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Our search identified no incidence data from these 9 countries; only strain-type distribution information was available. Burden of disease information was also scarce. Other sources of information, such as local surveillance websites or supranational organizations, which compiled the information sent by local health authorities to WHO for influenza surveillance, were very useful for our research and provided valuable information. Nevertheless, these individual sources were not sufficiently comprehensive and we needed to take information from each source to provide a bigger picture of the situation.

Reasons for this scarcity of data could include the observation that epidemiologists working in surveillance systems do not consider publishing peer-reviewed papers, as the information is disclosed in weekly reports. However this does not explain the lack of incidence data in combined peer-reviewed and other sources. As a result, clinicians cannot easily access the information.

Further, assessing disease burden is a complex task, especially as in addition to the direct disease burden, an important indirect burden, due to all the medical conditions that can become complicated or even fatal because of influenza, especially in the elderly, needs to be considered. Several methods which measure the indirect influenza-attributable burden, including complex modeling exercises, are being increasingly but not routinely used. The false perception that influenza B is a mild form of influenza, can account for the lack of research, and contribute to the lack of awareness among the medical community of the true circulation, potential mismatch and disease burden.

The second important point relates to the lack of predictable patterns in strain circulation seen in these countries. Even considering neighboring countries, such as Belgium and Luxemburg in the North; Austria, Switzerland, Slovakia and the Czech Republic in Central Europe; or Finland and Estonia in the North-East, it is not possible to see any common circulation pattern. Indeed, mismatch has occurred in at least one of the 11 seasons in every country with available information excludes Estonia and in 3 different seasons in 5 countries; even complete vaccine mismatch was observed.

As there is no identifiable trend, there is no way of predicting how important it will be in future seasons. A previous literature review of studies from — indicates that the burden of influenza B can be significant, regardless of age. Two previous studies reported that influenza B-related hospitalization following an ER visit is more likely in children compared to influenza A. Our review has some limitations, the first relating to country selection. Since our selection was based on convenience, we made no attempt to generalize our findings to any other countries or regions.

However, since the value of this review relies on the lack of distribution homogeneity and is moreover based on individual country results, we believe that our results are valuable when highlighting the lack of predictable trends. Although comprehensive, we did not embark upon a systematic review as we knew beforehand that some of the information sources would not be in report form. This would have been a significant limitation for the critical appraisal phase of a systematic review, and led us to descriptively process the information. Further, in the case of influenza, as surveillance web sites at local and supranational level are an invaluable source of data on virus circulation, we felt it was important to keep these relevant sources in our review.

Our results are therefore limited by the quality of the identified studies, but it should be remembered that the objective of this review was to describe all available epidemiological information. The data presented for these 9 small to medium-sized countries are considerably disparate and as such limits its impact on generalizability to the entire region of Europe.


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Furthermore, the results are bound by the inherent limitations of the studies included in the literature review. The comparability of data between countries are constrained by differences in individual study designs population-based, hospital-based, etc.

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In addition, drawing conclusions was hampered by gaps in laboratory surveillance, wherein some countries had no available data for many years. In summary, our review highlights the unpredictability of influenza B lineage circulation in the region, and the mismatch between the circulating influenza B and vaccine recommended lineages in the trivalent vaccine.

The findings also highlight the need for local research to better understand strain circulation and the burden of influenza, including influenza B, in the 9 European studies included in this review. The PubMed library was used to perform a search in January for relevant literature on influenza B. Limits applied in both searches included publication date January to January and language English, French, German and Dutch. The results were compared and discussed before the remaining references were assessed by one researcher. The results were compared and discussed and any disagreements were adjudicated by a third researcher, when necessary.

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A manual search of reference lists of included articles and narrative reviews was also performed to find additional peer-reviewed literature which was not retrieved from PubMed or the Cochrane library. An extensive search in other data sources was performed to retrieve information on epidemiological surveillance. Other national surveillance networks and annual reports were searched using Google.

We referred to the WHO website to check recommendations on the vaccine composition in the Northern Hemisphere. In each of the countries, one or several networks of sentinel physicians which report consultation rates due to influenza-like illness ILI and acute respiratory infection were reviewed. All data reported are descriptive. Epidemiological parameters extracted from publications were incidence rates and proportions of influenza B among laboratory-confirmed influenza cases, with subtyping results.

Outcome measures of disease burden included ER and GP visits, hospitalization and mortality rates, rates of complications and antibiotic consumption.


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Circulation patterns and vaccine mismatch were analyzed based on comparisons of vaccine and circulating B strains for each country by influenza season. MB and MVN report fees for services to their institution from the GSK group of companies during the conduct of the study and outside the submitted work.

All authors participated in the literature review design or implementation or analysis, and interpretation of the literature review; and the development of this manuscript. All authors had full access to the data and approved the final manuscript.

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The work described was carried out in accordance to ICMJE recommendations for conduct, reporting, editing and publications of scholarly work in medical journals. The corresponding author had responsibility to submit the final manuscript for publication. GlaxoSmithKline Biologicals SA funded all costs associated with the literature review and the development and publication of this manuscript. National Center for Biotechnology Information , U.

