [( . Because the )] TJ ET
BT 26.250 218.072 Td /F1 9.8 Tf  [(HDD only includes those hospitalized with H1N1, we were not able to compare this hospitalized population to non-hospitalized )] TJ ET
BT 26.250 206.167 Td /F1 9.8 Tf  [(H1N1 cases to see differences in demographics, diagnoses, or outcomes.)] TJ ET
BT 26.250 177.065 Td /F4 12.0 Tf  [(Conclusions)] TJ ET
Q
q
15.000 28.182 577.500 748.818 re W n
0.271 0.267 0.267 rg
BT 26.250 767.476 Td /F1 9.8 Tf  [(that, of the two criteria used, this group may be a more accurate estimate of actual influenza activity. Those with H1N1 had )] TJ ET
BT 26.250 755.571 Td /F1 9.8 Tf  [(higher rates of ICU admission compared to those with seasonal influenza. This is consistent with another published assessment )] TJ ET
BT 26.250 743.667 Td /F1 9.8 Tf  [(restricted to a metropolitan area in the United States )] TJ ET
0.267 0.267 0.267 rg
BT 254.400 743.667 Td /F1 9.8 Tf  [([13])] TJ ET
0.271 0.267 0.267 rg
BT 270.663 743.667 Td /F1 9.8 Tf  [( . Also shown in the literature, H1N1 affected all age groups, but )] TJ ET
BT 26.250 731.762 Td /F1 9.8 Tf  [(frequently occurred in previously healthy, young adults with a wide range of socio-demographic characteristics and clinical )] TJ ET
BT 26.250 719.857 Td /F1 9.8 Tf  [(presentations )] TJ ET
0.267 0.267 0.267 rg
BT 87.490 719.857 Td /F1 9.8 Tf  [([26])] TJ ET
0.271 0.267 0.267 rg
BT 103.753 719.857 Td /F1 9.8 Tf  [( . In the Northern Hemisphere, hospitalized patients with confirmed or probable H1N1 infection ranged in age )] TJ ET
BT 26.250 707.952 Td /F1 9.8 Tf  [(from 21 days to 86 years, but 45% of hospitalized cases were under the age of 18 years, and only 5% of cases were 65 years of )] TJ ET
BT 26.250 696.048 Td /F1 9.8 Tf  [(age or older )] TJ ET
0.267 0.267 0.267 rg
BT 80.987 696.048 Td /F1 9.8 Tf  [([27])] TJ ET
0.271 0.267 0.267 rg
BT 97.249 696.048 Td /F1 9.8 Tf  [( . State reports based on laboratory-confirmed H1N1 data indicate that 45% were <19 years, 33% 19-49 years, )] TJ ET
BT 26.250 684.143 Td /F1 9.8 Tf  [(15% 50-64 years, and 7% =65 years )] TJ ET
0.267 0.267 0.267 rg
BT 186.940 684.143 Td /F1 9.8 Tf  [([19])] TJ ET
0.271 0.267 0.267 rg
BT 203.203 684.143 Td /F1 9.8 Tf  [( . This is consistent with what we found in the minimum criteria \(50% were <18 years\), )] TJ ET
BT 26.250 672.238 Td /F1 9.8 Tf  [(but not the maximum \(23% were <18 years, and 51% were aged 45-64 years\). In fact, the maximum criteria showed a greater )] TJ ET
BT 26.250 660.333 Td /F1 9.8 Tf  [(distribution of 45-64 year olds during the H1N1 pandemic compared to prior seasonal influenza seasons.)] TJ ET
BT 26.250 640.929 Td /F1 9.8 Tf  [(Similar trends existed in relation to race/ethnic group characteristics. Unpublished statewide 2009 H1N1 epidemiological data )] TJ ET
BT 26.250 629.024 Td /F1 9.8 Tf  [(suggests that there have been disproportionate numbers of laboratory-confirmed and hospitalized H1N1 cases among certain )] TJ ET
BT 26.250 617.119 Td /F1 9.8 Tf  [(racial/ethnic groups in Massachusetts. The Massachusetts DPH found that rates of lab-confirmed H1N1-related hospitalization )] TJ ET
BT 26.250 605.214 Td /F1 9.8 Tf  [(were three to four times higher in Black and Hispanic populations compared to White, non-Hispanic populations \(Alfred )] TJ ET
BT 26.250 593.310 Td /F1 9.8 Tf  [(DeMaria, MDPH, personal communication, 2010\). Furthermore, the CDC reports greater proportions of hospitalizations and )] TJ ET
BT 26.250 581.405 Td /F1 9.8 Tf  [(deaths among particular ethnic groups in Chicago )] TJ ET
0.267 0.267 0.267 rg
BT 243.558 581.405 Td /F1 9.8 Tf  [([28])] TJ ET
0.271 0.267 0.267 rg
BT 259.821 581.405 Td /F1 9.8 Tf  [( and among American Indian/Alaskan Natives compared to other racial )] TJ ET
BT 26.250 569.500 Td /F1 9.8 Tf  [(groups )] TJ ET
0.267 0.267 0.267 rg
BT 58.766 569.500 Td /F1 9.8 Tf  [([29])] TJ ET
0.271 0.267 0.267 rg
BT 75.029 569.500 Td /F1 9.8 Tf  [( . From our analyses, we can see that both H1N1 selection criteria have higher proportions of Black and Hispanic )] TJ ET
BT 26.250 557.595 Td /F1 9.8 Tf  [(groups compared to seasonal influenza. However, proportions of non-White race/ethnic groups among those in the narrow )] TJ ET
BT 26.250 545.691 Td /F1 9.8 Tf  [(criteria \(47% White, non-Hispanic\) correspond more closely to rates in published epidemiological reports compared to broad )] TJ ET
BT 26.250 533.786 Td /F1 9.8 Tf  [(criteria \(70% White, non-Hispanic\).)] TJ ET
BT 26.250 514.381 Td /F1 9.8 Tf  [(From the results described, it becomes clear that although the maximum criteria have been used to describe influenza activity )] TJ ET
BT 26.250 502.476 Td /F1 9.8 Tf  [(and have correlated with confirmed influenza in prior studies )] TJ ET
0.267 0.267 0.267 rg
BT 288.525 502.476 Td /F1 9.8 Tf  [([20])] TJ ET
BT 304.788 502.476 Td /F1 9.8 Tf  [([25])] TJ ET
0.271 0.267 0.267 rg
BT 321.051 502.476 Td /F1 9.8 Tf  [( , these selection criteria may be too non-specific for the )] TJ ET
BT 26.250 490.572 Td /F1 9.8 Tf  [(purposes of influenza case detection among those hospitalized with H1N1. The maximum criteria utilized in this study display )] TJ ET
BT 26.250 478.667 Td /F1 9.8 Tf  [(high frequencies of ILI-related discharges � even during summer months, which is typically outside of the influenza season )] TJ ET
BT 26.250 466.762 Td /F1 9.8 Tf  [(\(Figure 1\). Furthermore, those included in the maximum criteria do not correspond with epidemiological descriptions presented )] TJ ET
BT 26.250 454.857 Td /F1 9.8 Tf  [(in the literature, the total caseload between Apr-Sept 2009 \(n=10,976\) could be a gross overrepresentation of actual )] TJ ET
BT 26.250 442.953 Td /F1 9.8 Tf  [(hospitalized cases, and since additional respiratory syndromes are included in the maximum selection criteria, misclassification )] TJ ET
BT 26.250 431.048 Td /F1 9.8 Tf  [(due to non-influenza is not a possibility � it is a certainty. These results correspond with another recent assessment which found )] TJ ET
BT 26.250 419.143 Td /F1 9.8 Tf  [(that these same criteria did not sufficiently monitor/detect the H1N1 outbreak, had inadequate sensitivity, and poor positive )] TJ ET
BT 26.250 407.238 Td /F1 9.8 Tf  [(predictive value for identifying ILI cases )] TJ ET
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BT 199.118 407.238 Td /F1 9.8 Tf  [([30])] TJ ET
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BT 215.381 407.238 Td /F1 9.8 Tf  [( .)] TJ ET
BT 26.250 387.834 Td /F1 9.8 Tf  [(However, there are major limitations to using the minimum criteria as an indicator for disease activity. Assigning influenza-)] TJ ET
BT 26.250 375.929 Td /F1 9.8 Tf  [(specific codes to patients in administrative data sources is not dependent on confirmed influenza test results, and there is no )] TJ ET
