Influenza-like-illness, deaths and health care costs

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1 Influenza-like-illness, deaths and health care costs Dr Rodney P Jones (ACMA, CGMA) Healthcare Analysis & Forecasting hcaf_rod@yahoo.co.uk Further articles in this series are available at The published version is available at It is somewhat unfortunate that the most volatile time for emergency admissions (and hence costs) for the UK NHS, namely the winter, lies in the last quarter of the financial year, i.e. financial forecasts can look absolutely fine for most of the year but can go horribly wrong at the very point in the year when little can be done to make compensating savings. Thanks to the Royal College of General Practitioners Birmingham Research and Surveillance Centre (now part of Public Health England), and a network of collecting GP practices, rates of Influenza-likeillness (ILI) in England have been available for many years. ILI is a catch all for genuine influenza and a host of other conditions which can present with typical influenza-like symptoms. Figure 1: Weekly rates of Influenza-like-illness in England since mid Rate of ILI per 100,000 population Aug-99 Feb-00 Aug-00 Feb-01 Aug-01 Feb-02 Aug-02 Feb-03 Aug-03 Feb-04 Aug-04 Feb-05 Aug-05 Feb-06 Aug-06 Feb-07 Aug-07 Feb-08 Aug-08 Feb-09 Aug-09 Feb-10 Aug-10 Feb-11 Aug-11 Feb-12 Aug-12 Feb-13 Aug-13 Feb-14

2 Figure 1 presents a summary of the weekly rates since mid Prior to 1999 large influenza events were fairly common, however in early 2000 both influenza and ILI dropped to historically very low values, and has remained low since then except for two occasions. The first is swine flu (influenza A(H1N1)2009), which arrived in the UK in late April 2009, and peaked in late July in England and Northern Ireland, there was a second wave peaking in October 2009 mainly in Northern Ireland. By the first week of January 2010 rates across England for ILI varied from 7 per 100,000 in the North East up to 17 per 100,000 in West Midlands, demonstrating regional variation (Health Protection Agency 2010). The second large peak shown in Figure 1, in December 2010, was a resurgence of the swine flu strain; plus Influenza B and another Influenza A strain (Ellis et al 2011). The Swine flu strain mainly affected children, and hence had little impact on deaths. This variable impact on deaths is illustrated in Fig. 2 where the cluster of very low deaths near to 100 ILI per 100,000 is for the Swine Flu epidemic. However, the more usual situation is that the ILI affects the elderly resulting in the large increase in deaths at higher ILI rates. Also note that ILI rates below 10 per 100,000 (which mainly occur during the summer) lead to a roughly linear increase in deaths, while above this the impact on deaths begins to taper off. These effects are obscured by the log scale in Figure 2 which is designed to make the low ILI rates more visible. Figure 2: Weekly deaths and ILI rates (2009 to 2014) in England 17,000 16,000 Weekly deaths (corrected) 15,000 14,000 13,000 12,000 11,000 10,000 9,000 8, Weekly influenza-like-illness (ILI) Footnote: Deaths have been corrected for the underlying trend between 1999 and 2014 using a non-linear polynomial. This correction is required to match with ILI rates which are normalised to a rate per 100,000 persons. The increase in deaths is of profound importance since it is usually associated with a large surge in respiratory admissions, i.e. illness precedes decease. In general, in-hospital deaths for respiratory

3 admissions (ICD-10 chapter J) show an exponential relationship with age giving around 1 in 10 deaths per admission at age 72, rising to 5 in 10 at age 100 (data is from a hospital with a low HSMR). In this respect, the emergence of a new influenza strain during 2014 meant that the influenza vaccine administered to the general public during that year was largely ineffective, and a large surge in influenza-related admissions then ensued in weeks 48 to 8 in 2014/15 (Public Health England 2015). On this occasion, the peak was also accompanied by a wide variety of other respiratory admissions, and at one hospital respiratory admissions occupied 20% of all available beds during January of This may have been due to the fact that inoculation with the wrong antigen mix can actually make matters worse (for some individuals) rather than better, due to the prior priming of the immune system to the wrong antigens. The final issue relates to the previously reported periods of unexplained higher deaths seen to occur in all Western countries, and which are apparently directly linked to unexplained increases in medical admissions (Jones 2015a-f, 2016). The key question is whether these periods of higher death and medical admission are related to ILI or due to another cause? To resolve this issue Fig. 3 gives running 12 month averages for deaths and ILI. Figure 3: Running 52 week average of deaths and ILI 9,850 9,750 9,650 Deaths ILI Average deaths 9,550 9,450 9, ,250 9, ,050 5 Jul-00 Nov-00 Mar-01 Jul-01 Nov-01 Mar-02 Jul-02 Nov-02 Mar-03 Jul-03 Nov-03 Mar-04 Jul-04 Nov-04 Mar-05 Jul-05 Nov-05 Mar-06 Jul-06 Nov-06 Mar-07 Jul-07 Nov-07 Mar-08 Jul-08 Nov-08 Mar-09 Jul-09 Nov-09 Mar-10 Jul-10 Nov-10 Mar-11 Jul-11 Nov-11 Mar-12 Jul-12 Nov-12 Mar-13 Jul-13 Nov-13 Mar-14 Average ILI 52 week period ending at: In a running total there are two fundamental shapes for the resulting trend. Plateau or table top shaped features arise from typical spike events such as winter influenza and the ILI line is composed of a series of such table top events. The onset of the winter outbreak lies at the foot of the leading edge of the table top feature. In complete opposition to this behaviour, unexplained step-like increases in death which endure for around 52 weeks, result in the inverted V shaped

