The Indian Journal of Pediatrics

, Volume 79, Issue 4, pp 459–466 | Cite as

Predictors of Mortality in Hospitalized Children with Pandemic H1N1 Influenza 2009 in Pune, India

  • Aarti Avinash Kinikar
  • Rajesh K. Kulkarni
  • Chhaya T. Valvi
  • Vidya Mave
  • Nikhil Gupte
  • Sandhya Khadse
  • Renu Bhardwaj
  • Anju Kagal
  • Shaila Puranik
  • Amita Gupta
  • Robert Bollinger
  • Arun Jamkar
Original Article

Abstract

Objective

To analyse the factors associated with increased mortality among Indian Children with H1N1.

Methods

Data were abstracted from available hospital records of children less than 12 y of age, who were admitted to Sassoon General Hospital in Pune, India, with confirmed pandemic 2009 H1N1 influenza infection from August 2009 through January 2010. Logistic regression analysis was used to identify clinical characteristics associated with mortality.

Results

Of 775 pediatric cases admitted with Influenza Like Illness (ILI), 92 (11.8%) had confirmed H1N1 influenza infection. The median age of HIN1 cases was 2.5 y; 13 (14%) had an associated co-morbid condition. Median duration of symptoms was 4 d (interquartile range (IQR), 3–7 d). All 92 H1N1 cases received oseltamivir and empiric antimicrobials on admission. Intensive care unit (ICU) admission was required for 88 (96%) children, and 20 (23%) required mechanical ventilation.Fifteen children (16%) died; mortality was associated with presence of diffuse alveolar infiltrate on admission chest radiography (odds ratio (OR) 45, 95%CI :5.4–370; p < 0.001), use of corticosteroids in ARDS in children who required mechanical ventilation (OR 8.12, 95%CI: 2.44–27.05; p = 0.001), SpO2 <80% on admission (OR 32.8, 95% CI: 5.8–185.5; p < 0.001) and presence of ARDS (OR 345.3, 95% CI :33.5–3564.1; p < 0.001). Necropsy from all children who died showed 9 (60%) had ARDS pattern and necrotizing pneumonitis, diffuse hemorrhage and interstitial pneumonia (n = 4 each, 27%) with gram positive organisms consistent with severe viral and bacterial co-infection.

Conclusions

Hypoxia, ARDS and use of corticosteroids in children with ARDS who were mechanically ventilated were the factors associated with increased odds of mortality. Necropsy also suggested bacterial co-infection as a risk factor.

