Populations at risk for severe or complicated influenza illness: systematic review and meta-analysis
Identifieur interne : 001825 ( Istex/Corpus ); précédent : 001824; suivant : 001826Populations at risk for severe or complicated influenza illness: systematic review and meta-analysis
Auteurs : Dominik Mertz ; Tae Hyong Kim ; Jennie Johnstone ; Po-Po Lam ; Michelle Science ; Stefan P. Kuster ; Shaza A. Fadel ; Dat Tran ; Eduardo Fernandez ; Neera Bhatnagar ; Mark LoebSource :
- BMJ : British Medical Journal [ 0959-8138 ] ; 2013.
English descriptors
- Teeft :
- Adverse effects, Antiviral treatment, August, Black participants, Body mass index, Cardiovascular, Cardiovascular disease, Cardiovascular diseases, Care unit admission ventilator support, Cause hospital admission, Cause mortality, Cerebrovascular insult, Chronic lung disease, Chronic lung diseases, Cohort studies, Comorbidity, Confidence interval, Confidence intervals, Convincing evidence, Diabetes mellitus, Disease control, Elderly participants, Elderly people, Eligibility criteria, Endocrinological disease, Ethnic minority group, Ethnicity, Gastrointestinal disease, Global health, Grade methodology, Hazard ratios, Healthcare workers, Heterogeneity, High risk, Higher risk, Hospital admission, Illicit drug, Immunocompromised participants, Influenza, Influenza infection, Influenza vaccination, Intensive care unit, Laboratory confirmation, Large overlap, Liver disease, Lower risk, Lung disease, Major risk factors, Mcmaster, Mcmaster university, Molecular medicine, Native populations, Neurocognitive disease, Neurological disease, Neuromuscular, Neuromuscular disease, Ntrl, Ntrl ntrl, Odds ratio, Odds ratio trend, Odds ratios, Original studies, Original study, Other outcomes, Other risk factors, Pandemic, Pandemic influenza, Pandemic influenza seasons, Participant, Pneumonia, Poor quality, Postpartum period, Potential risk factor, Prediction intervals, Pregnancy, Pregnant women, Preterm birth, Prioritise vaccination, Prognostic factors, Publication bias, Pulmonary disease, Recommendations assessment, Relative lack, Renal disease, Reprint, Research table, Risk combination, Risk combinations, Risk comparison, Risk comparisons, Risk estimates, Risk factor, Risk factors, Risk groups, Search strategy, Seasonal influenza, Severe influenza illness, Severe outcomes, Significant differences, Small number, Statistical significance, Study design, Study groups, Study quality, Study selection, Summary estimate, Summary estimates, Supplementary appendix, Systematic review, Systematic reviews, Third trimester, Trimester, Unadjusted risk estimates, Vaccination, Ventilator, Ventilator support, Weeks post partum, White participants, World health organization, Young children.
Abstract
Objective To evaluate risk factors for severe outcomes in patients with seasonal and pandemic influenza. Design 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. Results 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). Conclusion 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.
Url:
DOI: 10.1136/bmj.f5061
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ISTEX:76681876E6A34DBDA0B25341C91847422B62C2C8Le document en format XML
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Mertz</name><affiliation><mods:affiliation>Department of Medicine, McMaster University, Hamilton, ON, Canada</mods:affiliation></affiliation><affiliation><mods:affiliation>Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton</mods:affiliation></affiliation><affiliation><mods:affiliation>E-mail: loebm@mcmaster.ca</mods:affiliation></affiliation></author><author><name sortKey="Kim, Tae Hyong" sort="Kim, Tae Hyong" uniqKey="Kim T" first="Tae Hyong" last="Kim">Tae Hyong Kim</name><affiliation><mods:affiliation>Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton</mods:affiliation></affiliation><affiliation><mods:affiliation>E-mail: loebm@mcmaster.ca</mods:affiliation></affiliation></author><author><name sortKey="Johnstone, Jennie" sort="Johnstone, Jennie" uniqKey="Johnstone J" first="Jennie" last="Johnstone">Jennie Johnstone</name><affiliation><mods:affiliation>Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton</mods:affiliation></affiliation><affiliation><mods:affiliation>E-mail: loebm@mcmaster.ca</mods:affiliation></affiliation></author><author><name sortKey="Lam, Po Po" sort="Lam, Po Po" uniqKey="Lam P" first="Po-Po" last="Lam">Po-Po Lam</name><affiliation><mods:affiliation>Mount Sinai Hospital, Toronto, ON, Canada</mods:affiliation></affiliation><affiliation><mods:affiliation>Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto</mods:affiliation></affiliation><affiliation><mods:affiliation>E-mail: loebm@mcmaster.ca</mods:affiliation></affiliation></author><author><name sortKey="Science, Michelle" sort="Science, Michelle" uniqKey="Science M" first="Michelle" last="Science">Michelle Science</name><affiliation><mods:affiliation>Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada</mods:affiliation></affiliation><affiliation><mods:affiliation>E-mail: loebm@mcmaster.ca</mods:affiliation></affiliation></author><author><name sortKey="Kuster, Stefan P" sort="Kuster, Stefan P" uniqKey="Kuster S" first="Stefan P" last="Kuster">Stefan P. Kuster</name><affiliation><mods:affiliation>University Hospital and University of Zurich, Zurich, Switzerland</mods:affiliation></affiliation><affiliation><mods:affiliation>E-mail: loebm@mcmaster.ca</mods:affiliation></affiliation></author><author><name sortKey="Fadel, Shaza A" sort="Fadel, Shaza A" uniqKey="Fadel S" first="Shaza A" last="Fadel">Shaza