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Lafond KE, Porter RM, Whaley MJ, Suizan Z, Ran Z, Aleem MA, Thapa B, Sar B, Proschle VS, Peng Z, Feng L, Coulibaly D, Nkwembe E, Olmedo A, Ampofo W, Saha S, Chadha M, Mangiri A, Setiawaty V, Ali SS, Chaves SS, Otorbaeva D, Keosavanh O, Saleh M, Ho A, Alexander B, Oumzil H, Baral KP, Huang QS, Adebayo AA, Al-Abaidani I, von Horoch M, Cohen C, Tempia S, Mmbaga V, Chittaganpitch M, Casal M, Dang DA, Couto P, Nair H, Bresee JS, Olsen SJ, Azziz-Baumgartner E, Nuorti JP, Widdowson MA. Global burden of influenza-associated lower respiratory tract infections and hospitalizations among adults: A systematic review and meta-analysis. PLoS Med 2021; 18:e1003550. [PMID: 33647033 PMCID: PMC7959367 DOI: 10.1371/journal.pmed.1003550] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 03/15/2021] [Accepted: 01/27/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Influenza illness burden is substantial, particularly among young children, older adults, and those with underlying conditions. Initiatives are underway to develop better global estimates for influenza-associated hospitalizations and deaths. Knowledge gaps remain regarding the role of influenza viruses in severe respiratory disease and hospitalizations among adults, particularly in lower-income settings. METHODS AND FINDINGS We aggregated published data from a systematic review and unpublished data from surveillance platforms to generate global meta-analytic estimates for the proportion of acute respiratory hospitalizations associated with influenza viruses among adults. We searched 9 online databases (Medline, Embase, CINAHL, Cochrane Library, Scopus, Global Health, LILACS, WHOLIS, and CNKI; 1 January 1996-31 December 2016) to identify observational studies of influenza-associated hospitalizations in adults, and assessed eligible papers for bias using a simplified Newcastle-Ottawa scale for observational data. We applied meta-analytic proportions to global estimates of lower respiratory infections (LRIs) and hospitalizations from the Global Burden of Disease study in adults ≥20 years and by age groups (20-64 years and ≥65 years) to obtain the number of influenza-associated LRI episodes and hospitalizations for 2016. Data from 63 sources showed that influenza was associated with 14.1% (95% CI 12.1%-16.5%) of acute respiratory hospitalizations among all adults, with no significant differences by age group. The 63 data sources represent published observational studies (n = 28) and unpublished surveillance data (n = 35), from all World Health Organization regions (Africa, n = 8; Americas, n = 11; Eastern Mediterranean, n = 7; Europe, n = 8; Southeast Asia, n = 11; Western Pacific, n = 18). Data quality for published data sources was predominantly moderate or high (75%, n = 56/75). We estimate 32,126,000 (95% CI 20,484,000-46,129,000) influenza-associated LRI episodes and 5,678,000 (95% CI 3,205,000-9,432,000) LRI hospitalizations occur each year among adults. While adults <65 years contribute most influenza-associated LRI hospitalizations and episodes (3,464,000 [95% CI 1,885,000-5,978,000] LRI hospitalizations and 31,087,000 [95% CI 19,987,000-44,444,000] LRI episodes), hospitalization rates were highest in those ≥65 years (437/100,000 person-years [95% CI 265-612/100,000 person-years]). For this analysis, published articles were limited in their inclusion of stratified testing data by year and age group. Lack of information regarding influenza vaccination of the study population was also a limitation across both types of data sources. CONCLUSIONS In this meta-analysis, we estimated that influenza viruses are associated with over 5 million hospitalizations worldwide per year. Inclusion of both published and unpublished findings allowed for increased power to generate stratified estimates, and improved representation from lower-income countries. Together, the available data demonstrate the importance of influenza viruses as a cause of severe disease and hospitalizations in younger and older adults worldwide.
