{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,26]],"date-time":"2026-06-26T03:39:53Z","timestamp":1782445193756,"version":"3.54.5"},"update-to":[{"DOI":"10.12688\/wellcomeopenres.16620.1","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2021,6,10]],"date-time":"2021-06-10T00:00:00Z","timestamp":1623283200000}},{"DOI":"10.12688\/wellcomeopenres.16620.2","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2021,6,10]],"date-time":"2021-06-10T00:00:00Z","timestamp":1623283200000}}],"reference-count":19,"publisher":"F1000 Research Ltd","license":[{"start":{"date-parts":[[2021,6,10]],"date-time":"2021-06-10T00:00:00Z","timestamp":1623283200000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100000274","name":"British Heart Foundation","doi-asserted-by":"publisher","award":["FS\/18\/71\/33938"],"award-info":[{"award-number":["FS\/18\/71\/33938"]}],"id":[{"id":"10.13039\/501100000274","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100000272","name":"National Institute for Health Research Health Protection Research Unit","doi-asserted-by":"publisher","id":[{"id":"10.13039\/501100000272","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100010269","name":"Wellcome Trust","doi-asserted-by":"crossref","award":["201440"],"award-info":[{"award-number":["201440"]}],"id":[{"id":"10.13039\/100010269","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["wellcomeopenresearch.org"],"crossmark-restriction":false},"short-container-title":["Wellcome Open Res"],"abstract":"<ns4:p>\n                    <ns4:bold>Background:<\/ns4:bold>\n                    People of non-White ethnicity have a higher risk of severe outcomes following influenza infection. It is unclear whether this is driven by an increased risk of infection or complications. We therefore aimed to investigate the incidence of clinically diagnosed influenza\/influenza-like illness (ILI) by ethnicity in England from 2008-2018.\n                  <\/ns4:p>\n                  <ns4:p>\n                    <ns4:bold>Methods:<\/ns4:bold>\n                    We used linked primary and secondary healthcare data (from the Clinical Practice Research Datalink [CPRD] GOLD and Aurum databases and Hospital Episodes Statistics Admitted Patient Care [HES APC]). We included patients with recorded ethnicity who were aged 40-64 years and did not have a chronic health condition that would render them eligible for influenza vaccination. ILI infection was identified from diagnostic codes in CPRD and HES APC. We calculated crude annual infection incidence rates by ethnic group. Multivariable Poisson regression models with random effects were used to estimate any ethnic disparities in infection risk. Our main analysis adjusted for age, sex, and influenza year.\n                  <\/ns4:p>\n                  <ns4:p>\n                    <ns4:bold>Results:<\/ns4:bold>\n                    A total of 3,735,308 adults aged 40-64 years were included in the study; 87.6% White, 5.2% South Asian, 4.2% Black, 1.9% Other, and 1.1% Mixed. We identified 102,316 ILI episodes recorded among 94,623 patients. The rate of ILI was highest in the South Asian (9.6 per 1,000 person-years), Black (8.4 per 1,000 person-years) and Mixed (6.9 per 1,000 person-years) ethnic groups. The ILI rate in the White ethnic group was 5.7 per 1,000 person-years. After adjustment for age sex and influenza year, higher incidence rate ratios (IRR) for ILI were seen for South Asian (1.70, 95% CI 1.66-1.75), Black (1.48, 1.44-1.53) and Mixed (1.22, 1.15-1.30) groups compared to White ethnicity.\n                  <\/ns4:p>\n                  <ns4:p>\n                    <ns4:bold>Conclusions:<\/ns4:bold>\n                    Our results suggest that influenza infection risk differs between White and non-White groups who are not eligible for routine influenza vaccination.\n                  <\/ns4:p>","DOI":"10.12688\/wellcomeopenres.16620.3","type":"journal-article","created":{"date-parts":[[2021,6,10]],"date-time":"2021-06-10T09:27:22Z","timestamp":1623317242000},"page":"49","update-policy":"https:\/\/doi.org\/10.12688\/wellcomeopenres.crossmark-policy","source":"Crossref","is-referenced-by-count":15,"title":["Ethnic differences in the incidence of clinically diagnosed influenza: an England population-based cohort study 