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Crit Care. 2018 Dec 19;22(1):351. doi: 10.1186/s13054-018-2274-8.

Estimating severity of influenza epidemics from severe acute respiratory infections (SARI) in intensive care units.

Author information

Centre for Infectious Disease Control Netherlands, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands.
Centre for Infectious Disease Control Netherlands, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands.
National Intensive Care Evaluation, Amsterdam, the Netherlands.
Department of Intensive Care Medicine, University Medical Center, Utrecht University, Utrecht, Netherlands.
Department of Intensive Care, Leiden University Medical Center, Leiden, the Netherlands.
Nivel Primary Care Database - Sentinel Practices, Utrecht, the Netherlands.
Department of Medical Informatics, Amsterdam UMC, Location AMC, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands.



While influenza-like-illness (ILI) surveillance is well-organized at primary care level in Europe, few data are available on more severe cases. With retrospective data from intensive care units (ICU) we aim to fill this current knowledge gap. Using multiple parameters proposed by the World Health Organization we estimate the burden of severe acute respiratory infections (SARI) in the ICU and how this varies between influenza epidemics.


We analyzed weekly ICU admissions in the Netherlands (2007-2016) from the National Intensive Care Evaluation (NICE) quality registry (100% coverage of adult ICUs in 2016; population size 14 million) to calculate SARI incidence, SARI peak levels, ICU SARI mortality, SARI mean Acute Physiology and Chronic Health Evaluation (APACHE) IV score, and the ICU SARI/ILI ratio. These parameters were calculated both yearly and per separate influenza epidemic (defined epidemic weeks). A SARI syndrome was defined as admission diagnosis being any of six pneumonia or pulmonary sepsis codes in the APACHE IV prognostic model. Influenza epidemic periods were retrieved from primary care sentinel influenza surveillance data.


Annually, an average of 13% of medical admissions to adult ICUs were for a SARI but varied widely between weeks (minimum 5% to maximum 25% per week). Admissions for bacterial pneumonia (59%) and pulmonary sepsis (25%) contributed most to ICU SARI. Between the eight different influenza epidemics under study, the value of each of the severity parameters varied. Per parameter the minimum and maximum of those eight values were as follows: ICU SARI incidence 558-2400 cumulated admissions nationwide, rate 0.40-1.71/10,000 inhabitants; average APACHE score 71-78; ICU SARI mortality 13-20%; ICU SARI/ILI ratio 8-17 cases per 1000 expected medically attended ILI in primary care); peak-incidence 101-188 ICU SARI admissions in highest-incidence week, rate 0.07-0.13/10,000 population).


In the ICU there is great variation between the yearly influenza epidemic periods in terms of different influenza severity parameters. The parameters also complement each other by reflecting different aspects of severity. Prospective syndromic ICU SARI surveillance, as proposed by the World Health Organization, thereby would provide insight into the severity of ongoing influenza epidemics, which differ from season to season.


Burden; Influenza; Intensive care; Pneumonia; SARI; Severe acute respiratory infections; Severity

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