title: An ecological study of the determinants of differences in 2009 pandemic influenza mortality rates between countries in Europe.
abstract: BACKGROUND
  Pandemic A (H1N1) 2009 mortality rates varied widely from one country to another. Our aim was to identify potential socioeconomic determinants of pandemic mortality and explain between-country variation.
  
  
  METHODS
  Based on data from a total of 30 European countries, we applied random-effects Poisson regression models to study the relationship between pandemic mortality rates (May 2009 to May 2010) and a set of representative environmental, health care-associated, economic and demographic country-level parameters. The study was completed by June 2010.
  
  
  RESULTS
  Most regression approaches indicated a consistent, statistically significant inverse association between pandemic influenza-related mortality and per capita government expenditure on health. The findings were similar in univariable [coefficient: -0.00028, 95% Confidence Interval (CI): -0.00046, -0.00010, p = 0.002] and multivariable analyses (including all covariates, coefficient: -0.00107, 95% CI: -0.00196, -0.00018, p = 0.018). The estimate was barely insignificant when the multivariable model included only significant covariates from the univariate step (coefficient: -0.00046, 95% CI: -0.00095, 0.00003, p = 0.063).
  
  
  CONCLUSIONS
  Our findings imply a significant inverse association between public spending on health and pandemic influenza mortality. In an attempt to interpret the estimated coefficient (-0.00028) for the per capita government expenditure on health, we observed that a rise of 100 international dollars was associated with a reduction in the pandemic influenza mortality rate by approximately 2.8%. However, further work needs to be done to unravel the mechanisms by which reduced government spending on health may have affected the 2009 pandemic influenza mortality.
authors: Hellenic Centre for Disease Control and Prevention, Athens, Greece.
authors: Georgios
authors: G
authors: Nikolopoulos
authors: Pantelis
authors: P
authors: Bagos
authors: Theodoros
authors: T
authors: Lytras
authors: Stefanos
authors: S
authors: Bonovas
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