4 features which uniquely characterise the trend in deaths, i.e. ILI events are not the cause of the events regulating unexplained higher deaths. However the two are not totally inseparable, and hence the rapid decline in ILI in early 2000 leads to a corresponding decline in deaths, and an ILI initiated event explains a surge in deaths in January of In addition the ILI event in late 2009 generates a shoulder on the downward side of the inverted V shaped feature which has its peak in Feb-09, i.e. initiation in Mar-10. Recall that in the downward side of the inverted V the agent leading to the unexplained increase in deaths is absent and the apparent slope downward arises from the running sum via dilution of the step-increase after its cessation. Hence there is no possibility for interaction between the unknown agent and ILI in this downward part of the running 12 month total. The event initiating in late 2009 is a good example of interaction between the unknown agent and ILI. On this instance the ILI outbreak of December 2010 simply adds a table top feature on top of the inverted V arising from the unknown agent. The inverted V event with a peak in Apr-13 (initiation May-12) has only a very small ILI event which occurs almost at cessation of the effect of the unknown agent, i.e. the magnitude of this event is largely unchanged by ILI. The explanation offered by Public Health England (PHE) that the higher deaths in the winter of 2012/13 were due to influenza and other respiratory infections therefore lacks scientific merit (Jones 2013). Interestingly the Office for National Statistics (ONS) attempted to make the same explanation for 43,900 higher winter deaths in 2014/15 (ONS 2015). Once again the deaths had already increased in the summer of 2014 due to an outbreak of the agent (Jones 2015d), and any additional deaths arising from the incorrect influenza vaccine were of second order magnitude. An increase in respiratory admissions and deaths are seemingly a characteristic feature of this unknown agent (Jones 2014b). The ONS report also notes an increase in deaths due to dementia in the winter of 2014/15 which is also known to be a characteristic of these events (Jones & Goldeck 2014, Jones 2015e). In summary, both influenza and ILI have been at historically low levels since the start of Influenza and ILI are unable to explain the large increases in death which have occurred as a regular series since that point. The large increases in hospital admissions, which are proving financially crippling to the NHS, can therefore be correctly attributed to the effect of the unknown agent. While this analysis has concentrated on analysis of deaths in England & Wales it is important to note that the unknown agent demonstrates very small area spatial spread leading to large and localised increases in medical admissions and deaths (Jones & Beauchant 2015, Jones 2014a, 2015a-f). It is entirely unhelpful for UK government agencies to continue to seek to lay the blame for these events on influenza, thereby deflecting research and public attention away from a serious public health threat. References Ellis J, Galiano M, Pebody R, et al (2011) Virological analysis of fatal influenza cases in the United Kingdom during the early wave of influenza in winter 2010/11. Euro Surveil 16(1): Available online: eurosurveillance.org/viewarticle.aspx?articleid=19760

5 Health Protection Agency (2010) Weekly national influenza report, 08 January 2010 (week 01) bfile/hpaweb_c/ Jones R (2013) Analysing excess winter mortality: 2012/13. BJHCM 19(12): Jones R (2014a) Infectious-like Spread of an Agent Leading to Increased Medical Admissions and Deaths in Wigan (England), during 2011 and Brit J Med Medical Res4(28): Jones R (2014b) A Study of an Unexplained and Large Increase in Respiratory Deaths in England and Wales: Is the Pattern of Diagnoses Consistent with the Potential Involvement of Cytomegalovirus? Brit J Med Medical Res4(33): Jones R (2015a) A previously uncharacterized infectious-like event leading to spatial spread of deaths across England and Wales: Characteristics of the most recent event and a time series for past events. Brit J Med Medical Res 5(11): Jones R (2015b) Unexpected and Disruptive Changes in Admissions Associated with an Infectious-like Event Experienced at a Hospital in Berkshire, England around May of Brit J Med Medical Res 6(1): Jones R (2015c) Recurring Outbreaks of an Infection Apparently Targeting Immune Function, and Consequent Unprecedented Growth in Medical Admission and Costs in the United Kingdom: A Review. Brit J Med Medical Res 6(8): Jones R (2015d) Are emergency admissions contagious? BJHCM 21(5): Jones R (2015e) Unexpected Increase in Deaths from Alzheimer s, Dementia and Other Neurological Disorders in England and Wales during 2012 and J Neuroinfectious Dis 6:172. Jones R (2015f) Small area spread and step-like changes in emergency medical admissions in response to an apparently new type of infectious event. Fractal Geometry and Nonlinear Analysis in Medicine and Biology 1(2): Jones R (2016) Is cytomegalovirus involved in recurring periods of higher than expected death and medical admissions, occurring as clustered outbreaks in the northern and southern hemispheres? Brit J Med Medical Res 11 (2): Jones R, Goldeck D (2014) Unexpected and unexplained increase in death due to neurological disorders in 2012 in England and Wales: Is cytomegalovirus implicated? Medical Hypotheses 83(1): Jones R, Beauchant S (2015) Spread of a new type of infectious condition across Berkshire in England between June 2011 and March 2013: Effect on medical emergency admissions. Brit J Med Medical Res 6(1): Office for National Statistics (2015) Excess Winter Mortality in England and Wales 2014/15. Public Health England (2015) PHE Weekly National Influenza Report Summary of UK surveillance of influenza and other seasonal respiratory illnesses 22 January 2015 Week 4 report (up to week 3 data) eport_current_week_4x.pdf

Has the UK had a double epidemic?

Has the UK had a double epidemic? Dr Rodney P Jones Healthcare Analysis & Forecasting www.hcaf.biz hcaf_rod@yahoo.co.uk Introduction Outbreaks of a new type of epidemic, possibly due to immune manipulation,