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24 Aug 2013

Populations at risk for severe or complicated influenza illness: systematic review and meta-analysis (BMJ, abstract, edited)

[Source: British Medical Journal, full page: (LINK). Abstract, edited.]


Populations at risk for severe or complicated influenza illness: systematic review and meta-analysis

BMJ 2013; 347 doi: (Published 23 August 2013)

Cite this as: BMJ 2013;347:f5061

Dominik Mertz, assistant professor 1 2, Tae Hyong Kim, researcher 2, Jennie Johnstone, researcher 2, Po-Po Lam, researcher 3 4, Michelle Science, staff physician 5, Stefan P Kuster, staff physician 6, Shaza A Fadel, researcher 4, Dat Tran, assistant professor 5, Eduardo Fernandez, researcher 2, Neera Bhatnagar, librarian 7, Mark Loeb, professor 2 8 9

Author Affiliations: 1Department of Medicine, McMaster University, Hamilton, ON, Canada 2Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton 3Mount Sinai Hospital, Toronto, ON, Canada 4Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto 5Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada 6University Hospital and University of Zurich, Zurich, Switzerland 7Health Sciences Library, McMaster University, Hamilton 8Department of Pathology and Molecular Medicine, McMaster University, Hamilton 9Michael G DeGroote Institute for Infectious Disease Research, McMaster University, Hamilton

Correspondence to: M Loeb Department of Pathology and Molecular Medicine, McMaster University MDCL 3203, 1200 Main St. W, Hamilton, ON, Canada L8N 3Z5

Accepted 22 July 2013




To evaluate risk factors for severe outcomes in patients with seasonal and pandemic influenza.


Systematic review.

Study selection

Observational studies reporting on risk factor-outcome combinations of interest in participants with influenza. Outcomes included death, ventilator support, admission to hospital, admission to an intensive care unit, pneumonia, and composite outcomes.

Data sources

Medline, Embase, CINAHL, Global Health, and the Cochrane Central Register of Controlled Trials to March 2011.

Risk of bias assessment

Newcastle-Ottawa scale to assess the risk of bias. GRADE framework to evaluate the quality of evidence.


63 537 articles were identified of which 234 with a total of 610 782 participants met the inclusion criteria. The evidence supporting risk factors for severe outcomes of influenza ranged from being limited to absent. This was particularly relevant for the relative lack of data for non-2009 H1N1 pandemics and for seasonal influenza studies. Limitations in the published literature included lack of power and lack of adjustment for confounders was widespread: adjusted risk estimates were provided for only 5% of risk factor-outcome comparisons in 39 of 260 (15%) studies. The level of evidence was low for “any risk factor” (odds ratio for mortality 2.77, 95% confidence interval 1.90 to 4.05 for pandemic influenza and 2.04, 1.74 to 2.39 for seasonal influenza), obesity (2.74, 1.56 to 4.80 and 30.1, 1.74 to 2.39), cardiovascular diseases (2.92, 1.76 to 4.86 and 1.97, 1.06 to 3.67), and neuromuscular disease (2.68, 1.91 to 3.75 and 3.21, 1.84 to 5.58). The level of evidence was very low for all other risk factors. Some well accepted risk factors such as pregnancy and belonging to an ethnic minority group could not be identified as risk factors. In contrast, women who were less than four weeks post partum had a significantly increased risk of death from pandemic influenza (4.43, 1.24 to 15.81).


The level of evidence to support risk factors for influenza related complications is low and some well accepted risk factors, including pregnancy and ethnicity, could not be confirmed as risks. Rigorous and adequately powered studies are needed.