Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia.
Connecticut Emerging Infections Program, Yale School of Public Health, New Haven.
JAMA Netw Open. 2024 Nov 4;7(11):e2448003. doi: 10.1001/jamanetworkopen.2024.48003.
Seasonal influenza is associated with substantial disease burden. The relationship between census tract-based social vulnerability and clinical outcomes among patients with influenza remains unknown.
To characterize associations between social vulnerability and outcomes among patients hospitalized with influenza and to evaluate seasonal influenza vaccine and influenza antiviral utilization patterns across levels of social vulnerability.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective repeated cross-sectional study was conducted among adults with laboratory-confirmed influenza-associated hospitalizations from the 2014 to 2015 through the 2018 to 2019 influenza seasons. Data were from a population-based surveillance network of counties within 13 states. Data analysis was conducted in December 2023.
Census tract-based social vulnerability.
Associations between census tract-based social vulnerability and influenza outcomes (intensive care unit admission, invasive mechanical ventilation and/or extracorporeal membrane oxygenation support, and 30-day mortality) were estimated using modified Poisson regression as adjusted prevalence ratios. Seasonal influenza vaccine and influenza antiviral utilization were also characterized across levels of social vulnerability.
Among 57 964 sampled cases, the median (IQR) age was 71 (58-82) years; 55.5% (95% CI, 51.5%-56.0%) were female; 5.2% (5.0%-5.4%) were Asian or Pacific Islander, 18.3% (95% CI, 18.0%-18.6%) were Black or African American, and 64.6% (95% CI, 64.2%-65.0%) were White; and 6.6% (95% CI, 6.4%-68%) were Hispanic or Latino and 74.7% (95% CI, 74.3%-75.0%) were non-Hispanic or Latino. High social vulnerability was associated with higher prevalence of invasive mechanical ventilation and/or extracorporeal membrane oxygenation support (931 of 13 563 unweighted cases; adjusted prevalence ratio [aPR], 1.25 [95% CI, 1.13-1.39]), primarily due to socioeconomic status (790 of 11 255; aPR, 1.31 [95% CI, 1.17-1.47]) and household composition and disability (773 of 11 256; aPR, 1.20 [95% CI, 1.09-1.32]). Vaccination status, presence of underlying medical conditions, and respiratory symptoms partially mediated all significant associations. As social vulnerability increased, the proportion of patients receiving seasonal influenza vaccination declined (-19.4% relative change across quartiles; P < .001) as did the proportion vaccinated by October 31 (-6.8%; P < .001). No differences based on social vulnerability were found in in-hospital antiviral receipt, but early in-hospital antiviral initiation (-1.0%; P = .01) and prehospital antiviral receipt (-17.3%; P < .001) declined as social vulnerability increased.
In this cross-sectional study, social vulnerability was associated with a modestly increased prevalence of invasive mechanical ventilation and/or extracorporeal membrane oxygenation support among patients hospitalized with influenza. Contributing factors may have included worsened baseline respiratory health and reduced receipt of influenza prevention and prehospital or early in-hospital treatment interventions among persons residing in low socioeconomic areas.
重要性：季节性流感与大量疾病负担相关。在流感患者中，基于普查区的社会脆弱性与临床结局之间的关系仍不清楚。
目的：描述社会脆弱性与流感住院患者结局之间的关系，并评估流感疫苗和流感抗病毒药物在不同社会脆弱性水平下的使用模式。
设计、地点和参与者：这是一项回顾性的重复横断面研究，纳入了来自 2014 年至 2015 年至 2018 年至 2019 年流感季节期间，实验室确诊的流感相关住院患者。数据来自 13 个州的县的基于人群的监测网络。数据分析于 2023 年 12 月进行。
暴露因素：基于普查区的社会脆弱性。
主要结局和测量：使用修正泊松回归作为调整后的患病率比，估计基于普查区的社会脆弱性与流感结局（重症监护病房入院、有创机械通气和/或体外膜氧合支持以及 30 天死亡率）之间的关联。还根据社会脆弱性水平描述了季节性流感疫苗和流感抗病毒药物的使用情况。
结果：在 57964 例抽样病例中，中位数（IQR）年龄为 71（58-82）岁；55.5%（95%CI，51.5%-56.0%）为女性；5.2%（5.0%-5.4%）为亚洲或太平洋岛民，18.3%（95%CI，18.0%-18.6%）为黑人或非裔美国人，64.6%（95%CI，64.2%-65.0%）为白人；6.6%（95%CI，6.4%-68%）为西班牙裔或拉丁裔，74.7%（95%CI，74.3%-75.0%）为非西班牙裔或拉丁裔。高社会脆弱性与更高的有创机械通气和/或体外膜氧合支持的流行率相关（未加权病例数为 13563 例中的 931 例；调整后患病率比[aPR]，1.25[95%CI，1.13-1.39]），主要归因于社会经济地位（790/11255；aPR，1.31[95%CI，1.17-1.47]）和家庭组成和残疾（773/11256；aPR，1.20[95%CI，1.09-1.32]）。疫苗接种状况、基础医疗状况和呼吸道症状部分解释了所有显著关联。随着社会脆弱性的增加，接受季节性流感疫苗接种的患者比例下降（四分位距内相对变化为-19.4%；P<0.001），10 月 31 日之前接种疫苗的比例也下降（6.8%；P<0.001）。在住院期间接受抗病毒药物治疗方面，未发现基于社会脆弱性的差异，但早期住院期间抗病毒药物的使用（-1.0%；P=0.01）和住院前抗病毒药物的使用（-17.3%；P<0.001）随着社会脆弱性的增加而下降。
结论和相关性：在这项横断面研究中，社会脆弱性与流感住院患者有创机械通气和/或体外膜氧合支持的患病率略有增加相关。可能的原因包括居住在低社会经济地区的人群呼吸健康状况恶化以及流感预防和住院前或早期住院治疗干预措施的接受率降低。
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