Keywords

Pandemic 2009 H1N1 virus Mortality Children 

References

  1. 1.
    Jain S, Kamimoto L, Bramley AM, et al. Hospitalized patients with 2009 H1N1 influenza in the United States, April–June 2009. N Engl J Med. 2009;361:1935–44.PubMedCrossRefGoogle Scholar
  2. 2.
    Domínguez-Cherit G, Lapinsky SE, Macias AE, et al. Critically ill patients with 2009 influenz A (H1N1) in Mexico. JAMA. 2009;302:1880–87.PubMedCrossRefGoogle Scholar
  3. 3.
    Kumar A, Zarychanski R, Pinto R, et al. Critically ill patients with 2009 influenza A(H1N1) infection in Canada. JAMA. 2009;302:1872–79.PubMedCrossRefGoogle Scholar
  4. 4.
    Davies A, Jones D, Bailey M, et al. The Australia and New Zealand ExtracorMembrane Oxygenation (ANZ ECMO) Influenza Investigators. Extracorporeal membrane oxygenation for 2009 influenza A (H1N1) acute respiratory distress syndrome. JAMA. 2009;302:1888–95.PubMedCrossRefGoogle Scholar
  5. 5.
    Libster R, Bugna J, Coviello S, et al. Pediatric hospitalizations associated with 2009 pandemic influenza A (H1N1) in Argentina. N Engl J Med. 2010;362:45–55.PubMedCrossRefGoogle Scholar
  6. 6.
    Webb SA, Pettila V, Seppelt I, et al. Critical care services and 2009 H1N1 influenza in Australia and New Zealand. N Engl J Med. 2009;361:1925–36.PubMedCrossRefGoogle Scholar
  7. 7.
    CDC Realtime RTPCR(rTPCR) Protocol for Detection and Characterization of Swine Influenza (version 2009), Available at: http://www.who.int/csr/resources/publications/swineflu/CDCRealtimeRTPCR_SwineH1Assay-2009_20090430.pdf Accessed 29 January, 2010.
  8. 8.
    WHO Multicentre Growth Reference Study Group. WHO child growth standards: length/height-for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-for-age: methods and development. Geneva: World Health Organization; 2006.Google Scholar
  9. 9.
    Updated interim recommendations for the use of antiviral medications in the treatment and prevention of influenza for the 2009–2010 season. Atlanta: Centers for Disease Control and Prevention. (http://www.cdc.gov/h1n1flu/recommendations.htm Accessed 6 April, 2010
  10. 10.
    Hacket S, Hill L, Patel J, et al. Clinical characteristics of paediatric H1N1 admissions in Birmingham, UK. Lancet. 2009;374:605.CrossRefGoogle Scholar
  11. 11.
    Surveillance for pediatric deaths associated with 2009 pandemic influenza A (H1N1) virus infection: United States, April- August 2009. MMWR Morb Mortal Wkly Rep. 2009;58:941–47.Google Scholar
  12. 12.
    Neurologic complications associated with novel influenza A (H1N1) virus infection in children: Dallas, Texas, May 2009. MMWR MorbMortal Wkly Rep. 2009;58:773–78.Google Scholar
  13. 13.
    Perez CM, Dominguez MI, Ceballos ME, et al. Pandemic influenza A (H1N1) in HIV-1-infected patients. AIDS. 2010;24:2867–9.PubMedCrossRefGoogle Scholar
  14. 14.
    Bacterial coinfections in lung tissue specimens from fatal cases of 2009 pandemic influenza A (H1N1)—United States, May-August 2009. MMWR Morb Mortal Wkly Rep. 2009;58:1071–74.Google Scholar
  15. 15.
    Rodriguez EL, Tomashek KM, Gregory CJ, et al. Co-infection with dengue virus and pandemic (H1N1) 2009 virus. Emerg Infect Dis. 2010; 16. [serial on the Internet]. http://www.cdc.gov/EID/content/16/5/882.htm
  16. 16.
    Kulkarni R, Kinikar A, Valvi C. Clinical Profile of H1N1 Positive HIV- Infected Children. Indian Pediatr. 2010;48:131–132.Google Scholar
  17. 17.
    Mauad T, Hajjar LA, Callegari GD, et al. Lung pathology in fatal novel influenza A (H1N1) infection. Am J Respir Crit Care Med. 2010;181:72–9.PubMedCrossRefGoogle Scholar

Copyright information

© Dr. K C Chaudhuri Foundation 2011

Authors and Affiliations

  • Aarti Avinash Kinikar
    • 1
  • Rajesh K. Kulkarni
    • 1
  • Chhaya T. Valvi
    • 1
  • Vidya Mave
    • 5
  • Nikhil Gupte
    • 5
  • Sandhya Khadse
    • 1
  • Renu Bhardwaj
    • 2
  • Anju Kagal
    • 2
  • Shaila Puranik
    • 3
  • Amita Gupta
    • 6
  • Robert Bollinger
    • 6
  • Arun Jamkar
    • 4
  1. 1.Department of PediatricsB.J. Medical College and Sassoon General HospitalPuneIndia
  2. 2.Department of MicrobiologyB.J. Medical College and Sassoon General HospitalPuneIndia
  3. 3.Department of PathologyB.J. Medical College and Sassoon General HospitalPuneIndia
  4. 4.B.J. Medical College and Sassoon General HospitalPuneIndia
  5. 5.Clinical Trials UnitB.J. Medical CollegePuneIndia
  6. 6.Department of MedicineJohns Hopkins University School of MedicineBaltimoreUSA

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