title: Epidemiological characteristics and underlying risk factors for mortality during the autumn 2009 pandemic wave in Mexico.
abstract: BACKGROUND
  Elucidating the role of the underlying risk factors for severe outcomes of the 2009 A/H1N1 influenza pandemic could be crucial to define priority risk groups in resource-limited settings in future pandemics.
  
  
  METHODS
  We use individual-level clinical data on a large series of ARI (acute respiratory infection) hospitalizations from a prospective surveillance system of the Mexican Social Security medical system to analyze clinical features at presentation, admission delays, selected comorbidities and receipt of seasonal vaccine on the risk of A/H1N1-related death. We considered ARI hospitalizations and inpatient-deaths, and recorded demographic, geographic, and medical information on individual patients during August-December, 2009.
  
  
  RESULTS
  Seasonal influenza vaccination was associated with a reduced risk of death among A/H1N1 inpatients (OR = 0.43 (95% CI: 0.25, 0.74)) after adjustment for age, gender, geography, antiviral treatment, admission delays, comorbidities and medical conditions. However, this result should be interpreted with caution as it could have been affected by factors not directly measured in our study. Moreover, the effect of antiviral treatment against A/H1N1 inpatient death did not reach statistical significance (OR = 0.56 (95% CI: 0.29, 1.10)) probably because only 8.9% of A/H1N1 inpatients received antiviral treatment. Moreover, diabetes (OR = 1.6) and immune suppression (OR = 2.3) were statistically significant risk factors for death whereas asthmatic persons (OR = 0.3) or pregnant women (OR = 0.4) experienced a reduced fatality rate among A/H1N1 inpatients. We also observed an increased risk of death among A/H1N1 inpatients with admission delays >2 days after symptom onset (OR = 2.7). Similar associations were also observed for A/H1N1-negative inpatients.
  
  
  CONCLUSIONS
  Geographical variation in identified medical risk factors including prevalence of diabetes and immune suppression may in part explain between-country differences in pandemic mortality burden. Furthermore, access to care including hospitalization without delay and antiviral treatment and are also important factors, as well as vaccination coverage with the 2008-09 trivalent inactivated influenza vaccine.
authors: Division of Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, Bethesda, Maryland, United States of America. gchowell@asu.edu
authors: Gerardo
authors: G
authors: Chowell
authors: Santiago
authors: S
authors: Echevarría-Zuno
authors: Cécile
authors: C
authors: Viboud
authors: Lone
authors: L
authors: Simonsen
authors: Mark A
authors: MA
authors: Miller
authors: Irma
authors: I
authors: Fernández-Gárate
authors: Cesar
authors: C
authors: González-Bonilla
authors: Víctor H
authors: VH
authors: Borja-Aburto
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002648:Child; D002675:Child, Preschool; D005260:Female; D005843:Geography; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D053118:Influenza A Virus, H1N1 Subtype / Q000235:genetics*; D007251:Influenza, Human / Q000453:epidemiology* / Q000401:mortality* / Q000821:virology; D007297:Inpatients; D008297:Male; D008800:Mexico; D008875:Middle Aged; D016017:Odds Ratio; D058873:Pandemics; D011446:Prospective Studies; D012307:Risk Factors; D012621:Seasons; D014611:Vaccination