A. Fadel</name><affiliation><mods:affiliation>Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto</mods:affiliation></affiliation><affiliation><mods:affiliation>E-mail: loebm@mcmaster.ca</mods:affiliation></affiliation></author><author><name sortKey="Tran, Dat" sort="Tran, Dat" uniqKey="Tran D" first="Dat" last="Tran">Dat Tran</name><affiliation><mods:affiliation>Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada</mods:affiliation></affiliation><affiliation><mods:affiliation>E-mail: loebm@mcmaster.ca</mods:affiliation></affiliation></author><author><name sortKey="Fernandez, Eduardo" sort="Fernandez, Eduardo" uniqKey="Fernandez E" first="Eduardo" last="Fernandez">Eduardo Fernandez</name><affiliation><mods:affiliation>Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton</mods:affiliation></affiliation><affiliation><mods:affiliation>E-mail: loebm@mcmaster.ca</mods:affiliation></affiliation></author><author><name sortKey="Bhatnagar, Neera" sort="Bhatnagar, Neera" uniqKey="Bhatnagar N" first="Neera" last="Bhatnagar">Neera Bhatnagar</name><affiliation><mods:affiliation>Health Sciences Library, McMaster University, Hamilton</mods:affiliation></affiliation><affiliation><mods:affiliation>E-mail: loebm@mcmaster.ca</mods:affiliation></affiliation></author><author><name sortKey="Loeb, Mark" sort="Loeb, Mark" uniqKey="Loeb M" first="Mark" last="Loeb">Mark Loeb</name><affiliation><mods:affiliation>Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton</mods:affiliation></affiliation><affiliation><mods:affiliation>Department of Pathology and Molecular Medicine, McMaster University, Hamilton</mods:affiliation></affiliation><affiliation><mods:affiliation>Michael G DeGroote Institute for Infectious Disease Research, McMaster University, Hamilton</mods:affiliation></affiliation><affiliation><mods:affiliation>E-mail: loebm@mcmaster.ca</mods:affiliation></affiliation><affiliation><mods:affiliation>E-mail: loebm@mcmaster.ca</mods:affiliation></affiliation></author></analytic><monogr></monogr><series><title level="j">BMJ : British Medical Journal</title><title level="j" type="abbrev">BMJ</title><idno type="ISSN">0959-8138</idno><idno type="eISSN">1756-1833</idno><imprint><publisher>British Medical Journal Publishing Group</publisher><date type="published" when="2013">2013</date><biblScope unit="volume">347</biblScope></imprint><idno type="ISSN">0959-8138</idno></series></biblStruct></sourceDesc><seriesStmt><idno type="ISSN">0959-8138</idno></seriesStmt></fileDesc><profileDesc><textClass><keywords scheme="Teeft" xml:lang="en"><term>Adverse effects</term><term>Antiviral treatment</term><term>August</term><term>Black participants</term><term>Body mass index</term><term>Cardiovascular</term><term>Cardiovascular disease</term><term>Cardiovascular diseases</term><term>Care unit admission ventilator support</term><term>Cause hospital admission</term><term>Cause mortality</term><term>Cerebrovascular insult</term><term>Chronic lung disease</term><term>Chronic lung diseases</term><term>Cohort studies</term><term>Comorbidity</term><term>Confidence interval</term><term>Confidence intervals</term><term>Convincing evidence</term><term>Diabetes mellitus</term><term>Disease control</term><term>Elderly participants</term><term>Elderly people</term><term>Eligibility criteria</term><term>Endocrinological disease</term><term>Ethnic minority group</term><term>Ethnicity</term><term>Gastrointestinal disease</term><term>Global health</term><term>Grade methodology</term><term>Hazard ratios</term><term>Healthcare workers</term><term>Heterogeneity</term><term>High risk</term><term>Higher risk</term><term>Hospital admission</term><term>Illicit drug</term><term>Immunocompromised participants</term><term>Influenza</term><term>Influenza infection</term><term>Influenza vaccination</term><term>Intensive care unit</term><term>Laboratory confirmation</term><term>Large overlap</term><term>Liver disease</term><term>Lower risk</term><term>Lung disease</term><term>Major risk factors</term><term>Mcmaster</term><term>Mcmaster university</term><term>Molecular medicine</term><term>Native populations</term><term>Neurocognitive disease</term><term>Neurological disease</term><term>Neuromuscular</term><term>Neuromuscular disease</term><term>Ntrl</term><term>Ntrl ntrl</term><term>Odds ratio</term><term>Odds ratio trend</term><term>Odds ratios</term><term>Original studies</term><term>Original study</term><term>Other outcomes</term><term>Other risk factors</term><term>Pandemic</term><term>Pandemic influenza</term><term>Pandemic influenza seasons</term><term>Participant</term><term>Pneumonia</term><term>Poor quality</term><term>Postpartum period</term><term>Potential risk factor</term><term>Prediction intervals</term><term>Pregnancy</term><term>Pregnant women</term><term>Preterm birth</term><term>Prioritise vaccination</term><term>Prognostic factors</term><term>Publication bias</term><term>Pulmonary disease</term><term>Recommendations assessment</term><term>Relative lack</term><term>Renal disease</term><term>Reprint</term><term>Research table</term><term>Risk combination</term><term>Risk combinations</term><term>Risk comparison</term><term>Risk comparisons</term><term>Risk estimates</term><term>Risk factor</term><term>Risk factors</term><term>Risk groups</term><term>Search strategy</term><term>Seasonal influenza</term><term>Severe influenza illness</term><term>Severe outcomes</term><term>Significant differences</term><term>Small number</term><term>Statistical significance</term><term>Study design</term><term>Study groups</term><term>Study quality</term><term>Study selection</term><term>Summary estimate</term><term>Summary estimates</term><term>Supplementary appendix</term><term>Systematic review</term><term>Systematic reviews</term><term>Third trimester</term><term>Trimester</term><term>Unadjusted risk estimates</term><term>Vaccination</term><term>Ventilator</term><term>Ventilator support</term><term>Weeks post partum</term><term>White participants</term><term>World health organization</term><term>Young children</term></keywords></textClass><langUsage><language ident="en">en</language></langUsage></profileDesc></teiHeader><front><div type="abstract">Objective To evaluate risk factors for severe outcomes in patients with seasonal and pandemic influenza. Design 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. Results 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). Conclusion 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.