Abstract
.Data on the epidemiology of severe acute respiratory illness (SARI) in adults from low-income, high human immunodeficiency virus (HIV) prevalence African settings are scarce. We conducted adult SARI surveillance in Blantyre, Malawi. From January 2011 to December 2013, individuals aged ≥ 15 years with SARI (both inpatients and outpatients) were enrolled at a large teaching hospital in Blantyre, Malawi. Nasopharyngeal aspirates were tested for influenza and other respiratory viruses by polymerase chain reaction. We estimated hospital-attended influenza-positive SARI incidence rates and assessed factors associated with influenza positivity and clinical severity (Modified Early Warning Score > 4). We enrolled 1,126 SARI cases; 163 (14.5%) were positive for influenza. Human immunodeficiency virus prevalence was 50.3%. Annual incidence of hospital-attended influenza-associated SARI was 9.7–16.8 cases per 100,000 population. Human immunodeficiency virus was associated with a 5-fold greater incidence (incidence rate ratio 4.91, 95% confidence interval [CI]: 3.83–6.32). On multivariable analysis, female gender, as well as recruitment in hot, rainy season (December to March; adjusted odds ratios (aOR): 2.82, 95% CI: 1.57–5.06) and cool, dry season (April to August; aOR: 2.47, 95% CI: 1.35–4.15), was associated with influenza positivity, whereas influenza-positive patients were less likely to be HIV-infected (aOR: 0.59, 95% CI: 0.43–0.80) or have viral coinfection (aOR: 0.51, 95% CI: 0.36–0.73). Human immunodeficiency virus infection (aOR: 1.86; 95% CI: 1.35–2.56) and recruitment in hot, rainy season (aOR: 4.98, 95% CI: 3.17–7.81) were independently associated with clinical severity. In this high HIV prevalence population, influenza was associated with nearly 15% of hospital-attended SARI. Human immunodeficiency virus infection is an important risk factor for clinical severity in all-cause and influenza-associated SARI. Expanded access to HIV testing and antiretroviral treatment, as well as targeted influenza vaccination, may reduce the burden of SARI in Malawi and other high HIV prevalence settings.
Highlights
Pneumonia is an important cause of morbidity and mortality in adults in sub-Saharan Africa.[1]
Active surveillance for influenza and other respiratory viruses was established at a large urban teaching hospital in Malawi in January 2011. In this high Human immunodeficiency virus (HIV) prevalence and malaria-endemic setting, we aimed to describe the epidemiology and viral etiology and factors associated with clinical severity and influenza positivity among individuals aged 3 15 years with severe acute respiratory illness (SARI) during 2011–2013
Comprehensive hospital-based sentinel surveillance in our high HIV prevalence, malaria-endemic African setting has identified influenza as an important contributor to SARI in adults, substantiating data from other African studies.[9,10]
Summary
Pneumonia is an important cause of morbidity and mortality in adults in sub-Saharan Africa.[1]. Following the 2009 influenza A(H1N1) pandemic, respiratory viral surveillance capacity has increased substantially in Africa.[5] Currently, 23 sub-Saharan African countries contribute data to the WHO Global Surveillance and Response System.[6] Emerging data suggest that influenza viruses are frequently detected in mild (6.7–40.4%) and severe (4.6–25.5%) acute respiratory presentations in the region[7] and are associated with a higher mortality compared with developed settings because of the high prevalence of HIV infection and other comorbidities.[8] only a handful of studies have focused on adults[9,10] and few have comprehensively ascertained HIV status
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