Hospitalizations from pandemic Influenza [A(H1N1)pdm09] infections among type 1 and 2 diabetes patients in Spain

Influenza vaccination trend and related factors among patients with diabetes in Korea: Analysis using a nationwide database

BACKGROUND

Subjects with diabetes are at higher risk of serious influenza-related complications. We aimed to investigate the yearly trend of influenza vaccination and factors associated with being unvaccinated for influenza in subjects with diabetes using a nationwide observational study performed within the recent decade.

METHODS

Among 105,732 subjects from the Korea National Health and Nutrition Examination Survey between 2007 and 2019, 8,632 with diabetes were included. We investigated the yearly trend of influenza vaccination and factors associated with being unvaccinated for influenza.

RESULTS

During the study period, the prevalence of influenza vaccination in subjects with diabetes showed a tendency to increase every year, reaching almost 60% in 2019, which was higher than the rate in subjects without diabetes. Younger age (adjusted hazard ratio (aHR) [95% CI] 11.29 [8.63-14.75] for < 50 years; 6.16 [5.21-7.29] for 50-65 years), male (aHR 1.67 [1.52-1.87]), current smoker (aHR 1.31 [1.00-1.72], lower-income status (aHR 1.46 [1.17, 1.84]), and high education level (aHR 1.30 [1.01-1.67]) were associated with being unvaccinated. Also, a poorer glycemic control with HbA1c ≥ 9% was found to be correlated with unvaccinated status (aHR 1.48 [1.15-1.90]).

CONCLUSION

The influenza vaccination rate is still unsatisfactory in subjects with diabetes. Young age, males, low-income level, high education level, and poor glycemic control were associated with unvaccinated status. Considering the risk-benefits of influenza vaccination in patients with diabetes, physicians should make an effort to increase vaccination rates, especially in low vaccination rate groups.

Pandemics, past and present: The role of biological anthropology in interdisciplinary pandemic studies

Biological anthropologists are ideally suited for the study of pandemics given their strengths in human biology, health, culture, and behavior, yet pandemics have historically not been a major focus of research. The COVID‐19 pandemic has reinforced the need to understand pandemic causes and unequal consequences at multiple levels. Insights from past pandemics can strengthen the knowledge base and inform the study of current and future pandemics through an anthropological lens. In this paper, we discuss the distinctive social and epidemiological features of pandemics, as well as the ways in which biological anthropologists have previously studied infectious diseases, epidemics, and pandemics. We then review interdisciplinary research on three pandemics–1918 influenza, 2009 influenza, and COVID‐19–focusing on persistent social inequalities in morbidity and mortality related to sex and gender; race, ethnicity, and Indigeneity; and pre‐existing health and disability. Following this review of the current state of pandemic research on these topics, we conclude with a discussion of ways biological anthropologists can contribute to this field moving forward. Biological anthropologists can add rich historical and cross‐cultural depth to the study of pandemics, provide insights into the biosocial complexities of pandemics using the theory of syndemics, investigate the social and health impacts of stress and stigma, and address important methodological and ethical issues. As COVID‐19 is unlikely to be the last global pandemic, stronger involvement of biological anthropology in pandemic studies and public health policy and research is vital.

The triumvirate: why hypertension, obesity, and diabetes are risk factors for adverse effects in patients with COVID-19

The outbreak of coronavirus disease 2019 (COVID-19) caused by a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has become a pandemic. The cellular receptor for SARS-CoV-2 entry is the angiotensin-converting enzyme 2, a membrane-bound homolog of angiotensin-converting enzyme. Henceforth, this has brought the attention of the scientific community to study the interaction between COVID-19 and the renin-angiotensin system (RAS), as well as RAS inhibitors. However, these inhibitors are commonly used to treat hypertension, chronic kidney disorder, and diabetes. Obesity is a known risk factor for heart disease, diabetes, and hypertension, whereas diabetes and hypertension may be indirectly related to each other through the effects of obesity. Furthermore, people with hypertension, obesity, diabetes, and other related complications like cardiovascular and kidney diseases have a higher risk of severe COVID-19 infection than the general population and usually exhibit poor prognosis. This severity could be due to systemic inflammation and compromised immune response and RAS associated with these comorbid conditions. Therefore, there is an urgent need to develop evidence-based treatment methods that do not affect the severity of COVID-19 infection and effectively manage these chronic diseases in people with COVID-19.