BT 26.250 364.024 Td /F1 9.8 Tf  [(way, other than manual chart review, to confirm if someone who received an influenza diagnosis actually had the disease. We )] TJ ET
BT 26.250 352.119 Td /F1 9.8 Tf  [(were authorized to use this dataset only in a de-identified way, and manual chart review was therefore not feasible. Studies )] TJ ET
BT 26.250 340.215 Td /F1 9.8 Tf  [(investigating the use of ICD-9 codes to identify influenza cases have found that confirmed-positive pandemic 2009 H1N1 cases )] TJ ET
BT 26.250 328.310 Td /F1 9.8 Tf  [(were not uniformly coded as influenza, and nearly 10% of confirmed cases were not even captured in a syndromic surveillance )] TJ ET
BT 26.250 316.405 Td /F1 9.8 Tf  [(ILI algorithm )] TJ ET
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BT 82.605 316.405 Td /F1 9.8 Tf  [([25])] TJ ET
0.271 0.267 0.267 rg
BT 98.868 316.405 Td /F1 9.8 Tf  [( further suggesting that there are many difficulties detecting and tracking confirmed influenza cases using )] TJ ET
BT 26.250 304.500 Td /F1 9.8 Tf  [(administrative data sources. Finally, there is a lack of standard clinical protocol for coding influenza diagnoses, and it is difficult )] TJ ET
BT 26.250 292.596 Td /F1 9.8 Tf  [(to understand the process of clinical decision-making related to influenza diagnoses by analyzing ICD-9 codes.)] TJ ET
BT 26.250 273.191 Td /F4 9.8 Tf  [(Limitations)] TJ ET
BT 26.250 253.786 Td /F1 9.8 Tf  [(Data from correctional facilities and veteran�s hospitals in Massachusetts are not included in the HDD, and there is also limited )] TJ ET
BT 26.250 241.881 Td /F1 9.8 Tf  [(information related to treatments and diagnoses in emergency departments. Reports of those with self-reported ILI symptoms )] TJ ET
BT 26.250 229.977 Td /F1 9.8 Tf  [(during the H1N1 pandemic in the U.S. indicate that 40% of adults and 56% of children sought health care )] TJ ET
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BT 482.033 229.977 Td /F1 9.8 Tf  [([31])] TJ ET
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BT 498.296 229.977 Td /F1 9.8 Tf  [( . Because the )] TJ ET
BT 26.250 218.072 Td /F1 9.8 Tf  [(HDD only includes those hospitalized with H1N1, we were not able to compare this hospitalized population to non-hospitalized )] TJ ET
BT 26.250 206.167 Td /F1 9.8 Tf  [(H1N1 cases to see differences in demographics, diagnoses, or outcomes.)] TJ ET
BT 26.250 177.065 Td /F4 12.0 Tf  [(Conclusions)] TJ ET
Q
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BT 291.710 19.825 Td /F1 11.0 Tf  [(6)] TJ ET
BT 25.000 19.825 Td /F1 11.0 Tf  [(PLOS Currents Influenza)] TJ ET

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BT 26.250 767.476 Td /F1 9.8 Tf  [(This is the first population-based assessment of epidemiological characteristics of hospitalized H1N1 cases in Massachusetts, )] TJ ET
BT 26.250 755.571 Td /F1 9.8 Tf  [(and it is the first to include all possible hospitalized cases in the analysis. We found that large administrative data sets, like )] TJ ET
BT 26.250 743.667 Td /F1 9.8 Tf  [(HDD, can be used to detect hospitalizations for influenza during a pandemic, but estimated case counts vary widely depending )] TJ ET
BT 26.250 731.762 Td /F1 9.8 Tf  [(on the selection criteria used. We compared selection criteria currently in use for surveillance and case detections \(maximum )] TJ ET
BT 26.250 719.857 Td /F1 9.8 Tf  [(criteria\) with influenza-specific ICD-9 diagnosis codes \(minimum criteria\), and have provided a range of H1N1-related )] TJ ET
BT 26.250 707.952 Td /F1 9.8 Tf  [(hospitalizations. In this study, the maximum criteria overestimated H1N1 activity, and we do not recommend using these criteria )] TJ ET
BT 26.250 696.048 Td /F1 9.8 Tf  [(to characterize the epidemiology of influenza study populations. Those meeting minimum criteria most closely resemble )] TJ ET
BT 26.250 684.143 Td /F1 9.8 Tf  [(published descriptions of H1N1-related hospitalizations and meet the expected influenza case count, and we recommend using )] TJ ET
BT 26.250 672.238 Td /F1 9.8 Tf  [(the minimum criteria to describe populations hospitalized with influenza, despite the limitations noted above. We can confirm )] TJ ET
BT 26.250 660.333 Td /F1 9.8 Tf  [(that H1N1 affected a younger population, and disproportionately affected racial minorities in Massachusetts. There were also )] TJ ET
BT 26.250 648.429 Td /F1 9.8 Tf  [(higher rates of ICU admission compared to seasonal influenza.)] TJ ET
BT 26.250 629.024 Td /F1 9.8 Tf  [(Reporting population-level rates of disease, however, is challenging without large databases containing confirmed disease )] TJ ET
BT 26.250 617.119 Td /F1 9.8 Tf  [(indicators. Improving the quality of population-based data sources with reliable indicators of influenza could provide reasonable )] TJ ET
BT 26.250 605.214 Td /F1 9.8 Tf  [(indicators of disease. For now, however, one of the best ways to report disease activity in the U.S. is through ICD-9 codes, )] TJ ET
BT 26.250 593.310 Td /F1 9.8 Tf  [(which may not necessarily reflect care given or individual symptoms while in the hospital. With this in mind, future work should )] TJ ET
BT 26.250 581.405 Td /F1 9.8 Tf  [(establish a �best practice� for influenza case identification within administrative data sources to more accurately identify and )] TJ ET
BT 26.250 569.500 Td /F1 9.8 Tf  [(describe population-based rates of disease, severity, and mortality.)] TJ ET
BT 26.250 532.898 Td /F4 12.0 Tf  [(Acknowledgments:)] TJ ET
BT 26.250 512.943 Td /F1 9.8 Tf  [(The authors would like to acknowledge the following individuals for their contribution to this manuscript: Bruce Barton, PhD )] TJ ET
BT 26.250 501.039 Td /F1 9.8 Tf  [(\(UMMS\), John Brownstein, PhD \(CHIP\), Bruce Cohen, PhD \(MDPH\), James West, PhD \(MDPH\), Alan Rothman, MD \(URI\), )] TJ ET
BT 26.250 489.134 Td /F1 9.8 Tf  [(Richard Ellison, MD \(UMMS\), and Brian O�Sullivan, MD \(UMMS\).)] TJ ET
BT 26.250 452.531 Td /F4 12.0 Tf  [(Funding information:)] TJ ET
BT 26.250 432.577 Td /F1 9.8 Tf  [(We would like to acknowledge the support of Massachusetts Department of Public Health, Division of Epidemiology and )] TJ ET
BT 26.250 420.672 Td /F1 9.8 Tf  [(Immunization and Clinical and Population Health Research Department at University of Massachusetts Medical School.)] TJ ET
BT 26.250 384.070 Td /F4 12.0 Tf  [(Competing interests:)] TJ ET
BT 26.250 364.116 Td /F1 9.8 Tf  [(The authors have declared that no competing interests exist.)] TJ ET
BT 26.250 327.513 Td /F4 12.0 Tf  [(References)] TJ ET
BT 26.250 300.059 Td /F1 9.8 Tf  [(1.)] TJ ET
