• Dominik Mertz, Tae Hyong Kim, Jennie Johnstone, Po-Po Lam, Michelle Science, Stefan P Kuster, Shaza A Fadel, Dat Tran, Eduardo Fernandez, Neera Bhatnagar, and Mark Loeb.
• Department of Medicine, McMaster University, Hamilton, ON, Canada.
• BMJ. 2013 Jan 1;347:f5061.

ObjectiveTo evaluate risk factors for severe outcomes in patients with seasonal and pandemic influenza.DesignSystematic review.Study SelectionObservational studies reporting on risk factor-outcome combinations of interest in participants with influenza. Outcomes included death, ventilator support, admission to hospital, admission to an intensive care unit, pneumonia, and composite outcomes.Data SourcesMedline, Embase, CINAHL, Global Health, and the Cochrane Central Register of Controlled Trials to March 2011.Risk Of Bias AssessmentNewcastle-Ottawa scale to assess the risk of bias. GRADE framework to evaluate the quality of evidence.Results63 537 articles were identified of which 234 with a total of 610 782 participants met the inclusion criteria. The evidence supporting risk factors for severe outcomes of influenza ranged from being limited to absent. This was particularly relevant for the relative lack of data for non-2009 H1N1 pandemics and for seasonal influenza studies. Limitations in the published literature included lack of power and lack of adjustment for confounders was widespread: adjusted risk estimates were provided for only 5% of risk factor-outcome comparisons in 39 of 260 (15%) studies. The level of evidence was low for "any risk factor" (odds ratio for mortality 2.77, 95% confidence interval 1.90 to 4.05 for pandemic influenza and 2.04, 1.74 to 2.39 for seasonal influenza), obesity (2.74, 1.56 to 4.80 and 30.1, 1.74 to 2.39), cardiovascular diseases (2.92, 1.76 to 4.86 and 1.97, 1.06 to 3.67), and neuromuscular disease (2.68, 1.91 to 3.75 and 3.21, 1.84 to 5.58). The level of evidence was very low for all other risk factors. Some well accepted risk factors such as pregnancy and belonging to an ethnic minority group could not be identified as risk factors. In contrast, women who were less than four weeks post partum had a significantly increased risk of death from pandemic influenza (4.43, 1.24 to 15.81).ConclusionThe level of evidence to support risk factors for influenza related complications is low and some well accepted risk factors, including pregnancy and ethnicity, could not be confirmed as risks. Rigorous and adequately powered studies are needed.

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