</div></front></TEI><istex><corpusName>bmj</corpusName><keywords><teeft><json:string>ntrl</json:string><json:string>risk factor</json:string><json:string>influenza</json:string><json:string>risk factors</json:string><json:string>intensive care unit</json:string><json:string>pandemic influenza</json:string><json:string>higher risk</json:string><json:string>seasonal influenza</json:string><json:string>reprint</json:string><json:string>heterogeneity</json:string><json:string>august</json:string><json:string>severe outcomes</json:string><json:string>hospital admission</json:string><json:string>risk estimates</json:string><json:string>ventilator support</json:string><json:string>pandemic</json:string><json:string>cardiovascular disease</json:string><json:string>cause mortality</json:string><json:string>ventilator</json:string><json:string>comorbidity</json:string><json:string>lower 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evidence</json:string><json:string>illicit drug</json:string><json:string>influenza infection</json:string><json:string>gastrointestinal disease</json:string><json:string>elderly participants</json:string><json:string>risk groups</json:string><json:string>study design</json:string><json:string>molecular medicine</json:string><json:string>ntrl ntrl</json:string><json:string>odds ratio trend</json:string></teeft></keywords><author><json:item><name>Dominik Mertz</name><affiliations><json:string>Department of Medicine, McMaster University, Hamilton, ON, Canada</json:string><json:string>Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton</json:string><json:string>E-mail: loebm@mcmaster.ca</json:string></affiliations></json:item><json:item><name>Tae Hyong Kim</name><affiliations><json:string>Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton</json:string><json:string>E-mail: loebm@mcmaster.ca</json:string></affiliations></json:item><json:item><name>Jennie Johnstone</name><affiliations><json:string>Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton</json:string><json:string>E-mail: loebm@mcmaster.ca</json:string></affiliations></json:item><json:item><name>Po-Po Lam</name><affiliations><json:string>Mount Sinai Hospital, Toronto, ON, Canada</json:string><json:string>Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto</json:string><json:string>E-mail: loebm@mcmaster.ca</json:string></affiliations></json:item><json:item><name>Michelle Science</name><affiliations><json:string>Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada</json:string><json:string>E-mail: loebm@mcmaster.ca</json:string></affiliations></json:item><json:item><name>Stefan P Kuster</name><affiliations><json:string>University Hospital and University of Zurich, Zurich, Switzerland</json:string><json:string>E-mail: loebm@mcmaster.ca</json:string></affiliations></json:item><json:item><name>Shaza A Fadel</name><affiliations><json:string>Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto</json:string><json:string>E-mail: loebm@mcmaster.ca</json:string></affiliations></json:item><json:item><name>Dat Tran</name><affiliations><json:string>Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada</json:string><json:string>E-mail: loebm@mcmaster.ca</json:string></affiliations></json:item><json:item><name>Eduardo Fernandez</name><affiliations><json:string>Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton</json:string><json:string>E-mail: loebm@mcmaster.ca</json:string></affiliations></json:item><json:item><name>Neera Bhatnagar</name><affiliations><json:string>Health Sciences Library, McMaster University, Hamilton</json:string><json:string>E-mail: loebm@mcmaster.ca</json:string></affiliations></json:item><json:item><name>Mark Loeb</name><affiliations><json:string>Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton</json:string><json:string>Department of Pathology and Molecular Medicine, McMaster University, Hamilton</json:string><json:string>Michael G DeGroote Institute for Infectious Disease Research, McMaster University, Hamilton</json:string><json:string>E-mail: loebm@mcmaster.ca</json:string><json:string>E-mail: loebm@mcmaster.ca</json:string></affiliations></json:item></author><articleId><json:string>merd010478</json:string></articleId><arkIstex>ark:/67375/NVC-ZPKR88ML-5</arkIstex><language><json:string>eng</json:string></language><originalGenre><json:string>research-article</json:string></originalGenre><abstract>Objective To evaluate risk factors for severe outcomes in patients with seasonal and pandemic influenza. Design 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. Results 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). Conclusion 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.