24 The current study uses a prospective cohort of initially uninfected households with active case finding. This is considered to be the gold standard design for influenza household studies and should provide a relatively representative and unbiased description of transmission and shedding dynamics.25 The participants in this

study had been enrolled in the cohort since December 2007 and most had blood samples collected and tested by serology just prior to the pandemic such that prior immune status and susceptibility could be confirmed. The research was approved by the institutional review board of the National Institute of Hygiene and Epidemiology, Viet Nam, the Oxford Tropical Research Ethics Committee, University of Oxford, UK. All participants provided written informed consent. The investigations described here were conducted as part of an ongoing household-based influenza cohort study that has been Neratinib ic50 described in detail elsewhere.26 In brief, households from a commune in Ha Nam Province, in northern Viet Nam were selected at random. 940 members click here of 270 randomly selected households were enrolled. Index cases were detected via active surveillance for influenza-like illness (ILI), defined as a fever >38 °C

and cough, or sore throat. Health workers examined all persons in confirmed A(H1N1)pdm09 case households, including those without symptoms, each day for up to 15 days during the first pandemic wave (September–December 2009). Examinations included collection of nose- and throat-swabs for quantitative RT-PCR and full-genome sequencing; mouth temperature measurement, scored on a 5-tier scale (36–36.9 = 1, 37–37.9 = 2, 38–38.9 = 3, 39–39.9 = 4, ≥40 = 5); and evaluation of symptoms (sore

throat, nasal congestion, Exoribonuclease runny nose, sneezing, dry cough, wet cough, headache, diarrhoea, myalgia, fever, and wheeze), which were scored on a 3-tier scale (none = 0, mild = 1, or moderate/severe = 2). A cough was defined as wet or productive if sputum or material from the bronchi was expectorated. Participants were also asked if they took the day off work because of illness or to care for another household member that was ill, and if they took oseltamivir. Blood samples were collected for serology in June 2009 and April 2010. Separate flocked swabs (Copan, Brescia, Italy) were used to firmly swab the entire posterior pharynx and tonsillar area and the nasal cavity at the level of the turbinates. Nasal and throat swabs were combined in 1 tube containing 3 ml of viral transport medium, and transferred to the laboratory within 24 h where they were vortexed before aliquoting and storing the media at −80 °C. RNA was extracted from swab media and assessed by real-time reverse-transcriptase polymerase chain reaction (RT-PCR), according to WHO/USCDC protocols (CDC reference no. I-007-05, http://www.who.int/csr/resources/publications/swineflu/CDCRealtimeRTPCR_SwineH1Assay-2009_20090430.pdf).