Obesity Increases the Severity and Mortality of Influenza and COVID-19: A Systematic Review and Meta-Analysis

Since December 2019, COVID-19 has aroused global attention. Studies show the link between obesity and severe outcome of influenza and COVID-19. Thus, we aimed to compare the impacts of obesity on the severity and mortality of influenza and COVID-19 by performing a meta-analysis. A systematic search was performed in MEDLINE, EMASE, ClinicalTrials.gov, and Web of Science from January 2009 to July 2020. The protocol was registered onto PROSPERO (CRD42020201461). After selection, 46 studies were included in this meta-analysis. The pooled odds ratios (ORs) with 95% confidence intervals (CIs) were analyzed. We found obesity was a risk factor for the severity and mortality of influenza (ORsevere outcome = 1.56, CI: 1.28-1.90; ORmortality = 1.99, CI: 1.15-3.46). For COVID-19, obesity was a significant risk factor only for severe outcome (OR = 2.07, CI: 1.53-2.81) but not for mortality (OR = 1.57, CI: 0.85-2.90). Compared with obesity, morbid obesity was linked with a higher risk for the severity and mortality of both influenza (OR = 1.40, CI: 1.10-1.79) and COVID-19 (OR = 3.76, CI: 2.67-5.28). Thus, obesity should be recommended as a risk factor for the prognosis assessment of COVID-19. Special monitoring and earlier treatment should be implemented in patients with obesity and COVID-19.

The Second Wave of COVID-19 Pandemic Strikes during the Flu Season: An Awareness Perspective

Coinfection with both SARS-CoV-2 and influenza viruses seems to be a real and severe problem. However, coinfection is far from a simple matter, and cannot be considered having more unfavorable outcomes as a direct consequence. In reality, the aftermath is powerfully nuanced by the presence of risk factors and specific molecular mechanisms. Our objective was to raise awareness around the unpredictable association between COVID-19 pandemics and the upcoming flu season, and make arguments about the need to develop new routine testing protocols for both viruses, at least during the period with an expected high incidence. Our reasoning is built around the various impacts that the whole range of risk groups, common immunological mechanisms, and complex interactions, such as influenza vaccination, will have on patients' prognosis. We show that the more flawed clinical course is due to managing only one of the infections (and, subsequently, neglecting the other condition).

Vaccination adherence to influenza, pneumococcal and hepatitis B virus in adult type 1 diabetes mellitus patients

AIM

To document adherence to influenza, pneumococcal and hepatitis B virus (HBV) vaccination programme in adult type 1 diabetes mellitus (T1DM) patients.

MATERIALS AND METHODS

Observational retrospective study using data obtained from computerized clinical records. We contacted all adult T1DM registered in our database from a tertiary diabetes care hospital. Primary efficacy outcome was to describe influenza, pneumococcal and HBV vaccination status.

RESULTS

Three hundred patients were analyzed (male 53%). Mean age was 40.0±14.4years and T1DM duration was 19.7±11.8years. Thirty-five percent of the patients had complementary indications for studied vaccines. Adherence to vaccination program for influenza, pneumococcal and HBV was achieved by 55%, 18% and 17% of the patients, respectively. Only 3% of the subjects were vaccinated against the three microorganisms. Predictor of correct vaccination were: age, shorter diabetes duration, insulin pump treatment, better diabetes control and being a health professional. We detected 17 sick leaves, 127 lost working days and 3 hospitalizations due to flue during the follow-up.

CONCLUSIONS

The uptake of recommended vaccinations against influenza, pneumococcal and HBV in adult T1DM patients was below desirable levels. A special effort is required to all health professionals to implement immunization among adult people with T1DM. Clinical Trials NCT03478254.

