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Volume 19, Number 11—November 2013
Research

Severe Influenza-associated Respiratory Infection in High HIV Prevalence Setting, South Africa, 2009–2011

Cheryl CohenComments to Author , Jocelyn Moyes, Stefano Tempia, Michelle Groom, Sibongile Walaza, Marthi Pretorius, Halima Dawood, Meera Chhagan, Summaya Haffejee, Ebrahim Variava, Kathleen Kahn, Akhona Tshangela, Anne von Gottberg, Nicole Wolter, Adam L. Cohen, Babatyi Kgokong, Marietjie Venter, and Shabir A. Madhi
Author affiliations: National Health Laboratory Service, Johannesburg, South Africa (C. Cohen, J. Moyes, S. Walaza, M. Pretorius, A. Tshangela, A. von Gottberg, N. Wolter, B. Kgokong, M. Venter, S.A. Madhi); University of the Witwatersrand, Johannesburg (C. Cohen, J. Moyes, M. Groom, E. Variava, K. Kahn, A. von Gottberg, N. Wolter, S. A. Madhi); Centers for Disease Control and Prevention, Atlanta, Georgia, USA (S. Tempia, A.L. Cohen); Centers for Disease Control and Prevention–South Africa, Pretoria, South Africa (S. Tempia, A. L. Cohen); University of KwaZulu-Natal, Durban, South Africa (H. Dawood, M. Chhagan, S. Haffejee); Pietermaritzburg Metropolitan Hospital, Pietermaritzburg, South Africa (H. Dawood); Klerksdorp Tshepong Hospital, Klerksdorp, South Africa (E. Variava); Umeå University, Umeå, Sweden (K. Kahn); INDEPTH Network, Accra, Ghana (K. Kahn); University of Pretoria, Pretoria (M. Venter)

Main Article

Table 2

Comparison of the clinical and epidemiologic characteristics of HIV-infected and uninfected patients hospitalized with influenza-associated acute LRTI at 4 sentinel surveillance sites, South Africa 2009–2011*

Characteristic HIV-infected patients† HIV-uninfected patients† Univariate analysis
 Multivariable analysis
OR (95% CI) p value OR (95% CI) p value
Patient demographics
Age group, y <0.001 <0.001
<5 45/358 (13) 290/461 (63) Referent Referent
5–24 38/358 (11) 44/461 (10) 5.6 (3.3–9.5) 4.4 (2.4–8.2)
25–44 212/358 (59) 39/461 (8) 35.0 (22.0–55.7) 24.2 (14.1–41.7)
45–64 61/358 (17) 52/461 (11) 7.6 (4.7–12.3) 6.2 (3.4–11.3)
>65 2/358 (1) 36/461 (8) 0.4 (0.1–1.5) 0.2 (0.04–0.9)
Female sex 253/358 (71) 224/461 (49) 2.5 (1.9–3.4) <0.001 1.9 (1.2–2.8) 0.003
Black African race
 353/358 (99)
 445/460 (97)
 2.4 (0.9–6.6)
 0.096
4.0 (1.1–14.6)
 0.036
Year of hospitalization 0.002
2009 88/358 (25) 151/461 (33) Referent
2010 127/358 (35) 114/461 (25) 1.9 (1.3–2.8)
2011
 143/358 (40)
 196/461 (43)
 1.3 (0.9–1.8)
Co-infections and underlying medical conditions
Underlying condition excluding 
tuberculosis and HIV‡ 25/358 (7) 47/461 (10) 0.7 (0.4–1.1) 0.109 0.4 (0.2–0.8) 0.008
Smoking§ 32/299 (11) 24/151 (16) 0.6 (0.4–1.1) 0.117
Consumed alcohol§ 28/299 (9) 26/151 (17) 0.5 (0.3–0.9) 0.017
Underlying tuberculosis 60/357 (17) 19/461 (4) 4.7 (2.7–8.0) <0.001
Pneumococcal co-infection on PCR¶ 37/345 (11) 17/389 (4) 2.7 (1.5–5.0) <0.001 2.3 (1.0–5.0) 0.043
Viral respiratory co-infection# 82/358 (23) 152/456 (33) 0.6 (0.4–0.8) 0.001
Influenza type B (vs. A) 148/358 (41) 133/461 (29) 1.7 (1.3–2.3) <0.001 1.6 (1.0–2.4) 0.035
Received >2 doses of pneumococcal 
conjugate vaccine**
 3/39 (8)
 53/242 (22)
 0.3 (0.1–1.0)
 0.051
Clinical findings and treatment course
Symptoms >2 d before admission 296/358 (83) 295/461 (64) 2.7 (1.9–3.7) <0.001
Admission to intensive care 0/357 (0) 6/461 (1) Undefined 0.031
Mechanical ventilation 2/357 (1) 4/461 (1) 0.6 (0.1–3.5) 0.612
Oxygen required 142/357 (40) 141/461 (31) 1.5 (1.1–2.0) 0.006
Antimicrobial drugs prescribed at 
admission 351/358 (98) 438/460 (95) 2.5 (1.1–6.0) 0.036
Duration of hospitalization, d <0.001 <0.001
<2 20/352 (6) 149/460 (32) Referent Referent
2–7 217/352 (62) 241/460 (52) 6.7 (4.1–11.1) 2.8 (1.5–5.5)
>7 115/352 (33) 70/460 (15) 12.2 (7.0–21.3) 4.5 (2.1–9.5)
Median duration of hospitalization, d 
(range) 6 (4–8) 3 (1–6) 1.1 (1.05–1.13) <0.001
Case-fatality rate 19/356 (5) 6/461 (1) 4.3 (1.7–10.8) 0.002 3.9 (1.1–14.1) 0.038

*ORs and p values are shown for all variables included in the multivariable model. LRTI, lower respiratory tract infection; OR, odds ratio.
†Values are no. patients/total no. in category (%) except as indicated. Some data are missing or were not recorded.
‡Asthma, other chronic lung disease, chronic heart disease (valvular heart disease, coronary artery disease, or heart failure excluding hypertension), liver disease (cirrhosis or liver failure), renal disease (nephrotic syndrome, chronic renal failure), diabetes mellitis, immunocompromising conditions excluding HIV infection (organ transplant, immunosuppressive therapy, immunoglobulin deficiency, malignancy), neurologic disease (cerebrovascular accident, spinal cord injury, seizures, neuromuscular conditions) or pregnancy. Coexisting illnesses were considered absent in cases for which the medical records stated that the patient had no underlying medical condition or when there was no direct reference to that condition.
§Question asked of patients >12 y of age only.
¶Three additional cases of Streptococcus pneumoniae on blood culture not included
#Co-infection with influenza and >1 of the following: parainfluenza virus 1, 2, or 3; respiratory syncytial virus; enterovirus; human metapneumovirus; adenovirus; rhinovirus.
**Verified only for children <5 y of age.

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Page created: October 31, 2013
Page updated: October 31, 2013
Page reviewed: October 31, 2013
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