BT 38.132 300.059 Td /F1 9.8 Tf  [(Update: Influenza activity --- United States, August 30, 2009-January 9, 2010. MMWR.Morbidity and Mortality Weekly Report. )] TJ ET
BT 26.250 288.154 Td /F1 9.8 Tf  [(2010;59\(2\):38.)] TJ ET
BT 26.250 268.749 Td /F1 9.8 Tf  [(2.)] TJ ET
BT 38.132 268.749 Td /F1 9.8 Tf  [(Ercole A, Taylor BL, Rhodes A, Menon DK. Modelling the impact of an influenza A/H1N1 pandemic on critical care demand )] TJ ET
BT 26.250 256.845 Td /F1 9.8 Tf  [(from early pathogenicity data: The case for sentinel reporting. Anaesthesia. 2009;64\(9\):937.)] TJ ET
BT 26.250 237.440 Td /F1 9.8 Tf  [(3.)] TJ ET
BT 38.132 237.440 Td /F1 9.8 Tf  [(Ercole A, Menon DK, O'Donnell DR. Modelling the impact of pandemic influenza A\(H1N1\) on UK paediatric intensive care )] TJ ET
BT 26.250 225.535 Td /F1 9.8 Tf  [(demand. Arch Dis Child. 2009;94\(12\):962.)] TJ ET
BT 26.250 206.130 Td /F1 9.8 Tf  [(4.)] TJ ET
BT 38.132 206.130 Td /F1 9.8 Tf  [(Presanis A, Lipsitch M, De Angelis A, Hagy C, Reed S, Riley B, et al. The severity of pandemic H1N1 influenza in the United )] TJ ET
BT 26.250 194.226 Td /F1 9.8 Tf  [(States, April -- July 2009. PLoS Curr Influenza. 2009:RRN1042.)] TJ ET
BT 26.250 174.821 Td /F1 9.8 Tf  [(5.)] TJ ET
BT 38.132 174.821 Td /F1 9.8 Tf  [(Garske T, Legrand J, Donnelly C, Ward H, Cauchemez S, Fraser C, et al. Assessing the severity of the novel influenza )] TJ ET
BT 26.250 162.916 Td /F1 9.8 Tf  [(A/H1N1 pandemic. BMJ.British medical journal \(Clinical research ed.\). 2009;339:b2840.)] TJ ET
BT 26.250 143.511 Td /F1 9.8 Tf  [(6.)] TJ ET
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BT 26.250 100.297 Td /F1 9.8 Tf  [(2009, United States, April-July 2009. Emerging infectious diseases. 2009;15\(12\):2004.)] TJ ET
BT 26.250 80.892 Td /F1 9.8 Tf  [(8.)] TJ ET
BT 38.132 80.892 Td /F1 9.8 Tf  [(Yiannakoulias N, Russell ML, Svenson LW, Schopflocher DP. Doctors, patients and influenza-like illness: Clinicians or )] TJ ET
BT 26.250 68.988 Td /F1 9.8 Tf  [(patients at risk? Public Health. 2004;118\(7\):527-31.)] TJ ET
BT 26.250 49.583 Td /F1 9.8 Tf  [(9.)] TJ ET
BT 38.132 49.583 Td /F1 9.8 Tf  [(Fedson DS, Wajda A, Nicol JP, Hammond GW, Kaiser DL, Roos LL. Clinical effectiveness of influenza vaccination in )] TJ ET
Q
q
15.000 35.297 577.500 741.703 re W n
0.271 0.267 0.267 rg
BT 26.250 767.476 Td /F1 9.8 Tf  [(This is the first population-based assessment of epidemiological characteristics of hospitalized H1N1 cases in Massachusetts, )] TJ ET
BT 26.250 755.571 Td /F1 9.8 Tf  [(and it is the first to include all possible hospitalized cases in the analysis. We found that large administrative data sets, like )] TJ ET
BT 26.250 743.667 Td /F1 9.8 Tf  [(HDD, can be used to detect hospitalizations for influenza during a pandemic, but estimated case counts vary widely depending )] TJ ET
BT 26.250 731.762 Td /F1 9.8 Tf  [(on the selection criteria used. We compared selection criteria currently in use for surveillance and case detections \(maximum )] TJ ET
BT 26.250 719.857 Td /F1 9.8 Tf  [(criteria\) with influenza-specific ICD-9 diagnosis codes \(minimum criteria\), and have provided a range of H1N1-related )] TJ ET
BT 26.250 707.952 Td /F1 9.8 Tf  [(hospitalizations. In this study, the maximum criteria overestimated H1N1 activity, and we do not recommend using these criteria )] TJ ET
BT 26.250 696.048 Td /F1 9.8 Tf  [(to characterize the epidemiology of influenza study populations. Those meeting minimum criteria most closely resemble )] TJ ET
BT 26.250 684.143 Td /F1 9.8 Tf  [(published descriptions of H1N1-related hospitalizations and meet the expected influenza case count, and we recommend using )] TJ ET
BT 26.250 672.238 Td /F1 9.8 Tf  [(the minimum criteria to describe populations hospitalized with influenza, despite the limitations noted above. We can confirm )] TJ ET
BT 26.250 660.333 Td /F1 9.8 Tf  [(that H1N1 affected a younger population, and disproportionately affected racial minorities in Massachusetts. There were also )] TJ ET
BT 26.250 648.429 Td /F1 9.8 Tf  [(higher rates of ICU admission compared to seasonal influenza.)] TJ ET
BT 26.250 629.024 Td /F1 9.8 Tf  [(Reporting population-level rates of disease, however, is challenging without large databases containing confirmed disease )] TJ ET
BT 26.250 617.119 Td /F1 9.8 Tf  [(indicators. Improving the quality of population-based data sources with reliable indicators of influenza could provide reasonable )] TJ ET
BT 26.250 605.214 Td /F1 9.8 Tf  [(indicators of disease. For now, however, one of the best ways to report disease activity in the U.S. is through ICD-9 codes, )] TJ ET
BT 26.250 593.310 Td /F1 9.8 Tf  [(which may not necessarily reflect care given or individual symptoms while in the hospital. With this in mind, future work should )] TJ ET
BT 26.250 581.405 Td /F1 9.8 Tf  [(establish a �best practice� for influenza case identification within administrative data sources to more accurately identify and )] TJ ET
BT 26.250 569.500 Td /F1 9.8 Tf  [(describe population-based rates of disease, severity, and mortality.)] TJ ET
BT 26.250 532.898 Td /F4 12.0 Tf  [(Acknowledgments:)] TJ ET
BT 26.250 512.943 Td /F1 9.8 Tf  [(The authors would like to acknowledge the following individuals for their contribution to this manuscript: Bruce Barton, PhD )] TJ ET
BT 26.250 501.039 Td /F1 9.8 Tf  [(\(UMMS\), John Brownstein, PhD \(CHIP\), Bruce Cohen, PhD \(MDPH\), James West, PhD \(MDPH\), Alan Rothman, MD \(URI\), )] TJ ET
BT 26.250 489.134 Td /F1 9.8 Tf  [(Richard Ellison, MD \(UMMS\), and Brian O�Sullivan, MD \(UMMS\).)] TJ ET
BT 26.250 452.531 Td /F4 12.0 Tf  [(Funding information:)] TJ ET
BT 26.250 432.577 Td /F1 9.8 Tf  [(We would like to acknowledge the support of Massachusetts Department of Public Health, Division of Epidemiology and )] TJ ET
BT 26.250 420.672 Td /F1 9.8 Tf  [(Immunization and Clinical and Population Health Research Department at University of Massachusetts Medical School.)] TJ ET
BT 26.250 384.070 Td /F4 12.0 Tf  [(Competing interests:)] TJ ET
BT 26.250 364.116 Td /F1 9.8 Tf  [(The authors have declared that no competing interests exist.)] TJ ET
BT 26.250 327.513 Td /F4 12.0 Tf  [(References)] TJ ET
BT 26.250 300.059 Td /F1 9.8 Tf  [(1.)] TJ ET
BT 38.132 300.059 Td /F1 9.8 Tf  [(Update: Influenza activity --- United States, August 30, 2009-January 9, 2010. MMWR.Morbidity and Mortality Weekly Report. )] TJ ET
BT 26.250 288.154 Td /F1 9.8 Tf  [(2010;59\(2\):38.)] TJ ET
BT 26.250 268.749 Td /F1 9.8 Tf  [(2.)] TJ ET
BT 38.132 268.749 Td /F1 9.8 Tf  [(Ercole A, Taylor BL, Rhodes A, Menon DK. Modelling the impact of an influenza A/H1N1 pandemic on critical care demand )] TJ ET
BT 26.250 256.845 Td /F1 9.8 Tf  [(from early pathogenicity data: The case for sentinel reporting. Anaesthesia. 2009;64\(9\):937.)] TJ ET