</abstract><qualityIndicators><score>10</score><pdfWordCount>7847</pdfWordCount><pdfCharCount>53061</pdfCharCount><pdfVersion>1.4</pdfVersion><pdfPageCount>16</pdfPageCount><pdfPageSize>595.276 x 841.89 pts (A4)</pdfPageSize><refBibsNative>true</refBibsNative><abstractWordCount>341</abstractWordCount><abstractCharCount>2220</abstractCharCount><keywordCount>0</keywordCount></qualityIndicators><title>Populations at risk for severe or complicated influenza illness: systematic review and meta-analysis</title><pmid><json:string>23974637</json:string></pmid><genre><json:string>research-article</json:string></genre><host><title>BMJ : British Medical Journal</title><language><json:string>unknown</json:string></language><issn><json:string>0959-8138</json:string></issn><eissn><json:string>1756-1833</json:string></eissn><publisherId><json:string>bmj</json:string></publisherId><volume>347</volume><genre><json:string>journal</json:string></genre></host><namedEntities><unitex><date><json:string>2009</json:string><json:string>2011</json:string><json:string>2012</json:string><json:string>2013</json:string><json:string>1991</json:string></date><geogName></geogName><orgName><json:string>University of Toronto</json:string><json:string>ACIP</json:string><json:string>RESEARCH Figure Flow</json:string><json:string>University Hospital and University of Zurich, Zurich, Switzerland</json:string><json:string>Current World Health Organization and Center for Disease Control and Prevention</json:string><json:string>Department of Pathology and Molecular Medicine</json:string><json:string>Mount Sinai Hospital, Toronto, ON, Canada</json:string><json:string>Advisory Committee on Immunization Practices</json:string><json:string>RESEARCH Tables Table</json:string><json:string>Institute for Infectious Disease Research</json:string><json:string>Department of Clinical Epidemiology and Biostatistics</json:string><json:string>Division of Epidemiology</json:string><json:string>Department of Medicine</json:string><json:string>RESEARCH Table</json:string><json:string>Loeb Department of Pathology and Molecular Medicine</json:string><json:string>Prognosis Research Strategy</json:string><json:string>PROGRESS</json:string><json:string>Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada</json:string><json:string>CDC</json:string><json:string>Hamilton Health Sciences Foundation</json:string><json:string>World Health Organization</json:string><json:string>Recommended American Indians/Alaska Natives</json:string><json:string>Swiss National Science Foundation</json:string></orgName><orgName_funder></orgName_funder><orgName_provider></orgName_provider><persName><json:string>Systematic</json:string><json:string>Ann Intern</json:string><json:string>If</json:string><json:string>L. Incidence</json:string><json:string>Stephen Walter</json:string><json:string>Van Kerkhove</json:string><json:string>G. Severe</json:string></persName><placeName><json:string>PY</json:string><json:string>Germany</json:string><json:string>United States</json:string><json:string>Beijing</json:string><json:string>Ethnicity</json:string><json:string>Canada</json:string><json:string>Lichtenstein</json:string><json:string>American</json:string><json:string>China</json:string><json:string>Toronto</json:string><json:string>Europe</json:string><json:string>America</json:string><json:string>Israel</json:string><json:string>Ottawa</json:string></placeName><ref_url><json:string>http://www.bmj.com/content/</json:string><json:string>http://www.bmj.com/subscribe</json:string><json:string>http://bmj.com/video</json:string><json:string>http://creativecommons.org/licenses/by-nc/</json:string><json:string>http://www.bmj.com/permissions</json:string></ref_url><ref_bibl><json:string>Buda et al</json:string></ref_bibl><bibl></bibl></unitex></namedEntities><ark><json:string>ark:/67375/NVC-ZPKR88ML-5</json:string></ark><categories><wos></wos><scienceMetrix><json:string>1 - health sciences</json:string><json:string>2 - clinical medicine</json:string><json:string>3 - general & internal medicine</json:string></scienceMetrix><scopus><json:string>1 - Health Sciences</json:string><json:string>2 - Medicine</json:string><json:string>3 - General Medicine</json:string></scopus><inist><json:string>1 - sciences appliquees, technologies et medecines</json:string><json:string>2 - sciences biologiques et medicales</json:string><json:string>3 - sciences medicales</json:string></inist></categories><publicationDate>2013</publicationDate><copyrightDate>2013</copyrightDate><doi><json:string>10.1136/bmj.f5061</json:string></doi><id>76681876E6A34DBDA0B25341C91847422B62C2C8</id><score>1</score><fulltext><json:item><extension>pdf</extension><original>true</original><mimetype>application/pdf</mimetype><uri>https://api.istex.fr/ark:/67375/NVC-ZPKR88ML-5/fulltext.pdf</uri></json:item><json:item><extension>zip</extension><original>false</original><mimetype>application/zip</mimetype><uri>https://api.istex.fr/ark:/67375/NVC-ZPKR88ML-5/bundle.zip</uri></json:item><istex:fulltextTEI uri="https://api.istex.fr/ark:/67375/NVC-ZPKR88ML-5/fulltext.tei"><teiHeader><fileDesc><titleStmt><title level="a">Populations at risk for severe or complicated influenza illness: systematic review and meta-analysis</title></titleStmt><publicationStmt><authority>ISTEX</authority><publisher scheme="https://publisher-list.data.istex.fr">British Medical Journal Publishing Group</publisher><availability status="free"><p>Open Access</p></availability><date>2013</date></publicationStmt><notesStmt><note type="research-article" scheme="https://content-type.data.istex.fr/ark:/67375/XTP-1JC4F85T-7">research-article</note><note type="journal" scheme="https://publication-type.data.istex.fr/ark:/67375/JMC-0GLKJH51-B">journal</note></notesStmt><sourceDesc><biblStruct