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Intensive care surveillance of influenza, 11 EU countries, 2009–2016
Cornelia AdlhochEuropean Centre for Disease Prevention and Control
Options IX for the control of influenza, 24–28 August 2016
Thank you for the tireless commitment in collecting and providing high-quality European influenza surveillance data
Finland: Outi Lyytikäinen, Niina Ikonen, Satu Murtopuro, Anu Haveri; France: Blanchon Thierry, Clement Turbelin, Emmanuel Belchior, Isabelle Bonmarin, Sylvie Behillil, Bruno Lina, Martine Valette, Sylvie van der Werf, Vincent Enouf; Ireland: Lisa Domegan, Allison Waters, Joan O’Donnell, Margaret Duffy, SuzieCoughlan, Derval Igoe; Malta: Christopher Barbara, Jackie Maistre Melillo, Tanya Melillo, Graziella Zahra; Netherlands: Mariette Hooiveld, Anne Teirlinck, Adam Meijer, Frederika Dijkstra, Gé Donker, GuusRimmelzwaan, Marit de Lange; Portugal: Ana Paula Rodrigues , Helena Rebelo De Andrade, RaquelMoreira Guiomar; Romania: Emilia Lupulescu, Florin Popovici; Slovak Republic: Edita Staronová; Spain:Amparo Larrauri, Francisco Pozo, Inmaculada Casas, Leonardo Raul Ortiz De Lejarazu, Tomas Pumarola,Tomas Vega.
All practitioners and hospitals providing samples and epidemiological data.
I have no potential conflict of interest to report
Rational for severe disease surveillance
• to monitor and assess the impact of influenza
• to identify high risk groups and risk factors
Objective of the study
To describe confirmed influenza cases admitted to intensivecare units (ICU) in order to identify risk factors for fataloutcome in EU/EEA countries
Methods
Data collection
Laboratory-confirmed influenza cases admitted to ICU
- age and gender
- influenza type and A subtype
- underlying conditions, complications and vaccination status
- outcome
11 EU/EEA countries
2009/10 – 2015/16 (weeks 40–20)
Data analysis
Descriptive analysis
Uni- and multivariable logistic regression
Reporting countries and number of cases
Variable number of countries reporting each season, 11 in total
Age 58; 0-97 54; 0-100(median, range) (median, range)
Descriptive analysis
FatalN=621
RecoveredN=1 658
18% 19%
57% 55%
Descriptive analysis
FatalN=621
RecoveredN=1 658
Cases by (sub)type, age-group and outcome
A(H1N1)pdm09 affects mostly 40–64 year-olds, A(H3N2) 65+ year-olds
Descriptive analysis – chronic conditions
Lung disease 15% 15%
Heart disease 14% 8%
Diabetes 11% 11%
HIV 11% 5%
Obesity 10% 13%
Cancer 5% 2%
Kidney disease 5% 3%
Liver disease 4% 3%
Morbid obesity 4% 5%
Asthma 2% 3%
Pregnancy 2% 4%
FatalN=621
RecoveredN=1 658
Descriptive analysis - complications
ARDS 56% 53%
Pneumonia 34% 36%
Sepsis 9% 3%
FatalN=621
RecoveredN=1 658
Risk factors for fatal outcome pooled data 2009/10–2015/16, EU/EEA
Factors Univariable analysis Multivariable analysis
Odds ratio (95%CI) Adjusted odds ratio* (95%CI)
0–9 years Ref.
10–19 years 1.2 (0.5-2.7) 1.0 (0.4-2.4)
20–29 years 1.8 (1.0-3.4) 1.6 (0.8-3.2)
30–39 years 2.4 (1.4-4.2) 1.9 (1.1-3.4)
40–49 years 2.0 (1.2-3.4) 1.4 (0.8-2.5)
50–59 years 3.3 (2.0-5.5) 2.6 (1.5-4.4)
60–69 years 3.2 (1.9-5.4) 2.5 (1.5-4.3)
70–79 years 3.7 (2.2-6.3) 3.1 (1.8-5.5)
80+ years 3.7 (2.0-6.8) 3.6 (1.9-7.0)
Increasing age is a risk factor for fatal outcome
*adjusted for gender, season and countryBold: p<0.05
Risk factors for fatal outcome pooled data 2009/10–2015/16, EU/EEA
Univariable analysis Multivariable analysis
Virus (sub)type Odds ratio (95%CI) Adjusted odds ratio* (95%CI)
B Ref. Ref.
A(H1N1)pdm09 1.8 (1.3-2.4) 2.1 (1.5-3.1)
A(H3N2) 1.4 (1.0-2.1) 1.5 (1.0-2.3)
Vaccination status
Vaccinated 1.1 (0.8-1.4) 1.0 (0.8-1.4)
Complications
Sepsis 5.8 (3.7-9.1) 5.5 (3.4-8.9)
ARDS 1.2 (0.9-1.6)
Pneumonia 0.8 (0.6-1.1)
Infection with influenza A(H1N1)pdm09 is a risk factor for fatal outcome
*adjusted for gender, season and countryBold: p<0.05
Risk factors for fatal outcome pooled data 2009/10–2015/16, EU/EEA
Underlying conditions
Univariable analysis Multivariable analysis
Odds ratio (95%CI) Adjusted odds ratio* (95%CI)
Cancer 2.8 (1.7-4.7) 2.7 (1.5-4.9)
HIV 2.5 (1.7-3.5) 2.7 (1.8-4.0)
Kidney disease 1.9 (1.2-3.1) 1.8 (1.1-3.1)
Liver disease 1.6 (0.9-2.6) 2.2 (1.2-3.9)
Heart disease 1.5 (1.1-2.1) 1.3 (0.9-1.9)
Pregnancy 0.6 (0.3-1.0) 0.9 (0.5-1.7)
Asthma 0.6 (0.3-1.2)
Diabetes 1.0 (0.8-1.4)
Lung disease 0.9 (0.7-1.2)
Obesity 0.8 (0.6-1.1)
Morbid obesity 1.1 (0.7-1.7)
Cancer, kidney and liver disease, and HIV are risk factors for fatal outcome
*adjusted for gender, season and countryBold: p<0.05
Limitations
• Small subset of reporting countries might introduce bias
• Inconsistent reporting over time
• Lack of denominator data
Conclusions
• Identified risk factors for fatal outcome:
• Increasing age
• Infection with influenza A virus
• Cancer
• HIV
• Kidney disease
• Liver disease
• Vaccination not protective in these severely ill patients
• Need for more countries in EU/EEA to perform severe influenza surveillance
ECDC team:
Pasi Penttinen
Eeva Broberg
Julien Beauté
René Snacken
Joana Gomes Dias
Adrian Prodan
Gaetan Guyodo
...and the influenza programme at WHO Regional Office for Europe
Thank you for your attention!