BT 26.250 237.440 Td /F1 9.8 Tf  [(3.)] TJ ET
BT 38.132 237.440 Td /F1 9.8 Tf  [(Ercole A, Menon DK, O'Donnell DR. Modelling the impact of pandemic influenza A\(H1N1\) on UK paediatric intensive care )] TJ ET
BT 26.250 225.535 Td /F1 9.8 Tf  [(demand. Arch Dis Child. 2009;94\(12\):962.)] TJ ET
BT 26.250 206.130 Td /F1 9.8 Tf  [(4.)] TJ ET
BT 38.132 206.130 Td /F1 9.8 Tf  [(Presanis A, Lipsitch M, De Angelis A, Hagy C, Reed S, Riley B, et al. The severity of pandemic H1N1 influenza in the United )] TJ ET
BT 26.250 194.226 Td /F1 9.8 Tf  [(States, April -- July 2009. PLoS Curr Influenza. 2009:RRN1042.)] TJ ET
BT 26.250 174.821 Td /F1 9.8 Tf  [(5.)] TJ ET
BT 38.132 174.821 Td /F1 9.8 Tf  [(Garske T, Legrand J, Donnelly C, Ward H, Cauchemez S, Fraser C, et al. Assessing the severity of the novel influenza )] TJ ET
BT 26.250 162.916 Td /F1 9.8 Tf  [(A/H1N1 pandemic. BMJ.British medical journal \(Clinical research ed.\). 2009;339:b2840.)] TJ ET
BT 26.250 143.511 Td /F1 9.8 Tf  [(6.)] TJ ET
BT 38.132 143.511 Td /F1 9.8 Tf  [(Reichert T, Simonsen L, Sharma A, Pardo S, Fedson D, Miller M. Influenza and the winter increase in mortality in the United )] TJ ET
BT 26.250 131.607 Td /F1 9.8 Tf  [(States, 1959-1999. Am J Epidemiol. 2004;160\(5\):492.)] TJ ET
BT 26.250 112.202 Td /F1 9.8 Tf  [(7.)] TJ ET
BT 38.132 112.202 Td /F1 9.8 Tf  [(Reed C, Angulo F, Swerdlow D, Lipsitch M, Meltzer M, Jernigan D, et al. Estimates of the prevalence of pandemic \(H1N1\) )] TJ ET
BT 26.250 100.297 Td /F1 9.8 Tf  [(2009, United States, April-July 2009. Emerging infectious diseases. 2009;15\(12\):2004.)] TJ ET
BT 26.250 80.892 Td /F1 9.8 Tf  [(8.)] TJ ET
BT 38.132 80.892 Td /F1 9.8 Tf  [(Yiannakoulias N, Russell ML, Svenson LW, Schopflocher DP. Doctors, patients and influenza-like illness: Clinicians or )] TJ ET
BT 26.250 68.988 Td /F1 9.8 Tf  [(patients at risk? Public Health. 2004;118\(7\):527-31.)] TJ ET
BT 26.250 49.583 Td /F1 9.8 Tf  [(9.)] TJ ET
BT 38.132 49.583 Td /F1 9.8 Tf  [(Fedson DS, Wajda A, Nicol JP, Hammond GW, Kaiser DL, Roos LL. Clinical effectiveness of influenza vaccination in )] TJ ET
Q
q
15.000 35.297 577.500 741.703 re W n
0.271 0.267 0.267 rg
BT 26.250 767.476 Td /F1 9.8 Tf  [(This is the first population-based assessment of epidemiological characteristics of hospitalized H1N1 cases in Massachusetts, )] TJ ET
BT 26.250 755.571 Td /F1 9.8 Tf  [(and it is the first to include all possible hospitalized cases in the analysis. We found that large administrative data sets, like )] TJ ET
BT 26.250 743.667 Td /F1 9.8 Tf  [(HDD, can be used to detect hospitalizations for influenza during a pandemic, but estimated case counts vary widely depending )] TJ ET
BT 26.250 731.762 Td /F1 9.8 Tf  [(on the selection criteria used. We compared selection criteria currently in use for surveillance and case detections \(maximum )] TJ ET
BT 26.250 719.857 Td /F1 9.8 Tf  [(criteria\) with influenza-specific ICD-9 diagnosis codes \(minimum criteria\), and have provided a range of H1N1-related )] TJ ET
BT 26.250 707.952 Td /F1 9.8 Tf  [(hospitalizations. In this study, the maximum criteria overestimated H1N1 activity, and we do not recommend using these criteria )] TJ ET
BT 26.250 696.048 Td /F1 9.8 Tf  [(to characterize the epidemiology of influenza study populations. Those meeting minimum criteria most closely resemble )] TJ ET
BT 26.250 684.143 Td /F1 9.8 Tf  [(published descriptions of H1N1-related hospitalizations and meet the expected influenza case count, and we recommend using )] TJ ET
BT 26.250 672.238 Td /F1 9.8 Tf  [(the minimum criteria to describe populations hospitalized with influenza, despite the limitations noted above. We can confirm )] TJ ET
BT 26.250 660.333 Td /F1 9.8 Tf  [(that H1N1 affected a younger population, and disproportionately affected racial minorities in Massachusetts. There were also )] TJ ET
BT 26.250 648.429 Td /F1 9.8 Tf  [(higher rates of ICU admission compared to seasonal influenza.)] TJ ET
BT 26.250 629.024 Td /F1 9.8 Tf  [(Reporting population-level rates of disease, however, is challenging without large databases containing confirmed disease )] TJ ET
BT 26.250 617.119 Td /F1 9.8 Tf  [(indicators. Improving the quality of population-based data sources with reliable indicators of influenza could provide reasonable )] TJ ET
BT 26.250 605.214 Td /F1 9.8 Tf  [(indicators of disease. For now, however, one of the best ways to report disease activity in the U.S. is through ICD-9 codes, )] TJ ET
BT 26.250 593.310 Td /F1 9.8 Tf  [(which may not necessarily reflect care given or individual symptoms while in the hospital. With this in mind, future work should )] TJ ET
BT 26.250 581.405 Td /F1 9.8 Tf  [(establish a �best practice� for influenza case identification within administrative data sources to more accurately identify and )] TJ ET
BT 26.250 569.500 Td /F1 9.8 Tf  [(describe population-based rates of disease, severity, and mortality.)] TJ ET
BT 26.250 532.898 Td /F4 12.0 Tf  [(Acknowledgments:)] TJ ET
BT 26.250 512.943 Td /F1 9.8 Tf  [(The authors would like to acknowledge the following individuals for their contribution to this manuscript: Bruce Barton, PhD )] TJ ET
BT 26.250 501.039 Td /F1 9.8 Tf  [(\(UMMS\), John Brownstein, PhD \(CHIP\), Bruce Cohen, PhD \(MDPH\), James West, PhD \(MDPH\), Alan Rothman, MD \(URI\), )] TJ ET
BT 26.250 489.134 Td /F1 9.8 Tf  [(Richard Ellison, MD \(UMMS\), and Brian O�Sullivan, MD \(UMMS\).)] TJ ET
BT 26.250 452.531 Td /F4 12.0 Tf  [(Funding information:)] TJ ET
BT 26.250 432.577 Td /F1 9.8 Tf  [(We would like to acknowledge the support of Massachusetts Department of Public Health, Division of Epidemiology and )] TJ ET
BT 26.250 420.672 Td /F1 9.8 Tf  [(Immunization and Clinical and Population Health Research Department at University of Massachusetts Medical School.)] TJ ET
BT 26.250 384.070 Td /F4 12.0 Tf  [(Competing interests:)] TJ ET
BT 26.250 364.116 Td /F1 9.8 Tf  [(The authors have declared that no competing interests exist.)] TJ ET
BT 26.250 327.513 Td /F4 12.0 Tf  [(References)] TJ ET
BT 26.250 300.059 Td /F1 9.8 Tf  [(1.)] TJ ET
BT 38.132 300.059 Td /F1 9.8 Tf  [(Update: Influenza activity --- United States, August 30, 2009-January 9, 2010. MMWR.Morbidity and Mortality Weekly Report. )] TJ ET
BT 26.250 288.154 Td /F1 9.8 Tf  [(2010;59\(2\):38.)] TJ ET
BT 26.250 268.749 Td /F1 9.8 Tf  [(2.)] TJ ET
BT 38.132 268.749 Td /F1 9.8 Tf  [(Ercole A, Taylor BL, Rhodes A, Menon DK. Modelling the impact of an influenza A/H1N1 pandemic on critical care demand )] TJ ET
BT 26.250 256.845 Td /F1 9.8 Tf  [(from early pathogenicity data: The case for sentinel reporting. Anaesthesia. 2009;64\(9\):937.)] TJ ET
BT 26.250 237.440 Td /F1 9.8 Tf  [(3.)] TJ ET