type="inbook"><analytic><title level="a">Populations at risk for severe or complicated influenza illness: systematic review and meta-analysis</title><author xml:id="author-0000"><persName><forename type="first">Dominik</forename><surname>Mertz</surname></persName><email>loebm@mcmaster.ca</email><note type="biography">assistant professor</note><note type="correspondence"><p>Correspondence to: M Loeb Department of Pathology and Molecular Medicine, McMaster University MDCL 3203, 1200 Main St. W, Hamilton, ON, Canada L8N 3Z5</p></note><affiliation>assistant professor</affiliation><affiliation>Department of Medicine, McMaster University, Hamilton, ON, Canada</affiliation><affiliation>Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton</affiliation></author><author xml:id="author-0001"><persName><forename type="first">Tae Hyong</forename><surname>Kim</surname></persName><email>loebm@mcmaster.ca</email><note type="biography">researcher</note><note type="correspondence"><p>Correspondence to: M Loeb Department of Pathology and Molecular Medicine, McMaster University MDCL 3203, 1200 Main St. W, Hamilton, ON, Canada L8N 3Z5</p></note><affiliation>researcher</affiliation><affiliation>Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton</affiliation></author><author xml:id="author-0002"><persName><forename type="first">Jennie</forename><surname>Johnstone</surname></persName><email>loebm@mcmaster.ca</email><note type="biography">researcher</note><note type="correspondence"><p>Correspondence to: M Loeb Department of Pathology and Molecular Medicine, McMaster University MDCL 3203, 1200 Main St. W, Hamilton, ON, Canada L8N 3Z5</p></note><affiliation>researcher</affiliation><affiliation>Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton</affiliation></author><author xml:id="author-0003"><persName><forename type="first">Po-Po</forename><surname>Lam</surname></persName><email>loebm@mcmaster.ca</email><note type="biography">researcher</note><note type="correspondence"><p>Correspondence to: M Loeb Department of Pathology and Molecular Medicine, McMaster University MDCL 3203, 1200 Main St. W, Hamilton, ON, Canada L8N 3Z5</p></note><affiliation>researcher</affiliation><affiliation>Mount Sinai Hospital, Toronto, ON, Canada</affiliation><affiliation>Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto</affiliation></author><author xml:id="author-0004"><persName><forename type="first">Michelle</forename><surname>Science</surname></persName><email>loebm@mcmaster.ca</email><note type="biography">staff physician</note><note type="correspondence"><p>Correspondence to: M Loeb Department of Pathology and Molecular Medicine, McMaster University MDCL 3203, 1200 Main St. W, Hamilton, ON, Canada L8N 3Z5</p></note><affiliation>staff physician</affiliation><affiliation>Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada</affiliation></author><author xml:id="author-0005"><persName><forename type="first">Stefan P</forename><surname>Kuster</surname></persName><email>loebm@mcmaster.ca</email><note type="biography">staff physician</note><note type="correspondence"><p>Correspondence to: M Loeb Department of Pathology and Molecular Medicine, McMaster University MDCL 3203, 1200 Main St. W, Hamilton, ON, Canada L8N 3Z5</p></note><affiliation>staff physician</affiliation><affiliation>University Hospital and University of Zurich, Zurich, Switzerland</affiliation></author><author xml:id="author-0006"><persName><forename type="first">Shaza A</forename><surname>Fadel</surname></persName><email>loebm@mcmaster.ca</email><note type="biography">researcher</note><note type="correspondence"><p>Correspondence to: M Loeb Department of Pathology and Molecular Medicine, McMaster University MDCL 3203, 1200 Main St. W, Hamilton, ON, Canada L8N 3Z5</p></note><affiliation>researcher</affiliation><affiliation>Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto</affiliation></author><author xml:id="author-0007"><persName><forename type="first">Dat</forename><surname>Tran</surname></persName><email>loebm@mcmaster.ca</email><note type="biography">assistant professor</note><note type="correspondence"><p>Correspondence to: M Loeb Department of Pathology and Molecular Medicine, McMaster University MDCL 3203, 1200 Main St. W, Hamilton, ON, Canada L8N 3Z5</p></note><affiliation>assistant professor</affiliation><affiliation>Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada</affiliation></author><author xml:id="author-0008"><persName><forename type="first">Eduardo</forename><surname>Fernandez</surname></persName><email>loebm@mcmaster.ca</email><note type="biography">researcher</note><note type="correspondence"><p>Correspondence to: M Loeb Department of Pathology and Molecular Medicine, McMaster University MDCL 3203, 1200 Main St. W, Hamilton, ON, Canada L8N 3Z5</p></note><affiliation>researcher</affiliation><affiliation>Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton</affiliation></author><author xml:id="author-0009"><persName><forename type="first">Neera</forename><surname>Bhatnagar</surname></persName><email>loebm@mcmaster.ca</email><note type="biography">librarian</note><note type="correspondence"><p>Correspondence to: M Loeb Department of Pathology and Molecular Medicine, McMaster University MDCL 3203, 1200 Main St. W, Hamilton, ON, Canada L8N 3Z5</p></note><affiliation>librarian</affiliation><affiliation>Health Sciences Library, McMaster University, Hamilton</affiliation></author><author xml:id="author-0010" corresp="yes"><persName><forename type="first">Mark</forename><surname>Loeb</surname></persName><email>loebm@mcmaster.ca</email><email>loebm@mcmaster.ca</email><note