Scientific letter
Analysis of severe cases of epidemic influenza and its lethality in the last 5 flu seasons
Análisis de los casos graves de gripe epidémica y su letalidad en las últimas 5 temporadas gripales
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The objectives of this surveillance are to provide an estimate of severity in seasonal epidemics or influenza pandemics, to determine the impact they have on different health services. Likewise, it allows to identify and characterize the risk groups regarding the presentation of these cases by the different circulating influenza viruses or their association to certain underlying diseases.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Patients with influenza symptoms confirmed by the laboratory and requiring hospital admission due to the severity of their condition, that is, pneumonia, multiorgan failure, respiratory distress or admission to the ICU, are considered severe cases of influenza; likewise, it includes patients who develop the above signs and symptoms during their hospital stay due to another cause.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">We have reviewed the severe cases of influenza with hospital admission observed in the last 5 flu epidemic seasons in the University Hospital Son Espases, which acts as a reference hospital for this disease and covers a population of 200,000 inhabitants. Influenza confirmation was performed on patients’ respiratory samples using a commercially available molecular amplification technique that identifies and differentiates influenza types and subtypes (Allplex™, Seegene, Seoul, South Korea). Patient data were extracted from the medical records and Virology laboratory.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Throughout the last 5 flu seasons, 256 cases of severe flu have been detected. Of these, 121 (47.2%) occurred in women and 135 (52.8%) in men (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). 29 (11.3%) patients died, 19 (65.5%) were women and 10 (34.5%) were men. Of the total number of women with severe influenza, 19 died (15.7%), and of the total of men, 10 (7.4%) died (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Mortality rates in women have ranged from 7.1% in the 2012–2013 season, with a mixed flu circulation A (H1N1) pdm09 and influenza B, up to 25% in the 2016–2017 season, with influenza A (H3N2) being the most predominant. In men, the lowest percentage was detected in the 2012–2013 season, with 4.1%, and the highest, in the 2015–2016 season, with 11.3%.</p><p id="par0030" class="elsevierStylePara elsevierViewall">A progressive increase in the case-fatality rate associated with severe influenza has been observed from the 2012–2013 season (5.3%) to the 2016–2017 season (18.5%) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05). The low case-fatality rate of severe influenza B cases is verified throughout the study period.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Of all severe cases, 40.2% were caused by influenza A (H1N1) pdm09, 41.1% by influenza A (H3N2) and 18.7% by influenza B. The case-fatality rate associated with influenza subtypes were 10.6% for A (H1N1) pdm09, 16.1% for A (H3N2) and 2.1% for influenza B.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The criteria for admission of severe cases were pneumonia (43.5%), admission to the ICU (29.2%), respiratory distress (22.7%) and multi-organ failure (4.4%) (one patient could meet more than one clinical criterion simultaneously).</p><p id="par0045" class="elsevierStylePara elsevierViewall">This study highlights a progressive case-fatality rate increase in severe cases of influenza; and although there were only 27 of them in the last season, their case-fatality rate was 18.5%, the highest of the entire study. This case-fatality rate seems to be associated both with the flu infection itself (pathogenicity) and with the host characteristics.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The lower case-fatality rate of severe cases caused by subtype A (H1N1) pdm09 is confirmed, even though the number of cases is almost the same as that caused by subtype A (H3N2), as observed in the pandemic of 2009, and that could be due to the fact that it mainly affects previously healthy young people.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">A higher case-fatality rate has been detected in severe cases of influenza affecting the female population (15.7% versus 7.4%); this could be due to the longer life expectancy of women and the increased vulnerability over the years.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">On the other hand, there is evidence that severe cases caused by subtype A (H3N2) show a higher case-fatality rate, probably because they mainly affect the elderly population, with significant underlying diseases.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> Therefore, initiating specific antiviral treatment as soon as possible after the suspicion or diagnosis of influenza is recommended, regardless of whether the subtype involved in the severe case is known or not.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">A lower incidence of severe cases caused by influenza B has been observed (it has only represented 18.7% of all severe cases) and is associated with a very low case-fatality rate (2.1%) compared to influenza A. Influenza B mainly affects the paediatric and youth population and hardly associates significant complications.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In short, case-fatality rate in severe hospitalized flu cases seems to depend basically on the influenza type and subtype involved, which in turn vary in each seasonal flu epidemic. In our study, it could be inferred that the sex of the patient would be a predisposing factor to a higher influenza fatality, although a much larger study would be necessary to confirm it.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as: Reina J, López de Bilbao C, Riera M. Análisis de los casos graves de gripe epidémica y su letalidad en las últimas 5 temporadas gripales. Med Clin (Barc). 2018;151:82–83.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Season \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Women \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Men \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">A (H1N1) pdm09 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">A (H3N2) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">B \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2012–2013 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14/1<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24/1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2/2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">38/2 (5.3)<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2013–2014 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32/3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">28/2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">35/2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25/3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">60/5 (8.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2014–2015 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">33/7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">28/1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4/1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">50/7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">61/8 (13.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2015–2016 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26/4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">44/5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">47/8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">22/1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">70/9 (12.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2016–2017 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16/4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11/1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">27/5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">27/5 (18.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">121/19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">135/10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">103/11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">105/17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">48/1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">256/29 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15.7<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1813197.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Number of cases/number of deaths.</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Case-fatality rate.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Characteristics of severe cases of influenza, distribution of subtypes and associated case-fatality rate.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mantenimiento de la vigilancia de gripe estacional a través del sistema de vigilancia de gripe en España. Vigilancia epidemiológica de casos humanos por virus pandémico (H1N1)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Red Nacional de Vigilancia Epidemiológica" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "2009" "editorial" => "Ministerio de Sanidad y Consumo" "editorialLocalizacion" => "Madrid" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guía de procedimientos para la vigilancia de gripe en España" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Sistema de Vigilancia de la gripe en España" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "2014" "editorial" => "Ministerio de Sanidad y Consumo" "editorialLocalizacion" => "Madrid" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Two years after pandemic influenza A/2009/H1N1: what have we learned?" 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Barr" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/s12879-017-2432-7" "Revista" => array:5 [ "tituloSerie" => "BMC Infect Dis" "fecha" => "2017" "volumen" => "17" "paginaInicial" => "337" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28494805" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Burden of influenza B virus infections in Scotland in 2012/13 and epidemiological investigations between 2000 and 2012" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "H. Harvala" 1 => "D. Smith" 2 => "K. Salvatierra" 3 => "R. Gunson" 4 => "B. von Wissmann" 5 => "A. Reynolds" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Euro Surveill" "fecha" => "2014" "volumen" => "19" "paginaInicial" => "pii=20903" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015100000002/v1_201807220502/S2387020618302134/v1_201807220502/en/main.assets" "Apartado" => array:4 [ "identificador" => "43311" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015100000002/v1_201807220502/S2387020618302134/v1_201807220502/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020618302134?idApp=UINPBA00004N" ]
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