Influenza-associated disease burden in mainland China: a systematic review and meta-analysis

Abstract

Influenza causes substantial morbidity and mortality. Many original studies have been carried out to estimate disease burden of influenza in mainland China, while the full disease burden has not yet been systematically reviewed. We did a systematic review and meta-analysis to assess the burden of influenza-associated mortality, hospitalization, and outpatient visit in mainland China. We searched 3 English and 4 Chinese databases with studies published from 2005 to 2019. Studies reporting population-based rates of mortality, hospitalization, or outpatient visit attributed to seasonal influenza were included in the analysis. Fixed-effects or random-effects model was used to calculate pooled estimates of influenza-associated mortality depending on the degree of heterogeneity. Meta-regression was applied to explore the sources of heterogeneity. Publication bias was assessed by funnel plots and Egger's test. We identified 30 studies eligible for inclusion with 17, 8, 5 studies reporting mortality, hospitalization, and outpatient visit associated with influenza, respectively. The pooled influenza-associated all-cause mortality rates were 14.33 and 122.79 per 100,000 persons for all ages and ≥ 65 years age groups, respectively. Studies were highly heterogeneous in aspects of age group, cause of death, statistical model, geographic location, and study period, and these factors could explain 60.14% of the heterogeneity in influenza-associated mortality. No significant publication bias existed in estimates of influenza-associated all-cause mortality. Children aged < 5 years were observed with the highest rates of influenza-associated hospitalizations and ILI outpatient visits. People aged ≥ 65 years and < 5 years contribute mostly to mortality and morbidity burden due to influenza, which calls for targeted vaccination policy for older adults and younger children in mainland China.

Figure 1

Flow diagram for systematic review process. *If several publications reported on the same study, we only included the publication that provided the most data. The flow diagram was drawn using Adobe Illustrator software, version 22.0.0 (https://www.adobe.com/products/illustrator.html).

Figure 2

The distribution of published studies about influenza-associated disease burden. Two studies of mortality burden were not shown in the figure because they reported combined estimates of multiple cities or Disease Surveillance Points (DSP) sites. One study could have estimated influenza disease burden for multiple provinces or cities. The map was drawn using R software, version 3.5.2 (https://www.r-project.org/).