type="biography">professor</note><note type="correspondence"><p>Correspondence to: M Loeb Department of Pathology and Molecular Medicine, McMaster University MDCL 3203, 1200 Main St. W, Hamilton, ON, Canada L8N 3Z5</p></note><affiliation>professor</affiliation><affiliation>Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton</affiliation><affiliation>Department of Pathology and Molecular Medicine, McMaster University, Hamilton</affiliation><affiliation>Michael G DeGroote Institute for Infectious Disease Research, McMaster University, Hamilton</affiliation></author><idno type="istex">76681876E6A34DBDA0B25341C91847422B62C2C8</idno><idno type="ark">ark:/67375/NVC-ZPKR88ML-5</idno><idno type="DOI">10.1136/bmj.f5061</idno><idno type="href">bmj-347-bmj-f5061.pdf</idno><idno type="article-id">merd010478</idno><idno type="local">bmj;347/aug23_1/f5061</idno></analytic><monogr><title level="j">BMJ : British Medical Journal</title><title level="j" type="abbrev">BMJ</title><idno type="pISSN">0959-8138</idno><idno type="eISSN">1756-1833</idno><idno type="publisher-id">bmj</idno><idno type="PublisherID-hwp">bmj</idno><idno type="PublisherID-nlm-ta">BMJ</idno><imprint><publisher>British Medical Journal Publishing Group</publisher><date type="published" when="2013"></date><biblScope unit="volume">347</biblScope></imprint></monogr></biblStruct></sourceDesc></fileDesc><profileDesc><creation><date>2013</date></creation><langUsage><language ident="en">en</language></langUsage><abstract><p>Objective To evaluate risk factors for severe outcomes in patients with seasonal and pandemic influenza. Design 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. Results 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). Conclusion 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.</p></abstract></profileDesc><revisionDesc><change when="2013">Published</change></revisionDesc></teiHeader></istex:fulltextTEI><json:item><extension>txt</extension><original>false</original><mimetype>text/plain</mimetype><uri>https://api.istex.fr/ark:/67375/NVC-ZPKR88ML-5/fulltext.txt</uri></json:item></fulltext><metadata><istex:metadataXml wicri:clean="corpus bmj" wicri:toSee="no header"><istex:xmlDeclaration>version="1.0" encoding="UTF-8" standalone="no"</istex:xmlDeclaration><istex:docType PUBLIC="-//NLM//DTD Journal Archiving and Interchange DTD v2.3 20070202//EN" URI="archivearticle.dtd" name="istex:docType"></istex:docType><istex:document><article article-type="research-article"><front><journal-meta><journal-id journal-id-type="hwp">bmj</journal-id><journal-id journal-id-type="nlm-ta">BMJ</journal-id><journal-id journal-id-type="publisher-id">bmj</journal-id><journal-title>BMJ : British Medical Journal</journal-title><issn pub-type="epub">1756-1833</issn><publisher><publisher-name>British Medical Journal Publishing Group</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="publisher-id">merd010478</article-id><article-id pub-id-type="doi">10.1136/bmj.f5061</article-id><article-id pub-id-type="other">bmj;347/aug23_1/f5061</article-id><article-id pub-id-type="other">bmj;bmj.f5061</article-id><article-id pub-id-type="other">aug23_1</article-id><article-id pub-id-type="other">bmj.f5061</article-id><article-id pub-id-type="other">bmj.f5061</article-id><article-categories><subj-group subj-group-type="heading"><subject>Research</subject></subj-group></article-categories><title-group><article-title>Populations at risk for severe or complicated influenza illness: systematic review and meta-analysis</article-title></title-group><contrib-group><contrib contrib-type="author" corresp="no"><name><surname>Mertz</surname><given-names>Dominik</given-names></name><role>assistant professor</role><xref ref-type="aff" rid="aff1">1</xref><xref ref-type="aff" rid="aff2">2</xref></contrib><contrib contrib-type="author" corresp="no"><name><surname>Kim</surname><given-names>Tae Hyong</given-names></name><role>researcher</role><xref ref-type="aff" rid="aff2">2</xref></contrib><contrib contrib-type="author" corresp="no"><name><surname>Johnstone</surname><given-names>Jennie</given-names></name><role>researcher</role><xref ref-type="aff" rid="aff2">2</xref></contrib><contrib contrib-type="author" corresp="no"><name><surname>Lam</surname><given-names>Po-Po</given-names></name><role>researcher</role><xref ref-type="aff" rid="aff3">3</xref><xref ref-type="aff" rid="aff4">4</xref></contrib><contrib contrib-type="author" corresp="no"><name><surname>Science</surname><given-names>Michelle</given-names></name><role>staff physician</role><xref ref-type="aff" rid="aff5">5</xref></contrib><contrib contrib-type="author" corresp="no"><name><surname>Kuster</surname><given-names>Stefan P</given-names></name><role>staff physician</role><xref ref-type="aff" rid="aff6">6</xref></contrib><contrib contrib-type="author" corresp="no"><name><surname>Fadel</surname><given-names>Shaza A</given-names></name><role>researcher</role><xref ref-type="aff" rid="aff4">4</xref></contrib><contrib contrib-type="author" corresp="no"><name><surname>Tran</surname><given-names>Dat</given-names></name><role>assistant professor</role><xref ref-type="aff" rid="aff5">5</xref></contrib><contrib contrib-type="author" corresp="no"><name><surname>Fernandez</surname><given-names>Eduardo</given-names></name><role>researcher</role><xref ref-type="aff" rid="aff2">2</xref></contrib><contrib contrib-type="author" corresp="no"><name><surname>Bhatnagar</surname><given-names>Neera</given-names></name><role>librarian</role><xref ref-type="aff" rid="aff7">7</xref></contrib><contrib