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Original article
Clinical and laboratory features distinguishing pandemic H1N1 influenza-related pneumonia from interpandemic community-acquired pneumonia in adults
  1. Thomas Bewick1,
  2. Puja Myles2,
  3. Sonia Greenwood1,
  4. Jonathan S Nguyen-Van-Tam2,
  5. Stephen J Brett3,
  6. Malcolm G Semple4,
  7. Peter J Openshaw5,
  8. Barbara Bannister6,
  9. Robert C Read7,
  10. Bruce L Taylor8,
  11. Jim McMenamin9,
  12. Joanne E Enstone2,
  13. Karl G Nicholson10,
  14. Wei Shen Lim1,
  15. Influenza Clinical Information Network (FLU-CIN)
  1. 1Department of Respiratory Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
  2. 2Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK
  3. 3Centre for Peri-operative Medicine and Critical Care Research, Imperial College Healthcare NHS Trust, London, UK
  4. 4Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
  5. 5Centre for Respiratory Infections, National Heart and Lung Institute, Imperial College, London, UK
  6. 6Department of Health, Skipton House, London, UK
  7. 7Department of Infection and Immunity, University of Sheffield, Royal Hallamshire Hospital, Sheffield, UK
  8. 8Department of Critical Care, Portsmouth Hospitals NHS Trust, Portsmouth, UK
  9. 9Health Protection Scotland, NHS National Services, Glasgow, UK
  10. 10Infectious Diseases Unit, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Leicester, UK
  1. Correspondence to Dr Wei Shen Lim, Respiratory Medicine, Nottingham University Hospitals NHS Trust, City Hospital Campus, Hucknall Road, Nottingham NG5 1PB, UK; weishen.lim{at}


Background Early identification of patients with H1N1 influenza-related pneumonia is desirable for the early instigation of antiviral agents. A study was undertaken to investigate whether adults admitted to hospital with H1N1 influenza-related pneumonia could be distinguished clinically from patients with non-H1N1 community-acquired pneumonia (CAP).

Methods Between May 2009 and January 2010, clinical and epidemiological data of patients with confirmed H1N1 influenza infection admitted to 75 hospitals in the UK were collected by the Influenza Clinical Information Network (FLU-CIN). Adults with H1N1 influenza-related pneumonia were identified and compared with a prospective study cohort of adults with CAP hospitalised between September 2008 and June 2010, excluding those admitted during the period of the pandemic.

Results Of 1046 adults with confirmed H1N1 influenza infection in the FLU-CIN cohort, 254 (25%) had H1N1 influenza-related pneumonia on admission to hospital. In-hospital mortality of these patients was 11.4% compared with 14.0% in patients with inter-pandemic CAP (n=648). A multivariate logistic regression model was generated by assigning one point for each of five clinical criteria: age ≤65 years, mental orientation, temperature ≥38°C, leucocyte count ≤12×109/l and bilateral radiographic consolidation. A score of 4 or 5 predicted H1N1 influenza-related pneumonia with a positive likelihood ratio of 9.0. A score of 0 or 1 had a positive likelihood ratio of 75.7 for excluding it.

Conclusion There are substantial clinical differences between H1N1 influenza-related pneumonia and inter-pandemic CAP. A model based on five simple clinical criteria enables the early identification of adults admitted with H1N1 influenza-related pneumonia.

  • Pneumonia
  • influenza
  • H1N1
  • pandemic
  • respiratory infection
  • bacterial infection
  • viral infection

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and

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  • Funding The Department of Health in England was the main funder for FLU-CIN. Chairmanship of the FLU-CIN Strategy Group (that includes JSN-V-T, WSL, MGS, PJMO, RCR, BLT, SJB, JMcM, JEE and KGN as members) was provided by the Department of Health, England. The FLU-CIN Strategy Group had final responsibility for the interpretation of findings and decision to submit for publication. The CAP cohort study was funded by an unrestricted educational grant from Wyeth (now Pfizer).

  • Competing interests JSN-V-T has received funding to attend influenza related meetings, lecture and consultancy fees and research funding from several influenza antiviral drug and vaccine manufacturers and is a former employee of SmithKline Beecham plc (now GlaxoSmithKline), Roche Products Ltd and Sanofi-Pasteur MSD. SJB has received consultancy fees from GlaxoSmithKline and Baxter. MGS and BB are advisors to the Department of Health, England. PJMO is a member of the European Scientific Working Group on Influenza (ESWI) which is funded by the pharmaceutical industry. JEE has received consultancy fees from GlaxoSmithKline and performed paid work for the Department of Health, England. KGN has received H5 avian influenza vaccines from Novartis and H1N1 pandemic influenza vaccines from GlaxoSmithKline and Baxter to facilitate MRC and NIHR-funded trials. He has received consultancy fees from Novartis and GlaxoSmithKline and lecture fees from Baxter. A colleague of KGN at the University Hospitals of Leicester NHS Trust was Principal Investigator and recipient of research funding from Roche on antiviral resistance and from Novartis on pandemic H1N1 vaccines. WSL has received an unrestricted educational grant from Wyeth (now Pfizer).

  • Ethics approval Before commencement, FLU-CIN procedures were reviewed by the Ethics and Confidentiality Committee of the National Information Governance Board for Health and Social Care in England and approved for collection, storage and use of personal data for surveillance purposes. Full ethical approval was obtained from the Nottingham Research Ethics Committee for the conduct of the CAP cohort study.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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