Infection Studies in Pigs and Porcine Airway Epithelial Cells Reveal an Evolution of A(H1N1)pdm09 Influenza A Viruses Toward Lower Virulence

We analyzed the virulence of pandemic H1N1 2009 influenza A viruses in vivo and in vitro. Selected viruses isolated in 2009, 2010, 2014, and 2015 were assessed using an aerosol-mediated high-dose infection model for pigs as well as air-liquid interface cultures of differentiated airway epithelial cells. Using a dyspnea score, rectal temperature, lung lesions, and viral load in the lung as parameters, the strains from 2014–2015 were significantly less virulent than the strains isolated in 2009–2010. In vitro, the viruses from 2009–2010 also differed from the 2014–2015 viruses by increased release of infectious virus, a more pronounced loss of ciliated cells, and a reduced thickness of the epithelial cell layer. Our in vivo and in vitro results reveal an evolution of A(H1N1)pdm09 viruses toward lower virulence. Our in vitro culture system can be used to predict the virulence of influenza viruses.

Higher frequency of hospitalization but lower relative mortality for pandemic influenza in people with type 2 diabetes

BACKGROUND

There is limited evidence linking type 2 diabetes (T2D) to influenza-related complications.

OBJECTIVES

To test a set of research questions relating to pandemic influenza vaccination, hospitalization and mortality in people with and without T2D.

METHODS

In this population-based cohort study, we linked individual-level data from several national registers for all Norwegian residents aged 30 years or more as of January 2009. People with or without T2D at baseline (n = 2 992 228) were followed until December 2013. We used Cox regression to estimate adjusted hazard ratios (aHRs).

RESULTS

Pandemic influenza hospitalization was more common in individuals with T2D (aHR = 2.46, 95% CI 2.04-2.98). The mortality hazard ratio associated with hospitalization for pandemic influenza was lower in people with T2D (aHR = 1.82, 95% CI 1.21-2.74) than in those without T2D (aHR = 3.89, 95% CI 3.27-4.62). The same pattern was observed when restricting to 90-day mortality (aHR = 3.89, 95% CI 1.25-12.06 amongst those with T2D and aHR = 10.79, 95% CI 7.23-16.10 amongst those without T2D). The rate of hospitalization for pandemic influenza was 78% lower in those vaccinated compared to nonvaccinated amongst people with T2D (aHR = 0.22, 95% CI 0.11-0.39), whilst the corresponding estimate for those without T2D was 59% lower (aHR = 0.41, 95% CI 0.33-0.52). Mortality was 25% lower in those vaccinated compared to nonvaccinated amongst people with T2D (aHR = 0.75, 95% CI 0.73-0.77), whilst the corresponding estimate for those without T2D was 9% (aHR = 0.91, 95% CI 0.90-0.92).

CONCLUSIONS

There may have been a lower threshold for pandemic influenza hospitalization for people with T2D, rather than more severe influenza infection. Our combined results support the importance of influenza vaccination amongst people with T2D, especially during pandemics.

Rapid detection and clinical spectrum of the novel influenza H1N1 strain in a diabetic pediatric population

OBJECTIVES

H1N1 infection in diabetic patients is of special concern and serious interest since the virus can place individuals, especially children, at great possible risk of subsequently developing type 1 diabetes. This work aims to describe the demographic characteristics, clinical features, and severity of illness of children with type 1 diabetes mellitus (DM), compare the incidence of pandemic H1N1 virus in children with that of the general pediatric population with influenza-like symptoms, and identify the complications of H1N1 virus infection associated with glycemic control.

METHODS

The present study included 45 children and adolescents with type 1 diabetes, who were subject to clinical and laboratory investigations. Another 30 healthy adolescents and children with a mean age of 10.43 ± 4.38 years were included as a control group. H1N1 reverse-transcriptase quantitative PCR (RT-Q PCR) was tested for H1N1 virus detection.

