Incidence of influenza virus infection among pregnant women: a systematic review

Abstract

Background: The World Health Organization (WHO) considers pregnant women to be a risk group for severe influenza disease. We conducted a systematic review to evaluate influenza disease incidence in pregnant women in order to inform estimates of influenza vaccine impact for low-resource countries.

Methods: We performed electronic literature searches, targeting studies on the following outcomes in pregnant women: attack rate, hospitalization rate, intensive care unit admission rate, mortality rate, and disability-adjusted life years lost. Only original studies published in peer-reviewed journals that had laboratory confirmation for influenza virus infection and included population-based incidence rates with denominator data were included. We summarized study characteristics in descriptive tables and outcome-specific Forest plots. We generated summary incidence rates using random effects models and assessed statistical heterogeneity by visual examination of Forest plots, and by χ ² and I² tests.

Results: We identified 1543 articles, of which nine articles met the study inclusion criteria. Five were case series, three were cohort studies, and one was a randomized controlled trial. Eight studies were from high-income countries, and one was from an upper middle-income country. Six studies reported results for pandemic influenza, and three reported seasonal influenza. Statistical heterogeneity was high for all outcomes, and methodologies and duration of surveillance varied considerably among studies; therefore, we did not perform meta-analyses.

Conclusions: Study quality was very low according to GRADE criteria. More data on influenza disease incidence in pregnant women, particularly in low- and middle-income countries and for seasonal influenza disease, are needed to inform public health decision-making.

Fig. 1

Flow diagram of systematic literature review of influenza illness in pregnancy

Fig. 2

a Forest plot showing distribution of incidence of influenza virus infectionof any kind from serology studies in pregnant women, per 10,000 pregnancies, with 95% confidence intervals. b Forest plot showing distribution of incidence of symptomatic influenza virus infections in pregnant women, per 10,000 pregnancies, with 95% confidence intervals. c Forest plot showing distribution of incidence of influenza-associated hospital admissions in pregnant women, per 10,000 pregnancies, with 95% confidence intervals. d Forest plot showing distribution of incidence of influenza-associated ICU admissions in pregnant women, per 10,000 pregnancies, with 95% confidence intervals. e Forest plot showing distribution of incidence of influenza-associated deaths in pregnant women, per 10,000 pregnancies, with 95% confidence intervals