BT 38.132 237.440 Td /F1 9.8 Tf  [(Ercole A, Menon DK, O'Donnell DR. Modelling the impact of pandemic influenza A\(H1N1\) on UK paediatric intensive care )] TJ ET
BT 26.250 225.535 Td /F1 9.8 Tf  [(demand. Arch Dis Child. 2009;94\(12\):962.)] TJ ET
BT 26.250 206.130 Td /F1 9.8 Tf  [(4.)] TJ ET
BT 38.132 206.130 Td /F1 9.8 Tf  [(Presanis A, Lipsitch M, De Angelis A, Hagy C, Reed S, Riley B, et al. The severity of pandemic H1N1 influenza in the United )] TJ ET
BT 26.250 194.226 Td /F1 9.8 Tf  [(States, April -- July 2009. PLoS Curr Influenza. 2009:RRN1042.)] TJ ET
BT 26.250 174.821 Td /F1 9.8 Tf  [(5.)] TJ ET
BT 38.132 174.821 Td /F1 9.8 Tf  [(Garske T, Legrand J, Donnelly C, Ward H, Cauchemez S, Fraser C, et al. Assessing the severity of the novel influenza )] TJ ET
BT 26.250 162.916 Td /F1 9.8 Tf  [(A/H1N1 pandemic. BMJ.British medical journal \(Clinical research ed.\). 2009;339:b2840.)] TJ ET
BT 26.250 143.511 Td /F1 9.8 Tf  [(6.)] TJ ET
BT 38.132 143.511 Td /F1 9.8 Tf  [(Reichert T, Simonsen L, Sharma A, Pardo S, Fedson D, Miller M. Influenza and the winter increase in mortality in the United )] TJ ET
BT 26.250 131.607 Td /F1 9.8 Tf  [(States, 1959-1999. Am J Epidemiol. 2004;160\(5\):492.)] TJ ET
BT 26.250 112.202 Td /F1 9.8 Tf  [(7.)] TJ ET
BT 38.132 112.202 Td /F1 9.8 Tf  [(Reed C, Angulo F, Swerdlow D, Lipsitch M, Meltzer M, Jernigan D, et al. Estimates of the prevalence of pandemic \(H1N1\) )] TJ ET
BT 26.250 100.297 Td /F1 9.8 Tf  [(2009, United States, April-July 2009. Emerging infectious diseases. 2009;15\(12\):2004.)] TJ ET
BT 26.250 80.892 Td /F1 9.8 Tf  [(8.)] TJ ET
BT 38.132 80.892 Td /F1 9.8 Tf  [(Yiannakoulias N, Russell ML, Svenson LW, Schopflocher DP. Doctors, patients and influenza-like illness: Clinicians or )] TJ ET
BT 26.250 68.988 Td /F1 9.8 Tf  [(patients at risk? Public Health. 2004;118\(7\):527-31.)] TJ ET
BT 26.250 49.583 Td /F1 9.8 Tf  [(9.)] TJ ET
BT 38.132 49.583 Td /F1 9.8 Tf  [(Fedson DS, Wajda A, Nicol JP, Hammond GW, Kaiser DL, Roos LL. Clinical effectiveness of influenza vaccination in )] TJ ET
Q
q
0.000 0.000 0.000 rg
BT 291.710 19.825 Td /F1 11.0 Tf  [(7)] TJ ET
BT 25.000 19.825 Td /F1 11.0 Tf  [(PLOS Currents Influenza)] TJ ET

Q
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0.271 0.267 0.267 rg
q
15.000 52.477 577.500 724.523 re W n
0.271 0.267 0.267 rg
BT 26.250 767.476 Td /F1 9.8 Tf  [(Manitoba. JAMA. 1993;270\(16\):1956-61.)] TJ ET
BT 26.250 748.071 Td /F1 9.8 Tf  [(10.)] TJ ET
BT 43.553 748.071 Td /F1 9.8 Tf  [(Lazarus R, Kleinman KP, Dashevsky I, DeMaria A, Platt R. Using automated medical records for rapid identification of )] TJ ET
BT 26.250 736.167 Td /F1 9.8 Tf  [(illness syndromes \(syndromic surveillance\): The example of lower respiratory infection. BMC Public Health. 2001;1:9-.)] TJ ET
BT 26.250 716.762 Td /F1 9.8 Tf  [(11.)] TJ ET
BT 43.553 716.762 Td /F1 9.8 Tf  [(Menec V, Black C, MacWilliam L, Aoki F. The impact of influenza-associated respiratory illnesses on hospitalizations, )] TJ ET
BT 26.250 704.857 Td /F1 9.8 Tf  [(physician visits, emergency room visits, and mortality. Canadian Journal of Public Health. 2003;94\(1\):59-63.)] TJ ET
BT 26.250 685.452 Td /F1 9.8 Tf  [(12.)] TJ ET
BT 43.553 685.452 Td /F1 9.8 Tf  [(Kwong J, Li P, Redelmeier D. Influenza morbidity and mortality in elderly patients receiving statins: A cohort study. PloS )] TJ ET
BT 26.250 673.548 Td /F1 9.8 Tf  [(one. 2009;4\(11\):e8087-.)] TJ ET
BT 26.250 654.143 Td /F1 9.8 Tf  [(13.)] TJ ET
BT 43.553 654.143 Td /F1 9.8 Tf  [(Bagdure D, Curtis DJ, Dobyns E, Glode MP, Dominguez SR. Hospitalized children with 2009 pandemic influenza A \(H1N1\): )] TJ ET
BT 26.250 642.238 Td /F1 9.8 Tf  [(Comparison to seasonal influenza and risk factors for admission to the ICU. PLoS One. 2010 Dec 15;5\(12\):e15173.)] TJ ET
BT 26.250 622.833 Td /F1 9.8 Tf  [(14.)] TJ ET
BT 43.553 622.833 Td /F1 9.8 Tf  [(Falagas ME, Cholevas NV, Kapaskelis AM, Vouloumanou EK, Michalopoulos A, Rafailidis PI. Epidemiological aspects of )] TJ ET
BT 26.250 610.929 Td /F1 9.8 Tf  [(2009 H1N1 influenza: The accumulating experience from the Northern Hemisphere. Eur J Clin Microbiol Infect Dis. 2010 )] TJ ET
BT 26.250 599.024 Td /F1 9.8 Tf  [(Nov;29\(11\):1327-47.)] TJ ET
BT 26.250 579.619 Td /F1 9.8 Tf  [(15.)] TJ ET
BT 43.553 579.619 Td /F1 9.8 Tf  [(Falagas ME, Koletsi PK, Baskouta E, Rafailidis PI, Dimopoulos G, Karageorgopoulos DE. Pandemic A\(H1N1\) 2009 )] TJ ET
BT 26.250 567.714 Td /F1 9.8 Tf  [(influenza: Review of the Southern Hemisphere experience. Epidemiol Infect. 2011 Jan;139\(1\):27-40.)] TJ ET
BT 26.250 548.310 Td /F1 9.8 Tf  [(16.)] TJ ET
BT 43.553 548.310 Td /F1 9.8 Tf  [(La Ruche G, Tarantola A, Barboza P, Vaillant L, Gueguen J, Gastellu-Etchegorry M. The 2009 pandemic H1N1 influenza )] TJ ET
BT 26.250 536.405 Td /F1 9.8 Tf  [(and indigenous populations of the Americas and the Pacific. Euro surveillance. 2009;14\(42\).)] TJ ET
BT 26.250 517.000 Td /F1 9.8 Tf  [(17.)] TJ ET
BT 43.553 517.000 Td /F1 9.8 Tf  [(Acute hospital case mix databases [homepage on the Internet]. Commonwealth of Massachusetts, Division of Healthcare )] TJ ET
BT 26.250 505.095 Td /F1 9.8 Tf  [(Finance and Policy. 2010. Available from: )] TJ ET
BT 26.250 493.191 Td /F1 9.8 Tf  [(http://www.mass.gov/?pageID=eohhs2terminal&L=5&L0=Home&L1=Researcher&L2=Physical+Health+and+Treatment&L3=Health+Care+Delivery+System&L4=DHCFP+Data+Resources&sid=Eeohhs2&b=terminalcontent&f=dhcfp_researcher_clinical_databases&csid=Eeohhs2.)] TJ ET
BT 26.250 473.786 Td /F1 9.8 Tf  [(18.)] TJ ET
BT 43.553 473.786 Td /F1 9.8 Tf  [(MA Department of Public Health. Weekly flu report, October 1, 2009. 2009:http://publichealth.blog.state.ma.us/h1n1-swine-)] TJ ET
BT 26.250 461.881 Td /F1 9.8 Tf  [(flu/page/10/.)] TJ ET
BT 26.250 442.476 Td /F1 9.8 Tf  [(19.)] TJ ET
BT 43.553 442.476 Td /F1 9.8 Tf  [(CDC estimates of 2009 H1N1 influenza cases, hospitalizations and deaths in the United States, April 2009 - January 16, )] TJ ET
BT 26.250 430.572 Td /F1 9.8 Tf  [(2010 [homepage on the Internet]. Available from: http://www.cdc.gov/h1n1flu/estimates_2009_h1n1.htm.)] TJ ET
BT 26.250 411.167 Td /F1 9.8 Tf  [(20.)] TJ ET
BT 43.553 411.167 Td /F1 9.8 Tf  [(Marsden-Haug N, Foster V, Gould P, Elbert E, Wang H, Pavlin J. Code-based syndromic surveillance for influenzalike )] TJ ET
BT 26.250 399.262 Td /F1 9.8 Tf  [(illness by international classification of diseases, ninth revision. Emerging infectious diseases. 2007;13\(2\):207.)] TJ ET
BT 26.250 379.857 Td /F1 9.8 Tf  [(21.)] TJ ET
BT 43.553 379.857 Td /F1 9.8 Tf  [(Sills MR, Hall M, Simon HK, Fieldston ES, Walter N, Levin JE, et al. Resource burden at children's hospitals experiencing )] TJ ET