RESULTS

Diabetic patients positive for (H1N1) showed significantly higher random blood sugar (RBS) levels than diabetic patients negative for (H1N1). Moreover, the H1N1-positive patients had significantly higher hemoglobin (Hb) g/dL, platelet counts, total leukocyte counts (TLCs), and CRP levels. Newly diagnosed patients who were tested positive for (H1N1) and diabetic ketoacidosis (DKA) had significantly higher RBS levels and TLCs than patients who were presented with hyperglycemia.

CONCLUSION

RT-PCR is a rapid and specific method for influenza A (H1N1) virus diagnosis. In addition, early administration of oseltamivir no later than 48 hours after the infection is highly recommended in either diabetic or DKA patients suspected of having H1N1.

The burden of common infections in children and adolescents with diabetes mellitus: A Pediatric Health Information System study

BACKGROUND

People with diabetes mellitus (DM) have increased infection risk. The healthcare utilization of pediatric and adolescent diabetic patients with infection is not well defined. This study evaluates the number of pediatric and adolescent patients with DM that seek medical treatment for infection management and assesses its socioeconomic impact.

METHODS

A retrospective analysis was performed using the Pediatric Health Information System (PHIS) database on children and adolescents with DM who presented to the Emergency Department (ED) or were hospitalized for infection management from 2008 to 2014. The PHIS database collects admission, demographic, and economic data from 44 freestanding children's hospitals across the United States.

RESULTS

In total, 123 599 diabetic patient encounters were identified (77% type 1 DM, 23% type 2 DM). ED visits and hospitalizations for type 1 DM and type 2 DM increased throughout the study period. Total charges for these encounters were greater than $250 million dollars per year and increased each year. Infection encounters make up more than 30% of that cost while accounting for only 14% of the visits. Respiratory infections were the most common type of infection followed by skin and soft tissue infections for both ED care and inpatient hospitalizations. Patients with infections had longer hospital length of stay and higher cost per day than those without infections.

CONCLUSIONS

Children and adolescents with type 1 and type 2 DM commonly present to the ED and require hospitalization for infection evaluation and management. Encounters with infection make up a large proportion of a growing economic burden on the United States' healthcare system. As the prevalence of DM grows, this burden can be expected to become even more significant. Cost-effective strategies for the prevention of infection in pediatric patients with DM are needed.

Benefits of flu vaccination for persons with diabetes mellitus: A review

Diabetes mellitus imposes a significant and increasing burden on society, with major consequences for human health, welfare and the economy worldwide. Persons with diabetes mellitus are at increased risk of developing severe complications after influenza virus infection and guidelines advise vaccination. The present evidence for influenza vaccine effectiveness in persons with diabetes mellitus is mainly based on observational studies with clinical endpoints like hospitalization and death, indicating a beneficial reduction of morbidity and mortality. Further supportive evidence comes from serological studies, in which persons with diabetes mellitus usually develop similar antibody levels after vaccination as healthy people. Observational studies may be prone to selection bias, and serological studies may not completely mirror vaccine effectiveness in the field. Although more controlled trials in persons with diabetes mellitus with laboratory-confirmed, influenza-specific outcomes would be desirable to better estimate the effect of vaccination, the currently available data justify routine influenza vaccination in persons with diabetes mellitus. As in this risk group, the use of influenza vaccine is far below target worldwide, efforts should be made to increase vaccination coverage.

Influenza Virus and Glycemic Variability in Diabetes: A Killer Combination?

Following the 2009 H1N1 influenza virus pandemic, numerous studies identified the striking link between diabetes mellitus and influenza disease severity. Typically, influenza virus is a self-limiting infection but in individuals who have a pre-existing chronic illness, such as diabetes mellitus, severe influenza can develop. Here, we discuss the latest clinical and experimental evidence for the role of diabetes in predisposing the host to severe influenza. We explore the possible mechanisms that underlie this synergy and highlight the, as yet, unexplored role that blood glucose oscillations may play in disease development. Diabetes is one of the world’s fastest growing chronic diseases and influenza virus represents a constant and pervasive threat to human health. It is therefore imperative that we understand how diabetes increases influenza severity in order to mitigate the burden of future influenza epidemics and pandemics.