contrib-type="author" corresp="yes"><name><surname>Loeb</surname><given-names>Mark</given-names></name><role>professor</role><xref ref-type="aff" rid="aff2">2</xref><xref ref-type="aff" rid="aff8">8</xref><xref ref-type="aff" rid="aff9">9</xref></contrib><aff id="aff1"><label>1</label>Department of Medicine, McMaster University, Hamilton, ON, Canada</aff><aff id="aff2"><label>2</label>Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton</aff><aff id="aff3"><label>3</label>Mount Sinai Hospital, Toronto, ON, Canada</aff><aff id="aff4"><label>4</label>Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto</aff><aff id="aff5"><label>5</label>Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada</aff><aff id="aff6"><label>6</label>University Hospital and University of Zurich, Zurich, Switzerland</aff><aff id="aff7"><label>7</label>Health Sciences Library, McMaster University, Hamilton</aff><aff id="aff8"><label>8</label>Department of Pathology and Molecular Medicine, McMaster University, Hamilton</aff><aff id="aff9"><label>9</label>Michael G DeGroote Institute for Infectious Disease Research, McMaster University, Hamilton</aff></contrib-group><author-notes><corresp>Correspondence to: M Loeb Department of Pathology and Molecular Medicine, McMaster University MDCL 3203, 1200 Main St. W, Hamilton, ON, Canada L8N 3Z5 <email>loebm@mcmaster.ca</email></corresp></author-notes><pub-date pub-type="collection"><year>2013</year></pub-date><pub-date pub-type="epub-original"><year>2013</year></pub-date><volume>347</volume><volume-id pub-id-type="other">347</volume-id><volume-id pub-id-type="other">347</volume-id><elocation-id>f5061</elocation-id><history><date date-type="accepted"><day>22</day><month>July</month><year>2013</year></date></history><permissions><copyright-statement>© Mertz et al 2013</copyright-statement><copyright-year>2013</copyright-year><copyright-holder>Mertz et al</copyright-holder><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc/3.0/"><p>This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: <ext-link xlink:href="http://creativecommons.org/licenses/by-nc/3.0/" ext-link-type="uri">http://creativecommons.org/licenses/by-nc/3.0/</ext-link>.</p></license></permissions><self-uri content-type="pdf" xlink:role="full-text" xlink:href="bmj-347-bmj-f5061.pdf"></self-uri><abstract><p><bold>Objective</bold> To evaluate risk factors for severe outcomes in patients with seasonal and pandemic influenza.</p><p><bold>Design</bold> Systematic review.</p><p><bold>Study selection</bold> 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.</p><p><bold>Data sources</bold> Medline, Embase, CINAHL, Global Health, and the Cochrane Central Register of Controlled Trials to March 2011.</p><p><bold>Risk of bias assessment</bold> Newcastle-Ottawa scale to assess the risk of bias. GRADE framework to evaluate the quality of evidence.</p><p><bold>Results</bold> 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).</p><p><bold>Conclusion</bold> 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.</p></abstract></article-meta></front></article></istex:document></istex:metadataXml><mods version="3.6"><titleInfo><title>Populations at risk for severe or complicated influenza illness: systematic review and meta-analysis</title></titleInfo><titleInfo type="alternative" contentType="CDATA"><title>Populations at risk for severe or complicated influenza illness: systematic review and meta-analysis</title></titleInfo><name type="personal"><namePart type="given">Dominik</namePart><namePart type="family">Mertz</namePart><affiliation>Department of Medicine, McMaster University, Hamilton, ON, Canada</affiliation><affiliation>Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton</affiliation><affiliation>E-mail: loebm@mcmaster.ca</affiliation><description>Correspondence to: M Loeb Department of Pathology and Molecular Medicine, McMaster University MDCL 3203, 1200 Main St. W, Hamilton, ON, Canada L8N 3Z5</description><description>assistant professor</description><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Tae Hyong</namePart><namePart type="family">Kim</namePart><affiliation>Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton</affiliation><affiliation>E-mail: loebm@mcmaster.ca</affiliation><description>Correspondence to: M Loeb Department of Pathology and Molecular Medicine, McMaster University MDCL 3203, 1200 Main St. W, Hamilton, ON, Canada L8N 3Z5</description><description>researcher</description><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Jennie</namePart><namePart type="family">Johnstone</namePart><affiliation>Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton</affiliation><affiliation>E-mail: loebm@mcmaster.ca</affiliation><description>Correspondence to: M Loeb Department of Pathology and Molecular Medicine, McMaster University MDCL 3203, 1200 Main St. W, Hamilton, ON, Canada L8N 3Z5</description><description>researcher</description><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Po-Po</namePart><namePart type="family">Lam</namePart><affiliation>Mount Sinai Hospital, Toronto, ON, Canada</affiliation><affiliation>Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto</affiliation><affiliation>E-mail: loebm@mcmaster.ca</affiliation><description>Correspondence to: M Loeb Department of Pathology and Molecular Medicine, McMaster University MDCL 3203, 1200 Main St. W, Hamilton, ON, Canada L8N 3Z5</description><description>researcher</description><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Michelle</namePart><namePart type="family">Science</namePart><affiliation>Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada</affiliation><affiliation>E-mail: