An Under-Recognized Influenza Epidemic Identified by Rapid Influenza Testing, Southern Sri Lanka, 2013

L. Gayani Tillekeratne Duke Global Health Institute, Durham, North Carolina; Departments of Medicine, Microbiology, and Pediatrics, Faculty of Medicine, Ruhuna University, Galle, Sri Lanka; Teaching Hospital Karapitiya, Galle, Sri Lanka; Genetech Research Institute, Colombo, Sri Lanka; Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Medicine, Duke University, Durham, North Carolina

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Champica K. Bodinayake Duke Global Health Institute, Durham, North Carolina; Departments of Medicine, Microbiology, and Pediatrics, Faculty of Medicine, Ruhuna University, Galle, Sri Lanka; Teaching Hospital Karapitiya, Galle, Sri Lanka; Genetech Research Institute, Colombo, Sri Lanka; Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Medicine, Duke University, Durham, North Carolina

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Ajith Nagahawatte Duke Global Health Institute, Durham, North Carolina; Departments of Medicine, Microbiology, and Pediatrics, Faculty of Medicine, Ruhuna University, Galle, Sri Lanka; Teaching Hospital Karapitiya, Galle, Sri Lanka; Genetech Research Institute, Colombo, Sri Lanka; Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Medicine, Duke University, Durham, North Carolina

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Dhammika Vidanagama Duke Global Health Institute, Durham, North Carolina; Departments of Medicine, Microbiology, and Pediatrics, Faculty of Medicine, Ruhuna University, Galle, Sri Lanka; Teaching Hospital Karapitiya, Galle, Sri Lanka; Genetech Research Institute, Colombo, Sri Lanka; Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Medicine, Duke University, Durham, North Carolina

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Vasantha Devasiri Duke Global Health Institute, Durham, North Carolina; Departments of Medicine, Microbiology, and Pediatrics, Faculty of Medicine, Ruhuna University, Galle, Sri Lanka; Teaching Hospital Karapitiya, Galle, Sri Lanka; Genetech Research Institute, Colombo, Sri Lanka; Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Medicine, Duke University, Durham, North Carolina

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Wasantha Kodikara Arachchi Duke Global Health Institute, Durham, North Carolina; Departments of Medicine, Microbiology, and Pediatrics, Faculty of Medicine, Ruhuna University, Galle, Sri Lanka; Teaching Hospital Karapitiya, Galle, Sri Lanka; Genetech Research Institute, Colombo, Sri Lanka; Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Medicine, Duke University, Durham, North Carolina

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Ruvini Kurukulasooriya Duke Global Health Institute, Durham, North Carolina; Departments of Medicine, Microbiology, and Pediatrics, Faculty of Medicine, Ruhuna University, Galle, Sri Lanka; Teaching Hospital Karapitiya, Galle, Sri Lanka; Genetech Research Institute, Colombo, Sri Lanka; Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Medicine, Duke University, Durham, North Carolina

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Aruna Dharshan De Silva Duke Global Health Institute, Durham, North Carolina; Departments of Medicine, Microbiology, and Pediatrics, Faculty of Medicine, Ruhuna University, Galle, Sri Lanka; Teaching Hospital Karapitiya, Galle, Sri Lanka; Genetech Research Institute, Colombo, Sri Lanka; Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Medicine, Duke University, Durham, North Carolina

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Truls Østybe Duke Global Health Institute, Durham, North Carolina; Departments of Medicine, Microbiology, and Pediatrics, Faculty of Medicine, Ruhuna University, Galle, Sri Lanka; Teaching Hospital Karapitiya, Galle, Sri Lanka; Genetech Research Institute, Colombo, Sri Lanka; Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Medicine, Duke University, Durham, North Carolina

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Megan E. Reller Duke Global Health Institute, Durham, North Carolina; Departments of Medicine, Microbiology, and Pediatrics, Faculty of Medicine, Ruhuna University, Galle, Sri Lanka; Teaching Hospital Karapitiya, Galle, Sri Lanka; Genetech Research Institute, Colombo, Sri Lanka; Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Medicine, Duke University, Durham, North Carolina

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Christopher W. Woods Duke Global Health Institute, Durham, North Carolina; Departments of Medicine, Microbiology, and Pediatrics, Faculty of Medicine, Ruhuna University, Galle, Sri Lanka; Teaching Hospital Karapitiya, Galle, Sri Lanka; Genetech Research Institute, Colombo, Sri Lanka; Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Medicine, Duke University, Durham, North Carolina

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Influenza accounts for a large burden of acute respiratory tract infections in high-income countries; data from lower-income settings are limited due to lack of confirmatory testing. Consecutive outpatients presenting to the largest tertiary care hospital in southern Sri Lanka were surveyed for influenza-like illness (ILI), defined as acute onset of fever ≥ 38.0°C and cough. Patients were administered a questionnaire and nasal/nasopharyngeal sampling for rapid influenza A/B testing. We enrolled 311 patients with ILI from March to November 2013: 170 (54.7%) children and 172 (55.3%) males. Approximately half (147, 47.3%) tested positive for influenza, but 253 (81.4%) were prescribed antibiotics. On bivariable analysis, symptoms associated with influenza included pain with breathing (P < 0.001), headache (P = 0.005), fatigue (P = 0.003), arthralgias (P = 0.003), and myalgias (P = 0.006) in children and pain with breathing (P = 0.01), vomiting (P = 0.03), and arthralgias (P = 0.03) in adults. Our final clinical predictive models had low sensitivity and fair specificity—50.0% (95% CI: 38.6–61.4%) and 83.2% (95% CI: 73.4–90.0%), respectively, in children and 52.2% (95% CI: 39.9–64.2%) and 81.4% (95% CI: 70.0–89.4%), respectively, in adults. Our study confirms the ability of rapid influenza testing to identify an influenza epidemic in a setting in which testing is not routinely available.

Author Notes

* Address correspondence to L. Gayani Tillekeratne, Duke Global Health Institute, 310 Trent Drive, Durham, NC 27710. E-mail: gayani.tillekeratne@dm.duke.edu
† These authors are co-senior authors.

Financial support: This work was supported by the NIH Research Training Grant #R25 TW009337 funded by the Fogarty International Center and the National Institute of Mental Health.

Authors' addresses: L. Gayani Tillekeratne and Truls Østybe, Global Health Institute, Duke University, Durham, NC, E-mails: gayani.tillekeratne@dm.duke.edu and truls.ostbye@dm.duke.edu. Champica K. Bodinayake, Ajith Nagahawatte, and Vasantha Devasiri, Departments of Medicine, Microbiology and Pediatrics, Ruhuna University, Galle, Sri Lanka, E-mails: bodinayake@yahoo.co.uk, ajithnagahawatte@yahoo.co.uk, and vdevasiri@gmail.com. Dhammika Vidanagama and Wasantha Kodikara Arachchi, Teaching Hospital Karapitiya, Galle, Sri Lanka, E-mails: dhammikasv@yahoo.com and kody@sltnet.lk. Ruvini Kurukulasooriya, Duke-Ruhuna Collaborative Research Center, Ruhuna University, Galle, Sri Lanka, E-mail: ruhunasearch@gmail.com. Aruna Dharshan De Silva, Genetech, Research Institute, Colombo, Sri Lanka, E-mail: dslv90@yahoo.com. Megan E. Reller, Department of Pathology, Johns Hopkins University, Baltimore, MD, E-mail: mreller1@jhmi.edu. Christopher W. Woods, Department of Medicine, Duke University, Durham, NC, and Global Health Institute, Duke University, Durham, NC, E-mail: chris.woods@duke.edu.

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