Journal List Hum Vaccin Immunother v. Hum Vaccin Immunother. Published online Feb Author information Article notes Copyright and License information Disclaimer. Color versions of one or more of the figures in the article can be found online at www. The moral rights of the named author s have been asserted. This article has been cited by other articles in PMC. Keywords: co-circulation, Europe, influenza B, influenza vaccine, lineages, quadrivalent, trivalent, vaccine mismatch. Open in a separate window. Figure 1. Epidemiology of influenza B infection No data on the incidence of the 2 influenza B lineages were identified in the review.

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Summary of influenza B burden of disease from the literature review. Influenza-related hospitalization and mortality Data on overall influenza-related hospitalization and mortality combined with proportions of influenza B were limited and, where available, these data were primarily focused on the pediatric population. Figure 2.

Table 2. Overview of circulating influenza B lineage, by country, by influenza season. National epidemiologic surveillance No additional information was found with a search of local Ministries of Health MoH websites and Google and the retrieved information confirmed our previous findings. Discussion Data on influenza B epidemiology and burden of disease are essential to understand the level of risk and protection that current trivalent vaccination can provide.

Methods Comprehensive literature review The PubMed library was used to perform a search in January for relevant literature on influenza B. Selection procedure. Step 1. Screening of full text articles selected in Step 1. These articles were either included in the evidence tables or were excluded if the article did not contain relevant information or contained poor quality information.

At this stage, critical appraisal of full text articles, using a standard set of criteria, took place. Screening during data-extraction phase Further scrutiny of the article during the data-extraction phase possibly leading to exclusion.

Gray literature and other data sources An extensive search in other data sources was performed to retrieve information on epidemiological surveillance. Authors' contributions All authors participated in the literature review design or implementation or analysis, and interpretation of the literature review; and the development of this manuscript.

Funding GlaxoSmithKline Biologicals SA funded all costs associated with the literature review and the development and publication of this manuscript. Global burden of respiratory infections due to seasonal influenza in young children: a systematic review and meta-analysis. The impact of influenza on working days lost: a review of the literature. Clinical manifestations of influenza A and B in children and adults at a tertiary hospital in Korea during the — season. Comparison of clinical features and outcomes of medically attended influenza A and influenza B in a defined population over four seasons: — through — Estimates of mortality attributable to influenza and RSV in the United States during — by influenza type or subtype, age, cause of death, and risk status.

Wkly Epidemiol Rec ; Estimating vaccine effectiveness against laboratory-confirmed influenza using a sentinel physician network: results from the — season of dual A and B vaccine mismatch in Canada. Component-specific effectiveness of trivalent influenza vaccine as monitored through a sentinel surveillance network in Canada, — Efficacy of live attenuated influenza vaccine in children against influenza B viruses by lineage and antigenic similarity. The impact of smoking bans in cantons where stricter tobacco bans are in place show the health benefits of such measures.

A study from the canton of Vaud reported an improvement in lung function, physical well-being and respiratory symptoms among hospitality workers after a similar ban [8]. The current federal smoking ban is lax but allows cantons to implement stricter regulations. At the time of the vote, 15 of the 26 cantons already had stricter regulations in place, 8 of which are very similar to the demands of the initiative.

Workers in various cantons do not have the same rights as some are not protected from second-hand smoke and must even give written consent to work in a smoking environment.


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Other environmental pollutants as well as radiation are regulated at the federal level with the same maximal tolerated doses throughout the country and no one would call this into question. The negative economical aspect of second-hand smoke bans on the hospitality business is often referred to by tobacco proponents but a large body of evidence shows that such bans have no impact or even a positive impact on the economy [10], and this argument was even verified locally after a ban in the Swiss canton of Ticino [11] which was published a few weeks prior to the ballot and thus received some attention from the press as well.

Comprehensive country-wide smoking bans do not affect the economy but patchy ones where neighbouring regions allow smoking may. Moreover, the health costs related to second-hand smoke in a small country such as Switzerland, with a population of 8 million, have been estimated at million CHF a year [12]. Their campaign used the following arguments table 1 :. The opponents claimed that the current law was the result of a good compromise from all parties and that the new initiative did not introduce any substantial improvements.

They specifically asserted that the population was already well protected from second-hand smoke. They stated that many businesses had made important investments after the entry into force of the current law, for example to equip their establishment with a dedicated smoking room and said that a new change would compromise legal security. A ban was also claimed as useless since the numbers of smokers was steadily decreasing. They argue that many cantons had already adopted stricter rules regarding passive smoking. Moreover, they stated that many businesses already underwent costly renovations in order to comply with the current law and that these investments would be lost if the law were to change again as stipulated in the initiative.

The argument that hotels would not be able to have smoking rooms was promoted as well. They also alerted the public about the detrimental impact on other sectors of the economy, notably suppliers, advertisement and communication companies.