loebm@mcmaster.ca</affiliation><description>Correspondence to: M Loeb Department of Pathology and Molecular Medicine, McMaster University MDCL 3203, 1200 Main St. W, Hamilton, ON, Canada L8N 3Z5</description><description>staff physician</description><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Stefan P</namePart><namePart type="family">Kuster</namePart><affiliation>University Hospital and University of Zurich, Zurich, Switzerland</affiliation><affiliation>E-mail: loebm@mcmaster.ca</affiliation><description>Correspondence to: M Loeb Department of Pathology and Molecular Medicine, McMaster University MDCL 3203, 1200 Main St. W, Hamilton, ON, Canada L8N 3Z5</description><description>staff physician</description><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Shaza A</namePart><namePart type="family">Fadel</namePart><affiliation>Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto</affiliation><affiliation>E-mail: loebm@mcmaster.ca</affiliation><description>Correspondence to: M Loeb Department of Pathology and Molecular Medicine, McMaster University MDCL 3203, 1200 Main St. W, Hamilton, ON, Canada L8N 3Z5</description><description>researcher</description><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Dat</namePart><namePart type="family">Tran</namePart><affiliation>Department of Pediatrics, The Hospital for Sick Children, University of Toronto, ON, Canada</affiliation><affiliation>E-mail: loebm@mcmaster.ca</affiliation><description>Correspondence to: M Loeb Department of Pathology and Molecular Medicine, McMaster University MDCL 3203, 1200 Main St. W, Hamilton, ON, Canada L8N 3Z5</description><description>assistant professor</description><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Eduardo</namePart><namePart type="family">Fernandez</namePart><affiliation>Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton</affiliation><affiliation>E-mail: loebm@mcmaster.ca</affiliation><description>Correspondence to: M Loeb Department of Pathology and Molecular Medicine, McMaster University MDCL 3203, 1200 Main St. W, Hamilton, ON, Canada L8N 3Z5</description><description>researcher</description><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Neera</namePart><namePart type="family">Bhatnagar</namePart><affiliation>Health Sciences Library, McMaster University, Hamilton</affiliation><affiliation>E-mail: loebm@mcmaster.ca</affiliation><description>Correspondence to: M Loeb Department of Pathology and Molecular Medicine, McMaster University MDCL 3203, 1200 Main St. W, Hamilton, ON, Canada L8N 3Z5</description><description>librarian</description><role><roleTerm type="text">author</roleTerm></role></name><name type="personal" displayLabel="corresp"><namePart type="given">Mark</namePart><namePart type="family">Loeb</namePart><affiliation>Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton</affiliation><affiliation>Department of Pathology and Molecular Medicine, McMaster University, Hamilton</affiliation><affiliation>Michael G DeGroote Institute for Infectious Disease Research, McMaster University, Hamilton</affiliation><affiliation>E-mail: loebm@mcmaster.ca</affiliation><affiliation>E-mail: loebm@mcmaster.ca</affiliation><description>Correspondence to: M Loeb Department of Pathology and Molecular Medicine, McMaster University MDCL 3203, 1200 Main St. W, Hamilton, ON, Canada L8N 3Z5</description><description>professor</description><role><roleTerm type="text">author</roleTerm></role></name><typeOfResource>text</typeOfResource><genre type="research-article" displayLabel="research-article" authority="ISTEX" authorityURI="https://content-type.data.istex.fr" valueURI="https://content-type.data.istex.fr/ark:/67375/XTP-1JC4F85T-7">research-article</genre><originInfo><publisher>British Medical Journal Publishing Group</publisher><dateIssued encoding="w3cdtf">2013</dateIssued><copyrightDate encoding="w3cdtf">2013</copyrightDate></originInfo><language><languageTerm type="code" authority="iso639-2b">eng</languageTerm><languageTerm type="code" authority="rfc3066">en</languageTerm></language><abstract>Objective To evaluate risk factors for severe outcomes in patients with seasonal and pandemic influenza. Design 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. Results 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). Conclusion 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.</abstract><relatedItem type="host"><titleInfo><title>BMJ : British Medical Journal</title></titleInfo><titleInfo type="abbreviated"><title>BMJ</title></titleInfo><genre type="journal" authority="ISTEX" authorityURI="https://publication-type.data.istex.fr" valueURI="https://publication-type.data.istex.fr/ark:/67375/JMC-0GLKJH51-B">journal</genre><identifier type="ISSN">0959-8138</identifier><identifier type="eISSN">1756-1833</identifier><identifier type="PublisherID">bmj</identifier><identifier type="PublisherID-hwp">bmj</identifier><identifier type="PublisherID-nlm-ta">BMJ</identifier><part><date>2013</date><detail type="volume"><caption>vol.</caption><number>347</number></detail></part></relatedItem><identifier type="istex">76681876E6A34DBDA0B25341C91847422B62C2C8</identifier><identifier type="ark">ark:/67375/NVC-ZPKR88ML-5</identifier><identifier type="DOI">10.1136/bmj.f5061</identifier><identifier type="href">bmj-347-bmj-f5061.pdf</identifier><identifier type="ArticleID">merd010478</identifier><identifier type="local">bmj;347/aug23_1/f5061</identifier><accessCondition type="use and reproduction" contentType="open-access">This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. 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