Identification of Rare PB2-D701N Mutation from a Patient with Severe Influenza: Contribution of the PB2-D701N Mutation to the Pathogenicity of Human Influenza

Several amino acid changes have been previously implicated in adaptation of avian influenza viruses to human hosts, among them the D701N change in the PB2 polymerase subunit that also is the main determinant of avian virus pathogenesis in animal models. However, previous studies using recombinant viruses did not provide conclusive information of the contribution of this PB2 residue to pathogenicity in human influenza virus strains. We identified this mutation in an A(H1N1)pdm09-like human influenza virus isolated from an infected patient with pneumonia and acute respiratory failure, admitted to the intensive care unit. An exhaustive search has revealed PB2-D701 as a highly conserved position in all available H1N1 human virus sequences in NCBI database, showing a very low prevalence of PB2-D701N change. Presence of PB2-701N amino acid correlates with severe or fatal outcome in those scarce cases with known disease outcome of the infection. In these patients, the residue PB2-701N may contribute to pathogenicity as it was previously reported in humans infected with avian viruses. This study helps to clarify a debate that has arisen regarding the role of PB2-D701N in human influenza virus pathogenicity.

Hospitalisation with community-acquired pneumonia among patients with type 2 diabetes: an observational population-based study in Spain from 2004 to 2013

OBJECTIVES

To describe trends in the incidence and outcomes of community-acquired pneumonia (CAP) hospitalisations among patients with or without diabetes in Spain (2004-2013).

DESIGN

Retrospective, observational study using the Spanish National Hospital Discharge Database (Conjunto Mínimo Básico de Datos (CMBD)).

SETTING

Spain.

PARTICIPANTS

We used national hospital discharge data to select all hospital admissions for CAP.

MAIN OUTCOME MEASURES

Incidence was calculated overall and stratified by diabetes status: type 2 diabetes mellitus (T2DM) and no diabetes.

RESULTS

We identified 901 136 admissions for CAP (24.8% with T2DM). Incidence rates of CAP increased significantly in patients with T2DM over time. The incidence was higher among people with T2DM for all time periods. Patients with T2DM were older and had higher comorbidity index than non-diabetics. Streptococcus pneumoniae decreased over time for both groups. Time trend analyses showed significant decreases in mortality during admission for CAP for patients with and without T2DM. Factors associated with higher mortality in both groups included: older age, higher comorbidity, mechanical ventilation, red cell transfusion, readmission and Staphylococcus aureus detection. Diabetes was associated with a lower in-hospital mortality (OR 0.92, 95% CI 0.91 to 0.94) after a CAP hospitalisation.

CONCLUSIONS

CAP incidence rates were higher and increased over time at a higher rate among patients with T2DM. Mortality decreased over time in all groups. The presence of diabetes is not a risk factor for death during admission for CAP.

Prevalence of Diabetes in the 2009 Influenza A (H1N1) and the Middle East Respiratory Syndrome Coronavirus: A Systematic Review and Meta-Analysis

Over the past two decades a number of severe acute respiratory infection outbreaks such as the 2009 influenza A (H1N1) and the Middle East respiratory syndrome coronavirus (MERS-CoV) have emerged and presented a considerable global public health threat. Epidemiologic evidence suggests that diabetic subjects are more susceptible to these conditions. However, the prevalence of diabetes in H1N1 and MERS-CoV has not been systematically described. The aim of this study is to conduct a systematic review and meta-analysis of published reports documenting the prevalence of diabetes in H1N1 and MERS-CoV and compare its frequency in the two viral conditions. Meta-analysis for the proportions of subjects with diabetes was carried out in 29 studies for H1N1 (n=92,948) and 9 for MERS-CoV (n=308). Average age of H1N1 patients (36.2±6.0 years) was significantly younger than that of subjects with MERS-CoV (54.3±7.4 years, P<0.05). Compared to MERS-CoV patients, subjects with H1N1 exhibited 3-fold lower frequency of cardiovascular diseases and 2- and 4-fold higher prevalence of obesity and immunosuppression, respectively. The overall prevalence of diabetes in H1N1 was 14.6% (95% CI: 12.3-17.0%; P<0.001), a 3.6-fold lower than in MERS-CoV (54.4%; 95% CI: 29.4-79.5; P<0.001). The prevalence of diabetes among H1N1 cases from Asia and North America was ~two-fold higher than those from South America and Europe. The prevalence of diabetes in MERS-CoV cases is higher than in H1N1. Regional comparisons suggest that an etiologic role of diabetes in MERS-CoV may exist distinctive from that in H1N1.