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Affiliation(s)
- Kathryn E. Lafond
- Influenza Division, US Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- Health Sciences Unit, Faculty of Social Sciences, Tampere University, Tampere, Finland
- * E-mail: (KEL); (MAW)
| | - Rachael M. Porter
- Influenza Division, US Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Melissa J. Whaley
- US Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Zhou Suizan
- Influenza Division, US Centers for Disease Control and Prevention, Beijing, China
| | - Zhang Ran
- Influenza Division, US Centers for Disease Control and Prevention, Beijing, China
| | - Mohammad Abdul Aleem
- Program for Emerging Infections, Infectious Diseases Division, icddr,b, Dhaka, Bangladesh
| | - Binay Thapa
- Royal Centre for Disease Control, Thimphu, Bhutan
| | - Borann Sar
- Centers for Disease Control and Prevention, Phnom Penh, Cambodia
| | | | - Zhibin Peng
- Division of Infectious Diseases, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Luzhao Feng
- School of Population Medicine & Public Health, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, China
| | | | - Edith Nkwembe
- Institut National de Recherches Biomédicales, Kinshasa, République Démocratique du Congo
| | | | - William Ampofo
- Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Siddhartha Saha
- Influenza Division, US Centers for Disease Control and Prevention, New Delhi, India
| | | | - Amalya Mangiri
- US Centers for Disease Control and Prevention, Jakarta, Indonesia
| | - Vivi Setiawaty
- National Institute of Health Research and Development, Jakarta, Indonesia
| | | | - Sandra S. Chaves
- Influenza Division, US Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Dinagul Otorbaeva
- Department of State Sanitary Epidemiological Surveillance, Bishkek, Kyrgyzstan
| | - Onechanh Keosavanh
- National Center for Laboratory and Epidemiology, Vientiane, Lao People’s Democratic Republic
| | - Majd Saleh
- Epidemiological Surveillance Program, Lebanese Ministry of Public Health, Beirut, Lebanon
| | - Antonia Ho
- MRC–University of Glasgow Centre for Virus Research, Glasgow, United Kingdom
- Malawi–Liverpool–Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | - Hicham Oumzil
- Virology Department, Institut National d’Hygiène, Rabat, Morocco
- Faculty of Medicine, Microbiology RPU, Mohammed V University, Rabat, Morocco
| | | | - Q. Sue Huang
- WHO National Influenza Centre, Institute of Environmental Science and Research, Wellington, New Zealand
| | - Adedeji A. Adebayo
- Nigeria Centre for Disease Control, Federal Ministry of Health, Abuja, Nigeria
| | - Idris Al-Abaidani
- Directorate General of Disease Surveillance and Control, Ministry of Health, Muscat, Oman
| | - Marta von Horoch
- Ministerio de Salud Publica y Bienestar Social, Asunción, Paraguay
| | - Cheryl Cohen
- National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Stefano Tempia
- Influenza Division, US Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- MassGenics, Duluth, Georgia, United States of America
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Malinee Chittaganpitch
- National Institute of Health, Department of Medical Sciences, Ministry of Public Health, Nonthaburi, Thailand
| | - Mariana Casal
- Arizona Department of Health Services, Phoenix, Arizona, United States of America
| | - Duc Anh Dang
- National Institute of Hygiene and Epidemiology, Hanoi, Vietnam
| | - Paula Couto
- Pan American Health Organization, Washington, District of Columbia, United States of America
| | - Harish Nair
- Centre for Global Health, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Joseph S. Bresee
- Influenza Division, US Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Sonja J. Olsen
- Influenza Division, US Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Eduardo Azziz-Baumgartner
- Influenza Division, US Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - J. Pekka Nuorti
- Health Sciences Unit, Faculty of Social Sciences, Tampere University, Tampere, Finland
- Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Marc-Alain Widdowson
- Division of Global Health Protection, US Centers for Disease Control and Prevention, Nairobi, Kenya
- Institute of Tropical Medicine, Antwerp, Belgium
- * E-mail: (KEL); (MAW)
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