BT 26.250 367.953 Td /F1 9.8 Tf  [(surge volumes during the spring 2009 H1N1 influenza pandemic. Acad Emerg Med. 2011 Feb;18\(2\):158-66.)] TJ ET
BT 26.250 348.548 Td /F1 9.8 Tf  [(22.)] TJ ET
BT 43.553 348.548 Td /F1 9.8 Tf  [(Wong CM, Yang L, Chan KP, Leung GM, Chan KH, Guan Y, et al. Influenza-associated hospitalization in a subtropical city. )] TJ ET
BT 26.250 336.643 Td /F1 9.8 Tf  [(PLoS Med. 2006 Apr;3\(4\):e121.)] TJ ET
BT 26.250 317.238 Td /F1 9.8 Tf  [(23.)] TJ ET
BT 43.553 317.238 Td /F1 9.8 Tf  [(Belongia EA, Irving SA, Waring SC, Coleman LA, Meece JK, Vandermause M, et al. Clinical characteristics and 30-day )] TJ ET
BT 26.250 305.334 Td /F1 9.8 Tf  [(outcomes for influenza A 2009 \(H1N1\), 2008-2009 \(H1N1\), and 2007-2008 \(H3N2\) infections. JAMA. 2010 Sep 8;304\(10\):1091-)] TJ ET
BT 26.250 293.429 Td /F1 9.8 Tf  [(8.)] TJ ET
BT 26.250 274.024 Td /F1 9.8 Tf  [(24.)] TJ ET
BT 43.553 274.024 Td /F1 9.8 Tf  [(Busi Rizzi E, Schinina V, Ferraro F, Rovighi L, Cristoforo M, Chiappetta D, et al. Radiological findings of pneumonia in )] TJ ET
BT 26.250 262.119 Td /F1 9.8 Tf  [(patients with swine-origin influenza A virus \(H1N1\). Radiol Med. 2010 Jun;115\(4\):507-15.)] TJ ET
BT 26.250 242.715 Td /F1 9.8 Tf  [(25.)] TJ ET
BT 43.553 242.715 Td /F1 9.8 Tf  [(Schirmer P, Lucero C, Oda G, Lopez J, Holodniy M. Effective detection of the 2009 H1N1 influenza pandemic in U.S. )] TJ ET
BT 26.250 230.810 Td /F1 9.8 Tf  [(Veterans Affairs Medical Centers using a national electronic biosurveillance system. PloS one. 2010;5\(3\):e9533-.)] TJ ET
BT 26.250 211.405 Td /F1 9.8 Tf  [(26.)] TJ ET
BT 43.553 211.405 Td /F1 9.8 Tf  [(Maritz J, Maree L, Preiser W. Pandemic influenza A \(H1N1\) 2009: The experience of the first six months. Clinical Chemistry )] TJ ET
BT 26.250 199.500 Td /F1 9.8 Tf  [(and Laboratory Medicine. 2010;48\(1\):11-21.)] TJ ET
BT 26.250 180.096 Td /F1 9.8 Tf  [(27.)] TJ ET
BT 43.553 180.096 Td /F1 9.8 Tf  [(Jain S, Kamimoto L, Bramley A, Schmitz A, Benoit S, Louie J, et al. Hospitalized patients with 2009 H1N1 influenza in the )] TJ ET
BT 26.250 168.191 Td /F1 9.8 Tf  [(United States, April-June 2009. New England Journal of Medicine, The. 2009;361\(20\):1935.)] TJ ET
BT 26.250 148.786 Td /F1 9.8 Tf  [(28.)] TJ ET
BT 43.553 148.786 Td /F1 9.8 Tf  [(2009 pandemic influenza A \(H1N1\) virus infections - Chicago, Illinois, April-July 2009. MMWR.Morbidity and Mortality )] TJ ET
BT 26.250 136.881 Td /F1 9.8 Tf  [(Weekly Report. 2009;58\(33\):913-8.)] TJ ET
BT 26.250 117.477 Td /F1 9.8 Tf  [(29.)] TJ ET
BT 43.553 117.477 Td /F1 9.8 Tf  [(Deaths related to 2009 pandemic influenza A \(H1N1\) among American Indian/Alaska Natives - 12 states, 2009. )] TJ ET
BT 26.250 105.572 Td /F1 9.8 Tf  [(MMWR.Morbidity and Mortality Weekly Report. 2009;58\(48\):1341.)] TJ ET
BT 26.250 86.167 Td /F1 9.8 Tf  [(30.)] TJ ET
BT 43.553 86.167 Td /F1 9.8 Tf  [(Centers for Disease Control and Prevention \(CDC\). Assessment of ESSENCE performance for influenza-like illness )] TJ ET
BT 26.250 74.262 Td /F1 9.8 Tf  [(surveillance after an influenza outbreak --- U.S. Air Force Academy, Colorado, 2009. MMWR Morb Mortal Wkly Rep. 2011 Apr )] TJ ET
BT 26.250 62.358 Td /F1 9.8 Tf  [(8;60\(13\):406-9.)] TJ ET
Q
q
15.000 52.477 577.500 724.523 re W n
0.271 0.267 0.267 rg
BT 26.250 767.476 Td /F1 9.8 Tf  [(Manitoba. JAMA. 1993;270\(16\):1956-61.)] TJ ET
BT 26.250 748.071 Td /F1 9.8 Tf  [(10.)] TJ ET
BT 43.553 748.071 Td /F1 9.8 Tf  [(Lazarus R, Kleinman KP, Dashevsky I, DeMaria A, Platt R. Using automated medical records for rapid identification of )] TJ ET
BT 26.250 736.167 Td /F1 9.8 Tf  [(illness syndromes \(syndromic surveillance\): The example of lower respiratory infection. BMC Public Health. 2001;1:9-.)] TJ ET
BT 26.250 716.762 Td /F1 9.8 Tf  [(11.)] TJ ET
BT 43.553 716.762 Td /F1 9.8 Tf  [(Menec V, Black C, MacWilliam L, Aoki F. The impact of influenza-associated respiratory illnesses on hospitalizations, )] TJ ET
BT 26.250 704.857 Td /F1 9.8 Tf  [(physician visits, emergency room visits, and mortality. Canadian Journal of Public Health. 2003;94\(1\):59-63.)] TJ ET
BT 26.250 685.452 Td /F1 9.8 Tf  [(12.)] TJ ET
BT 43.553 685.452 Td /F1 9.8 Tf  [(Kwong J, Li P, Redelmeier D. Influenza morbidity and mortality in elderly patients receiving statins: A cohort study. PloS )] TJ ET
BT 26.250 673.548 Td /F1 9.8 Tf  [(one. 2009;4\(11\):e8087-.)] TJ ET
BT 26.250 654.143 Td /F1 9.8 Tf  [(13.)] TJ ET
BT 43.553 654.143 Td /F1 9.8 Tf  [(Bagdure D, Curtis DJ, Dobyns E, Glode MP, Dominguez SR. Hospitalized children with 2009 pandemic influenza A \(H1N1\): )] TJ ET
BT 26.250 642.238 Td /F1 9.8 Tf  [(Comparison to seasonal influenza and risk factors for admission to the ICU. PLoS One. 2010 Dec 15;5\(12\):e15173.)] TJ ET
BT 26.250 622.833 Td /F1 9.8 Tf  [(14.)] TJ ET
BT 43.553 622.833 Td /F1 9.8 Tf  [(Falagas ME, Cholevas NV, Kapaskelis AM, Vouloumanou EK, Michalopoulos A, Rafailidis PI. Epidemiological aspects of )] TJ ET
BT 26.250 610.929 Td /F1 9.8 Tf  [(2009 H1N1 influenza: The accumulating experience from the Northern Hemisphere. Eur J Clin Microbiol Infect Dis. 2010 )] TJ ET
BT 26.250 599.024 Td /F1 9.8 Tf  [(Nov;29\(11\):1327-47.)] TJ ET
BT 26.250 579.619 Td /F1 9.8 Tf  [(15.)] TJ ET
BT 43.553 579.619 Td /F1 9.8 Tf  [(Falagas ME, Koletsi PK, Baskouta E, Rafailidis PI, Dimopoulos G, Karageorgopoulos DE. Pandemic A\(H1N1\) 2009 )] TJ ET
BT 26.250 567.714 Td /F1 9.8 Tf  [(influenza: Review of the Southern Hemisphere experience. Epidemiol Infect. 2011 Jan;139\(1\):27-40.)] TJ ET
BT 26.250 548.310 Td /F1 9.8 Tf  [(16.)] TJ ET
BT 43.553 548.310 Td /F1 9.8 Tf  [(La Ruche G, Tarantola A, Barboza P, Vaillant L, Gueguen J, Gastellu-Etchegorry M. The 2009 pandemic H1N1 influenza )] TJ ET
BT 26.250 536.405 Td /F1 9.8 Tf  [(and indigenous populations of the Americas and the Pacific. Euro surveillance. 2009;14\(42\).)] TJ ET
BT 26.250 517.000 Td /F1 9.8 Tf  [(17.)] TJ ET
BT 43.553 517.000 Td /F1 9.8 Tf  [(Acute hospital case mix databases [homepage on the Internet]. Commonwealth of Massachusetts, Division of Healthcare )] TJ ET
BT 26.250 505.095 Td /F1 9.8 Tf  [(Finance and Policy. 2010. Available from: )] TJ ET
BT 26.250 493.191 Td /F1 9.8 Tf  [(http://www.mass.gov/?pageID=eohhs2terminal&L=5&L0=Home&L1=Researcher&L2=Physical+Health+and+Treatment&L3=Health+Care+Delivery+System&L4=DHCFP+Data+Resources&sid=Eeohhs2&b=terminalcontent&f=dhcfp_researcher_clinical_databases&csid=Eeohhs2.)] TJ ET
BT 26.250 473.786 Td /F1 9.8 Tf  [(18.)] TJ ET
BT 43.553 473.786 Td /F1 9.8 Tf  [(MA Department of Public Health. Weekly flu report, October 1, 2009. 2009:http://publichealth.blog.state.ma.us/h1n1-swine-)] TJ ET
BT 26.250 461.881 Td /F1 9.8 Tf  [(flu/page/10/.)] TJ ET