Studying the burden of community-acquired pneumonia in adults aged ≥50 years in primary health care: an observational study in rural Crete, Greece

Background:

Community-acquired pneumonia (CAP) is a potentially life-threatening condition that often requires hospitalisation particularly in the elderly population or in patients with comorbidities.

Aims:

The aims of this study were to estimate the CAP frequency and severity in a well-defined primary healthcare setting in rural Crete, to record patient characteristics, their immunisation status and to estimate hospitalisation frequency and determinants.

Methods:

An observational study was designed and implemented in a rural setting within the prefecture of Heraklion in the island of Crete, Greece. Eligible patients were those aged 50 years or above, presenting with CAP based on signs and symptoms and positive X-ray findings.

Results:

A total of 124 CAP cases were recorded, 40 of which (32.3%) were hospitalised. Τhe age-standardised CAP incidence was estimated to be 236.7 cases per 100,000 persons aged ⩾50 years. Forty-three patients (35.2%) were vaccinated against pneumococcus. The most frequent chronic illnesses were heart disease (64.5%), chronic obstructive pulmonary disease (32.5%), and type 2 diabetes (21%). Hospitalisation determinants included advanced age (⩾74 years, Odds ratio (OR) 7.13; P value=0.001; 95% confidence interval (CI), 2.23–22.79), obesity (OR 3.36, P=0.037; 95% CI, 1.08–10.52), ⩾40 pack-years of smoking (OR 3.82, P value=0.040; 95% CI, 1.07–18.42), presence of multimorbidity (OR 5.77, P value=0.003; 95% CI, 1.81–18.42) and pneumococcal vaccination (OR 0.29, P value=0.041; 95% CI, 0.09–0.95).

Conclusions:

This study highlighted patient characteristics and aspects of CAP epidemiology in the context of a rural primary care setting in southern Europe where limited data have been published until now.

Working-age adults with diabetes experience greater susceptibility to seasonal influenza: a population-based cohort study

AIMS/HYPOTHESIS

The aim of this work was to compare the incidence of illness attributable to influenza in working-age adults (age <65 years) with and without diabetes.

METHODS

We performed a cohort study using administrative data from Manitoba, Canada, between 2000 and 2008. All working-age adults with diabetes were identified and matched with up to two non-diabetic controls. We analysed the rates of influenza-like illness physician visits and hospitalisations, pneumonia and influenza hospitalisations, and all-cause hospitalisations. Multivariable regressions were used to estimate the influenza-attributable rate of each outcome.

RESULTS

We included 745,777 person-years of follow-up among 166,715 subjects. The median age was 50-51 years and 48-49% were women; adults with diabetes had more comorbidities and were more likely to be vaccinated for influenza than those without diabetes. Compared with similar adults without diabetes, those with diabetes had a 6% greater (RR 1.06, 95% CI 1.02, 1.10; absolute risk difference 6 per 1,000 adults per year) increase in all-cause hospitalisations associated with influenza, representing a total of 54 additional hospitalisations. There were no differences in the influenza-attributable rates of influenza-like illness (p = 0.06) or pneumonia and influenza (p = 0.11).

CONCLUSIONS/INTERPRETATION

Guidelines calling for influenza vaccinations in diabetic, in addition to elderly, adults implicitly single out working-age adults with diabetes. The evidence supporting such guidelines has hitherto been scant. We found that working-age adults with diabetes appear more susceptible to serious influenza-attributable illness. These findings represent the strongest available evidence for targeting diabetes as an indication for influenza vaccination, irrespective of age.