A Danielle Iuliano1, Katherine M Roguski2, Howard H Chang3, David J Muscatello4, Rakhee Palekar5, Stefano Tempia2, Cheryl Cohen6, Jon Michael Gran7, Dena Schanzer8, Benjamin J Cowling9, Peng Wu9, Jan Kyncl10, Li Wei Ang11, Minah Park9, Monika Redlberger-Fritz12, Hongjie Yu13, Laura Espenhain14, Anand Krishnan15, Gideon Emukule16, Liselotte van Asten17, Susana Pereira da Silva18, Suchunya Aungkulanon19, Udo Buchholz20, Marc-Alain Widdowson16, Joseph S Bresee2. 1. Influenza Division, Centers for Disease Control and Prevention, Atlanta, GA, USA. Electronic address: aiuliano@cdc.gov. 2. Influenza Division, Centers for Disease Control and Prevention, Atlanta, GA, USA. 3. Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA. 4. Department of Biostatistics and Bioinformatics, University of New South Wales, Sydney, NSW, Australia. 5. Pan American Health Organization, Washington, DC, USA. 6. Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa. 7. Oslo Centre for Biostatistics and Epidemiology, Oslo University Hospital and University of Oslo, Norway; Domain for Infection Control and Environmental Health, Norwegian Institute of Public Health, Oslo, Norway. 8. Infection Disease Prevention and Control Branch, Public Health Agency Canada, Ottawa, ON, Canada. 9. WHO Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China. 10. Department of Infectious Diseases Epidemiology, National Institute of Public Health, Prague, Czech Republic. 11. Department of Infectious Diseases Epidemiology, Ministry of Health, Singapore. 12. Department of Virology, Medical University of Vienna, Vienna, Austria. 13. Key Laboratory of Surveillance and Early-warning on Infectious Disease, Division of Infectious Disease, Chinese Center for Disease Control and Prevention, Beijing, China. 14. Department of Infectious Disease Epidemiology, Statens Serum Institut, Copenhagen, Denmark. 15. All India Institute of Medical Sciences, New Delhi, India. 16. Centers for Disease Control and Prevention-Kenya, Nairobi, Kenya. 17. National Institute for Public Health and the Environment, Bilthoven, Netherlands. 18. Department of Epidemiology, National Health Institute Doutor Ricardo Jorge, Lisbon, Portugal. 19. International Health Policy Program, Ministry of Public Health, Nonthaburi, Thailand. 20. Department for Infectious Disease Epidemiology, Robert Koch-Institute, Berlin, Germany.
Abstract
BACKGROUND: Estimates of influenza-associated mortality are important for national and international decision making on public health priorities. Previous estimates of 250 000-500 000 annual influenza deaths are outdated. We updated the estimated number of global annual influenza-associated respiratory deaths using country-specific influenza-associated excess respiratory mortality estimates from 1999-2015. METHODS: We estimated country-specific influenza-associated respiratory excess mortality rates (EMR) for 33 countries using time series log-linear regression models with vital death records and influenza surveillance data. To extrapolate estimates to countries without data, we divided countries into three analytic divisions for three age groups (<65 years, 65-74 years, and ≥75 years) using WHO Global Health Estimate (GHE) respiratory infection mortality rates. We calculated mortality rate ratios (MRR) to account for differences in risk of influenza death across countries by comparing GHE respiratory infection mortality rates from countries without EMR estimates with those with estimates. To calculate death estimates for individual countries within each age-specific analytic division, we multiplied randomly selected mean annual EMRs by the country's MRR and population. Global 95% credible interval (CrI) estimates were obtained from the posterior distribution of the sum of country-specific estimates to represent the range of possible influenza-associated deaths in a season or year. We calculated influenza-associated deaths for children younger than 5 years for 92 countries with high rates of mortality due to respiratory infection using the same methods. FINDINGS: EMR-contributing countries represented 57% of the global population. The estimated mean annual influenza-associated respiratory EMR ranged from 0·1 to 6·4 per 100 000 individuals for people younger than 65 years, 2·9 to 44·0 per 100 000 individuals for people aged between 65 and 74 years, and 17·9 to 223·5 per 100 000 for people older than 75 years. We estimated that 291 243-645 832 seasonal influenza-associated respiratory deaths (4·0-8·8 per 100 000 individuals) occur annually. The highest mortality rates were estimated in sub-Saharan Africa (2·8-16·5 per 100 000 individuals), southeast Asia (3·5-9·2 per 100 000 individuals), and among people aged 75 years or older (51·3-99·4 per 100 000 individuals). For 92 countries, we estimated that among children younger than 5 years, 9243-105 690 influenza-associated respiratory deaths occur annually. INTERPRETATION: These global influenza-associated respiratory mortality estimates are higher than previously reported, suggesting that previous estimates might have underestimated disease burden. The contribution of non-respiratory causes of death to global influenza-associated mortality should be investigated. FUNDING: None.
BACKGROUND: Estimates of influenza-associated mortality are important for national and international decision making on public health priorities. Previous estimates of 250 000-500 000 annual influenza deaths are outdated. We updated the estimated number of global annual influenza-associated respiratory deaths using country-specific influenza-associated excess respiratory mortality estimates from 1999-2015. METHODS: We estimated country-specific influenza-associated respiratory excess mortality rates (EMR) for 33 countries using time series log-linear regression models with vital death records and influenza surveillance data. To extrapolate estimates to countries without data, we divided countries into three analytic divisions for three age groups (<65 years, 65-74 years, and ≥75 years) using WHO Global Health Estimate (GHE) respiratory infection mortality rates. We calculated mortality rate ratios (MRR) to account for differences in risk of influenza death across countries by comparing GHE respiratory infection mortality rates from countries without EMR estimates with those with estimates. To calculate death estimates for individual countries within each age-specific analytic division, we multiplied randomly selected mean annual EMRs by the country's MRR and population. Global 95% credible interval (CrI) estimates were obtained from the posterior distribution of the sum of country-specific estimates to represent the range of possible influenza-associated deaths in a season or year. We calculated influenza-associated deaths for children younger than 5 years for 92 countries with high rates of mortality due to respiratory infection using the same methods. FINDINGS: EMR-contributing countries represented 57% of the global population. The estimated mean annual influenza-associated respiratory EMR ranged from 0·1 to 6·4 per 100 000 individuals for people younger than 65 years, 2·9 to 44·0 per 100 000 individuals for people aged between 65 and 74 years, and 17·9 to 223·5 per 100 000 for people older than 75 years. We estimated that 291 243-645 832 seasonal influenza-associated respiratory deaths (4·0-8·8 per 100 000 individuals) occur annually. The highest mortality rates were estimated in sub-Saharan Africa (2·8-16·5 per 100 000 individuals), southeast Asia (3·5-9·2 per 100 000 individuals), and among people aged 75 years or older (51·3-99·4 per 100 000 individuals). For 92 countries, we estimated that among children younger than 5 years, 9243-105 690 influenza-associated respiratory deaths occur annually. INTERPRETATION: These global influenza-associated respiratory mortality estimates are higher than previously reported, suggesting that previous estimates might have underestimated disease burden. The contribution of non-respiratory causes of death to global influenza-associated mortality should be investigated. FUNDING: None.
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