BT 26.250 442.476 Td /F1 9.8 Tf  [(19.)] TJ ET
BT 43.553 442.476 Td /F1 9.8 Tf  [(CDC estimates of 2009 H1N1 influenza cases, hospitalizations and deaths in the United States, April 2009 - January 16, )] TJ ET
BT 26.250 430.572 Td /F1 9.8 Tf  [(2010 [homepage on the Internet]. Available from: http://www.cdc.gov/h1n1flu/estimates_2009_h1n1.htm.)] TJ ET
BT 26.250 411.167 Td /F1 9.8 Tf  [(20.)] TJ ET
BT 43.553 411.167 Td /F1 9.8 Tf  [(Marsden-Haug N, Foster V, Gould P, Elbert E, Wang H, Pavlin J. Code-based syndromic surveillance for influenzalike )] TJ ET
BT 26.250 399.262 Td /F1 9.8 Tf  [(illness by international classification of diseases, ninth revision. Emerging infectious diseases. 2007;13\(2\):207.)] TJ ET
BT 26.250 379.857 Td /F1 9.8 Tf  [(21.)] TJ ET
BT 43.553 379.857 Td /F1 9.8 Tf  [(Sills MR, Hall M, Simon HK, Fieldston ES, Walter N, Levin JE, et al. Resource burden at children's hospitals experiencing )] TJ ET
BT 26.250 367.953 Td /F1 9.8 Tf  [(surge volumes during the spring 2009 H1N1 influenza pandemic. Acad Emerg Med. 2011 Feb;18\(2\):158-66.)] TJ ET
BT 26.250 348.548 Td /F1 9.8 Tf  [(22.)] TJ ET
BT 43.553 348.548 Td /F1 9.8 Tf  [(Wong CM, Yang L, Chan KP, Leung GM, Chan KH, Guan Y, et al. Influenza-associated hospitalization in a subtropical city. )] TJ ET
BT 26.250 336.643 Td /F1 9.8 Tf  [(PLoS Med. 2006 Apr;3\(4\):e121.)] TJ ET
BT 26.250 317.238 Td /F1 9.8 Tf  [(23.)] TJ ET
BT 43.553 317.238 Td /F1 9.8 Tf  [(Belongia EA, Irving SA, Waring SC, Coleman LA, Meece JK, Vandermause M, et al. Clinical characteristics and 30-day )] TJ ET
BT 26.250 305.334 Td /F1 9.8 Tf  [(outcomes for influenza A 2009 \(H1N1\), 2008-2009 \(H1N1\), and 2007-2008 \(H3N2\) infections. JAMA. 2010 Sep 8;304\(10\):1091-)] TJ ET
BT 26.250 293.429 Td /F1 9.8 Tf  [(8.)] TJ ET
BT 26.250 274.024 Td /F1 9.8 Tf  [(24.)] TJ ET
BT 43.553 274.024 Td /F1 9.8 Tf  [(Busi Rizzi E, Schinina V, Ferraro F, Rovighi L, Cristoforo M, Chiappetta D, et al. Radiological findings of pneumonia in )] TJ ET
BT 26.250 262.119 Td /F1 9.8 Tf  [(patients with swine-origin influenza A virus \(H1N1\). Radiol Med. 2010 Jun;115\(4\):507-15.)] TJ ET
BT 26.250 242.715 Td /F1 9.8 Tf  [(25.)] TJ ET
BT 43.553 242.715 Td /F1 9.8 Tf  [(Schirmer P, Lucero C, Oda G, Lopez J, Holodniy M. Effective detection of the 2009 H1N1 influenza pandemic in U.S. )] TJ ET
BT 26.250 230.810 Td /F1 9.8 Tf  [(Veterans Affairs Medical Centers using a national electronic biosurveillance system. PloS one. 2010;5\(3\):e9533-.)] TJ ET
BT 26.250 211.405 Td /F1 9.8 Tf  [(26.)] TJ ET
BT 43.553 211.405 Td /F1 9.8 Tf  [(Maritz J, Maree L, Preiser W. Pandemic influenza A \(H1N1\) 2009: The experience of the first six months. Clinical Chemistry )] TJ ET
BT 26.250 199.500 Td /F1 9.8 Tf  [(and Laboratory Medicine. 2010;48\(1\):11-21.)] TJ ET
BT 26.250 180.096 Td /F1 9.8 Tf  [(27.)] TJ ET
BT 43.553 180.096 Td /F1 9.8 Tf  [(Jain S, Kamimoto L, Bramley A, Schmitz A, Benoit S, Louie J, et al. Hospitalized patients with 2009 H1N1 influenza in the )] TJ ET
BT 26.250 168.191 Td /F1 9.8 Tf  [(United States, April-June 2009. New England Journal of Medicine, The. 2009;361\(20\):1935.)] TJ ET
BT 26.250 148.786 Td /F1 9.8 Tf  [(28.)] TJ ET
BT 43.553 148.786 Td /F1 9.8 Tf  [(2009 pandemic influenza A \(H1N1\) virus infections - Chicago, Illinois, April-July 2009. MMWR.Morbidity and Mortality )] TJ ET
BT 26.250 136.881 Td /F1 9.8 Tf  [(Weekly Report. 2009;58\(33\):913-8.)] TJ ET
BT 26.250 117.477 Td /F1 9.8 Tf  [(29.)] TJ ET
BT 43.553 117.477 Td /F1 9.8 Tf  [(Deaths related to 2009 pandemic influenza A \(H1N1\) among American Indian/Alaska Natives - 12 states, 2009. )] TJ ET
BT 26.250 105.572 Td /F1 9.8 Tf  [(MMWR.Morbidity and Mortality Weekly Report. 2009;58\(48\):1341.)] TJ ET
BT 26.250 86.167 Td /F1 9.8 Tf  [(30.)] TJ ET
BT 43.553 86.167 Td /F1 9.8 Tf  [(Centers for Disease Control and Prevention \(CDC\). Assessment of ESSENCE performance for influenza-like illness )] TJ ET
BT 26.250 74.262 Td /F1 9.8 Tf  [(surveillance after an influenza outbreak --- U.S. Air Force Academy, Colorado, 2009. MMWR Morb Mortal Wkly Rep. 2011 Apr )] TJ ET
BT 26.250 62.358 Td /F1 9.8 Tf  [(8;60\(13\):406-9.)] TJ ET
Q
q
15.000 52.477 577.500 724.523 re W n
0.271 0.267 0.267 rg
BT 26.250 767.476 Td /F1 9.8 Tf  [(Manitoba. JAMA. 1993;270\(16\):1956-61.)] TJ ET
BT 26.250 748.071 Td /F1 9.8 Tf  [(10.)] TJ ET
BT 43.553 748.071 Td /F1 9.8 Tf  [(Lazarus R, Kleinman KP, Dashevsky I, DeMaria A, Platt R. Using automated medical records for rapid identification of )] TJ ET
BT 26.250 736.167 Td /F1 9.8 Tf  [(illness syndromes \(syndromic surveillance\): The example of lower respiratory infection. BMC Public Health. 2001;1:9-.)] TJ ET
BT 26.250 716.762 Td /F1 9.8 Tf  [(11.)] TJ ET
BT 43.553 716.762 Td /F1 9.8 Tf  [(Menec V, Black C, MacWilliam L, Aoki F. The impact of influenza-associated respiratory illnesses on hospitalizations, )] TJ ET
BT 26.250 704.857 Td /F1 9.8 Tf  [(physician visits, emergency room visits, and mortality. Canadian Journal of Public Health. 2003;94\(1\):59-63.)] TJ ET
BT 26.250 685.452 Td /F1 9.8 Tf  [(12.)] TJ ET
BT 43.553 685.452 Td /F1 9.8 Tf  [(Kwong J, Li P, Redelmeier D. Influenza morbidity and mortality in elderly patients receiving statins: A cohort study. PloS )] TJ ET
BT 26.250 673.548 Td /F1 9.8 Tf  [(one. 2009;4\(11\):e8087-.)] TJ ET
BT 26.250 654.143 Td /F1 9.8 Tf  [(13.)] TJ ET
BT 43.553 654.143 Td /F1 9.8 Tf  [(Bagdure D, Curtis DJ, Dobyns E, Glode MP, Dominguez SR. Hospitalized children with 2009 pandemic influenza A \(H1N1\): )] TJ ET
BT 26.250 642.238 Td /F1 9.8 Tf  [(Comparison to seasonal influenza and risk factors for admission to the ICU. PLoS One. 2010 Dec 15;5\(12\):e15173.)] TJ ET
BT 26.250 622.833 Td /F1 9.8 Tf  [(14.)] TJ ET
BT 43.553 622.833 Td /F1 9.8 Tf  [(Falagas ME, Cholevas NV, Kapaskelis AM, Vouloumanou EK, Michalopoulos A, Rafailidis PI. Epidemiological aspects of )] TJ ET
BT 26.250 610.929 Td /F1 9.8 Tf  [(2009 H1N1 influenza: The accumulating experience from the Northern Hemisphere. Eur J Clin Microbiol Infect Dis. 2010 )] TJ ET
BT 26.250 599.024 Td /F1 9.8 Tf  [(Nov;29\(11\):1327-47.)] TJ ET
BT 26.250 579.619 Td /F1 9.8 Tf  [(15.)] TJ ET
BT 43.553 579.619 Td /F1 9.8 Tf  [(Falagas ME, Koletsi PK, Baskouta E, Rafailidis PI, Dimopoulos G, Karageorgopoulos DE. Pandemic A\(H1N1\) 2009 )] TJ ET
BT 26.250 567.714 Td /F1 9.8 Tf  [(influenza: Review of the Southern Hemisphere experience. Epidemiol Infect. 2011 Jan;139\(1\):27-40.)] TJ ET
BT 26.250 548.310 Td /F1 9.8 Tf  [(16.)] TJ ET
BT 43.553 548.310 Td /F1 9.8 Tf  [(La Ruche G, Tarantola A, Barboza P, Vaillant L, Gueguen J, Gastellu-Etchegorry M. The 2009 pandemic H1N1 influenza )] TJ ET
