Implementing the World Health Organization Pandemic Influenza Severity Assessment framework-Singapore's experience

We report our experience in evaluating the severity of local influenza epidemics using the World Health Organization Pandemic Influenza Severity Assessment framework.

We assessed the severity of influenza by monitoring indicators of influenza transmissibility, seriousness of disease and impact on healthcare resource utilisation. Indicators were described by various parameters collected weekly from eight government hospitals, 20 government and 30 private primary care clinics, and the national public health laboratory. Transmissibility and seriousness of disease indicators were each represented by multiple parameters, and alert thresholds were set at the 70th and 90th percentile of a parameter's past 2-year surveillance data. We derived a collective measure for each indicator using the average percentile rank of the related parameters. Alert thresholds for the single impact parameter were set at predefined values and evaluated for its sensitivity, specificity and positive predictive value.

For the transmissibility and seriousness of disease parameters, calculation of the percentile rank was simple and independent of a parameter's underlying distribution. For the impact parameter, predefined alert thresholds had high sensitivity and specificity (>80%) but low positive predictive value (15%-30%). Assessment scales were used to qualitatively classify the activity of an indicator as low, moderate or high together with a confidence level.

We applied different methods for threshold setting depending on the attributes of each parameter and indicator. For indicators represented by multiple parameters, an aggregated assessment of the indicator's level of activity and confidence level of the assessment was needed for effective reporting.