Age as a Leading Indicator: A Multi-Outcome Analysis of Influenza Lead-Lag Relationships

Abstract

Prior work has shown that school-age childrens influenza activity precedes that of adults by one to two weeks. Whether this is robust across outcomes or constant across a seasons course is unexamined.

Using electronic health record data from two health systems in South Carolina (2016-2026) on individuals with an influenza diagnosis or positive test, we tested age-group lead-lag relationships across six measures using differenced cross-correlation and Granger causality, with significance confirmed via heteroskedasticity-robust block permutation. We tested whether relationships differed between a seasons growth and decline phases.

Children 5-17 years led every other age group by approximately one week in four out of six outcomes and were the only group showing any nonzero-lag relationship across 60 pairwise combinations. A screen of 150 source-target combinations identified 26 permutation-confirmed instances of childrens lower-acuity activity preceding elevated emergency department or inpatient burden in other age groups. The same-outcome lead was concentrated during a seasons growth phase, while the cross-severity lead was robust throughout both a seasons growth and decline.

School-age childrens influenza activity is a robust, multi-outcome leading indicator with distinct transmission-timing and severity-progression signals in different phases of seasonal epidemics, supporting incorporation of age-stratified, phase-aware indicators into influenza forecasting.

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BibTeX RIS

BibTeX

@misc{serman2026leading,
  title = {{Age as a Leading Indicator: A Multi-Outcome Analysis of Influenza Lead-Lag Relationships}},
  author = {E. A. Serman and A. Bleichrodt and I. Jayawardena and C. Liskey and L. Rennert},
  howpublished = {medRxiv},
  year = {2026},
  month = sep,
  doi = {10.64898/2026.09.29.26364022},
  url = {https://www.medrxiv.org/content/10.64898/2026.09.29.26364022v1},
  note = {CC BY},
}

RIS

TY  - UNPB
TI  - Age as a Leading Indicator: A Multi-Outcome Analysis of Influenza Lead-Lag Relationships
AU  - E. A. Serman
AU  - A. Bleichrodt
AU  - I. Jayawardena
AU  - C. Liskey
AU  - L. Rennert
PY  - 2026
DA  - 2026/09/29
PB  - medRxiv
DO  - 10.64898/2026.09.29.26364022
UR  - https://www.medrxiv.org/content/10.64898/2026.09.29.26364022v1
AB  - Prior work has shown that school-age childrens influenza activity precedes that of adults by one to two weeks. Whether this is robust across outcomes or constant across a seasons course is unexamined.  Using electronic health record data from two health systems in South Carolina (2016-2026) on individuals with an influenza diagnosis or positive test, we tested age-group lead-lag relationships across six measures using differenced cross-correlation and Granger causality, with significance confirmed via heteroskedasticity-robust block permutation. We tested whether relationships differed between a seasons growth and decline phases.  Children 5-17 years led every other age group by approximately one week in four out of six outcomes and were the only group showing any nonzero-lag relationship across 60 pairwise combinations. A screen of 150 source-target combinations identified 26 permutation-confirmed instances of childrens lower-acuity activity preceding elevated emergency department or inpatient burden in other age groups. The same-outcome lead was concentrated during a seasons growth phase, while the cross-severity lead was robust throughout both a seasons growth and decline.  School-age childrens influenza activity is a robust, multi-outcome leading indicator with distinct transmission-timing and severity-progression signals in different phases of seasonal epidemics, supporting incorporation of age-stratified, phase-aware indicators into influenza forecasting.
ER  -

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