BT 26.250 536.405 Td /F1 9.8 Tf  [(and indigenous populations of the Americas and the Pacific. Euro surveillance. 2009;14\(42\).)] TJ ET
BT 26.250 517.000 Td /F1 9.8 Tf  [(17.)] TJ ET
BT 43.553 517.000 Td /F1 9.8 Tf  [(Acute hospital case mix databases [homepage on the Internet]. Commonwealth of Massachusetts, Division of Healthcare )] TJ ET
BT 26.250 505.095 Td /F1 9.8 Tf  [(Finance and Policy. 2010. Available from: )] TJ ET
BT 26.250 493.191 Td /F1 9.8 Tf  [(http://www.mass.gov/?pageID=eohhs2terminal&L=5&L0=Home&L1=Researcher&L2=Physical+Health+and+Treatment&L3=Health+Care+Delivery+System&L4=DHCFP+Data+Resources&sid=Eeohhs2&b=terminalcontent&f=dhcfp_researcher_clinical_databases&csid=Eeohhs2.)] TJ ET
BT 26.250 473.786 Td /F1 9.8 Tf  [(18.)] TJ ET
BT 43.553 473.786 Td /F1 9.8 Tf  [(MA Department of Public Health. Weekly flu report, October 1, 2009. 2009:http://publichealth.blog.state.ma.us/h1n1-swine-)] TJ ET
BT 26.250 461.881 Td /F1 9.8 Tf  [(flu/page/10/.)] TJ ET
BT 26.250 442.476 Td /F1 9.8 Tf  [(19.)] TJ ET
BT 43.553 442.476 Td /F1 9.8 Tf  [(CDC estimates of 2009 H1N1 influenza cases, hospitalizations and deaths in the United States, April 2009 - January 16, )] TJ ET
BT 26.250 430.572 Td /F1 9.8 Tf  [(2010 [homepage on the Internet]. Available from: http://www.cdc.gov/h1n1flu/estimates_2009_h1n1.htm.)] TJ ET
BT 26.250 411.167 Td /F1 9.8 Tf  [(20.)] TJ ET
BT 43.553 411.167 Td /F1 9.8 Tf  [(Marsden-Haug N, Foster V, Gould P, Elbert E, Wang H, Pavlin J. Code-based syndromic surveillance for influenzalike )] TJ ET
BT 26.250 399.262 Td /F1 9.8 Tf  [(illness by international classification of diseases, ninth revision. Emerging infectious diseases. 2007;13\(2\):207.)] TJ ET
BT 26.250 379.857 Td /F1 9.8 Tf  [(21.)] TJ ET
BT 43.553 379.857 Td /F1 9.8 Tf  [(Sills MR, Hall M, Simon HK, Fieldston ES, Walter N, Levin JE, et al. Resource burden at children's hospitals experiencing )] TJ ET
BT 26.250 367.953 Td /F1 9.8 Tf  [(surge volumes during the spring 2009 H1N1 influenza pandemic. Acad Emerg Med. 2011 Feb;18\(2\):158-66.)] TJ ET
BT 26.250 348.548 Td /F1 9.8 Tf  [(22.)] TJ ET
BT 43.553 348.548 Td /F1 9.8 Tf  [(Wong CM, Yang L, Chan KP, Leung GM, Chan KH, Guan Y, et al. Influenza-associated hospitalization in a subtropical city. )] TJ ET
BT 26.250 336.643 Td /F1 9.8 Tf  [(PLoS Med. 2006 Apr;3\(4\):e121.)] TJ ET
BT 26.250 317.238 Td /F1 9.8 Tf  [(23.)] TJ ET
BT 43.553 317.238 Td /F1 9.8 Tf  [(Belongia EA, Irving SA, Waring SC, Coleman LA, Meece JK, Vandermause M, et al. Clinical characteristics and 30-day )] TJ ET
BT 26.250 305.334 Td /F1 9.8 Tf  [(outcomes for influenza A 2009 \(H1N1\), 2008-2009 \(H1N1\), and 2007-2008 \(H3N2\) infections. JAMA. 2010 Sep 8;304\(10\):1091-)] TJ ET
BT 26.250 293.429 Td /F1 9.8 Tf  [(8.)] TJ ET
BT 26.250 274.024 Td /F1 9.8 Tf  [(24.)] TJ ET
BT 43.553 274.024 Td /F1 9.8 Tf  [(Busi Rizzi E, Schinina V, Ferraro F, Rovighi L, Cristoforo M, Chiappetta D, et al. Radiological findings of pneumonia in )] TJ ET
BT 26.250 262.119 Td /F1 9.8 Tf  [(patients with swine-origin influenza A virus \(H1N1\). Radiol Med. 2010 Jun;115\(4\):507-15.)] TJ ET
BT 26.250 242.715 Td /F1 9.8 Tf  [(25.)] TJ ET
BT 43.553 242.715 Td /F1 9.8 Tf  [(Schirmer P, Lucero C, Oda G, Lopez J, Holodniy M. Effective detection of the 2009 H1N1 influenza pandemic in U.S. )] TJ ET
BT 26.250 230.810 Td /F1 9.8 Tf  [(Veterans Affairs Medical Centers using a national electronic biosurveillance system. PloS one. 2010;5\(3\):e9533-.)] TJ ET
BT 26.250 211.405 Td /F1 9.8 Tf  [(26.)] TJ ET
BT 43.553 211.405 Td /F1 9.8 Tf  [(Maritz J, Maree L, Preiser W. Pandemic influenza A \(H1N1\) 2009: The experience of the first six months. Clinical Chemistry )] TJ ET
BT 26.250 199.500 Td /F1 9.8 Tf  [(and Laboratory Medicine. 2010;48\(1\):11-21.)] TJ ET
BT 26.250 180.096 Td /F1 9.8 Tf  [(27.)] TJ ET
BT 43.553 180.096 Td /F1 9.8 Tf  [(Jain S, Kamimoto L, Bramley A, Schmitz A, Benoit S, Louie J, et al. Hospitalized patients with 2009 H1N1 influenza in the )] TJ ET
BT 26.250 168.191 Td /F1 9.8 Tf  [(United States, April-June 2009. New England Journal of Medicine, The. 2009;361\(20\):1935.)] TJ ET
BT 26.250 148.786 Td /F1 9.8 Tf  [(28.)] TJ ET
BT 43.553 148.786 Td /F1 9.8 Tf  [(2009 pandemic influenza A \(H1N1\) virus infections - Chicago, Illinois, April-July 2009. MMWR.Morbidity and Mortality )] TJ ET
BT 26.250 136.881 Td /F1 9.8 Tf  [(Weekly Report. 2009;58\(33\):913-8.)] TJ ET
BT 26.250 117.477 Td /F1 9.8 Tf  [(29.)] TJ ET
BT 43.553 117.477 Td /F1 9.8 Tf  [(Deaths related to 2009 pandemic influenza A \(H1N1\) among American Indian/Alaska Natives - 12 states, 2009. )] TJ ET
BT 26.250 105.572 Td /F1 9.8 Tf  [(MMWR.Morbidity and Mortality Weekly Report. 2009;58\(48\):1341.)] TJ ET
BT 26.250 86.167 Td /F1 9.8 Tf  [(30.)] TJ ET
BT 43.553 86.167 Td /F1 9.8 Tf  [(Centers for Disease Control and Prevention \(CDC\). Assessment of ESSENCE performance for influenza-like illness )] TJ ET
BT 26.250 74.262 Td /F1 9.8 Tf  [(surveillance after an influenza outbreak --- U.S. Air Force Academy, Colorado, 2009. MMWR Morb Mortal Wkly Rep. 2011 Apr )] TJ ET
BT 26.250 62.358 Td /F1 9.8 Tf  [(8;60\(13\):406-9.)] TJ ET
Q
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BT 291.710 19.825 Td /F1 11.0 Tf  [(8)] TJ ET
BT 25.000 19.825 Td /F1 11.0 Tf  [(PLOS Currents Influenza)] TJ ET

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BT 26.250 759.976 Td /F1 9.8 Tf  [(31.)] TJ ET
BT 43.553 759.976 Td /F1 9.8 Tf  [(Centers for Disease Control and Prevention \(CDC\). Self-reported influenza-like illness during the 2009 H1N1 influenza )] TJ ET
BT 26.250 748.071 Td /F1 9.8 Tf  [(pandemic--United States, September 2009 - March 2010. MMWR Morb Mortal Wkly Rep. 2011 Jan 21;60\(2\):37-41.)] TJ ET
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BT 26.250 759.976 Td /F1 9.8 Tf  [(31.)] TJ ET
BT 43.553 759.976 Td /F1 9.8 Tf  [(Centers for Disease Control and Prevention \(CDC\). Self-reported influenza-like illness during the 2009 H1N1 influenza )] TJ ET
BT 26.250 748.071 Td /F1 9.8 Tf  [(pandemic--United States, September 2009 - March 2010. MMWR Morb Mortal Wkly Rep. 2011 Jan 21;60\(2\):37-41.)] TJ ET
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BT 26.250 759.976 Td /F1 9.8 Tf  [(31.)] TJ ET
BT 43.553 759.976 Td /F1 9.8 Tf  [(Centers for Disease Control and Prevention \(CDC\). Self-reported influenza-like illness during the 2009 H1N1 influenza )] TJ ET
BT 26.250 748.071 Td /F1 9.8 Tf  [(pandemic--United States, September 2009 - March 2010. MMWR Morb Mortal Wkly Rep. 2011 Jan 21;60\(2\):37-41.)] TJ ET
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BT 291.710 19.825 Td /F1 11.0 Tf  [(9)] TJ ET
BT 25.000 19.825 Td /F1 11.0 Tf  [(PLOS Currents Influenza)] TJ ET

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