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Multicenter Study
, 339, b5213

Mortality From Pandemic A/H1N1 2009 Influenza in England: Public Health Surveillance Study

Multicenter Study

Mortality From Pandemic A/H1N1 2009 Influenza in England: Public Health Surveillance Study

Liam J Donaldson et al. BMJ.


Objective: To establish mortality from pandemic A/H1N1 2009 influenza up to 8 November 2009.

Design: Investigation of all reported deaths related to pandemic A/H1N1 in England.

Setting: Mandatory reporting systems established in acute hospitals and primary care.

Participants: Physicians responsible for the patient.

Main outcome measures: Numbers of deaths from influenza combined with mid-range estimates of numbers of cases of influenza to calculate age specific case fatality rates. Underlying conditions, time course of illness, and antiviral treatment.

Results: With the official mid-range estimate for incidence of pandemic A/H1N1, the overall estimated case fatality rate was 26 (range 11-66) per 100 000. It was lowest for children aged 5-14 (11 (range 3-36) per 100 000) and highest for those aged >or=65 (980 (range 300-3200) per 100 000). In the 138 people in whom the confirmed cause of death was pandemic A/H1N1, the median age was 39 (interquartile range 17-57). Two thirds of patients who died (92, 67%) would now be eligible for the first phase of vaccination in England. Fifty (36%) had no, or only mild, pre-existing illness. Most patients (108, 78%) had been prescribed antiviral drugs, but of these, 82 (76%) did not receive them within the first 48 hours of illness.

Conclusions: Viewed statistically, mortality in this pandemic compares favourably with 20th century influenza pandemics. A lower population impact than previous pandemics, however, is not a justification for public health inaction. Our data support the priority vaccination of high risk groups. We observed delayed antiviral use in most fatal cases, which suggests an opportunity to reduce deaths by making timely antiviral treatment available, although the lack of a control group limits the ability to extrapolate from this observation. Given that a substantial minority of deaths occur in previously healthy people, there is a case for extending the vaccination programme and for continuing to make early antiviral treatment widely available.

Conflict of interest statement

Competing interests: LJD is the chief medical officer for England. In this role he advises the government on public health policy, including the management of the pandemic. PDR, BME, FECG, IEY, and OTM support him in this task. All authors have completed the unified competing interest form at (available on request from the corresponding author) (URL) and declare (1) no financial support for the submitted work from anyone other than their employer; (2) no financial relationships with commercial entities that might have an interest in the submitted work; (3) no spouses, partners, or children with relationships with commercial entities that might have an interest in the submitted work; and (4) no non-financial interests that may be relevant to the submitted work.


Fig 1 Weekly estimated incidence of pandemic A/H1N1 cases (mid-range estimates) and confirmed deaths in England (source: Health Protection Agency)
Fig 2 Age and pre-morbid health of patients who died from causes related to pandemic A/H1N1

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