2008-2018"],"prefix":"10.12688","volume":"6","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1599-7504","authenticated-orcid":false,"given":"Jennifer","family":"Davidson","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amitava","family":"Banerjee","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3817-8790","authenticated-orcid":false,"given":"Rohini","family":"Mathur","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7156-7640","authenticated-orcid":false,"given":"Mary","family":"Ramsay","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9168-6022","authenticated-orcid":false,"given":"Liam","family":"Smeeth","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jemma","family":"Walker","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0576-2015","authenticated-orcid":false,"given":"Helen","family":"McDonald","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4524-3180","authenticated-orcid":false,"given":"Charlotte","family":"Warren-Gash","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"2560","published-online":{"date-parts":[[2021,6,10]]},"reference":[{"key":"ref-1","article-title":"Are some ethnic groups more vulnerable to COVID-19 than others?","author":"L Platt","year":"2020","journal-title":"The Institute for Fiscal Studies,"},{"key":"ref-2","article-title":"ICNARC report on COVID-19 in critical care.","year":"2020"},{"key":"ref-3","doi-asserted-by":"publisher","first-page":"2020.09.22.20198754","DOI":"10.1101\/2020.09.22.20198754","article-title":"Ethnic differences in COVID-19 infection, hospitalisation, and mortality: an OpenSAFELY analysis of 17 million adults in England.","author":"R Mathur","year":"2020","journal-title":"medRxiv."},{"key":"ref-4","doi-asserted-by":"publisher","first-page":"100630","DOI":"10.1016\/j.eclinm.2020.100630","article-title":"Ethnicity and clinical outcomes in COVID-19: A systematic review and meta-analysis.","volume":"29","author":"S Sze","year":"2020","journal-title":"EClinicalMedicine."},{"key":"ref-5","article-title":"Influenza: the green book, chapter 19","year":"2020"},{"key":"ref-6","article-title":"Seasonal flu vaccine uptake in GP patients: monthly data, 2020 to 2021"},{"key":"ref-7","doi-asserted-by":"publisher","first-page":"3231-8","DOI":"10.1016\/j.vaccine.2018.04.074","article-title":"Population-level factors predicting variation in influenza vaccine uptake among adults and young children in England, 2015\/16 and 2016\/17.","volume":"36","author":"E Tessier","year":"2018","journal-title":"Vaccine."},{"key":"ref-8","doi-asserted-by":"publisher","first-page":"2620-8","DOI":"10.1016\/j.vaccine.2015.03.049","article-title":"Phased introduction of a universal childhood influenza vaccination programme in England: Population-level factors predicting variation in national uptake during the first year, 2013\/14.","volume":"33","author":"H Green","year":"2015","journal-title":"Vaccine."},{"key":"ref-9","doi-asserted-by":"publisher","first-page":"1082-7","DOI":"10.1136\/jech-2015-207014","article-title":"Factors associated with influenza vaccine uptake during a universal vaccination programme of preschool children in England and Wales: A cohort study.","volume":"70","author":"P Hardelid","year":"2016","journal-title":"J Epidemiol Community Health."},{"key":"ref-10","doi-asserted-by":"publisher","first-page":"3375-83","DOI":"10.1017\/S0950268815000576","article-title":"Ethnicity, deprivation and mortality due to 2009 pandemic influenza A(H1N1) in England during the 2009\/2010 pandemic and the first post-pandemic season.","volume":"143","author":"H Zhao","year":"2015","journal-title":"Epidemiol Infect."},{"key":"ref-11","doi-asserted-by":"publisher","first-page":"479-88","DOI":"10.1111\/irv.12483","article-title":"Social determinants of influenza hospitalization in the United States.","volume":"11","author":"R Chandrasekhar","year":"2017","journal-title":"Influenza Other Respi Viruses."},{"key":"ref-12","doi-asserted-by":"publisher","first-page":"827-36","DOI":"10.1093\/ije\/dyv098","article-title":"Data Resource Profile: Clinical Practice Research Datalink (CPRD).","volume":"44","author":"E Herrett","year":"2015","journal-title":"Int J Epidemiol."},{"key":"ref-13","doi-asserted-by":"publisher","first-page":"1740-1740g","DOI":"10.1093\/ije\/dyz034","article-title":"Data resource profile: Clinical Practice Research Datalink (CPRD) Aurum.","volume":"48","author":"A Wolf","year":"2019","journal-title":"Int J Epidemiol."},{"key":"ref-14","doi-asserted-by":"publisher","first-page":"1866-1868","DOI":"10.1016\/S0140-6736(20)32465-X","article-title":"Urgent actions and policies needed to address COVID-19 among UK ethnic minorities.","volume":"396","author":"R Mathur","year":"2020","journal-title":"Lancet."},{"key":"ref-15","article-title":"Housing, household transmission and ethnicity, 26 November 2020","year":"2020"},{"key":"ref-16","doi-asserted-by":"publisher","first-page":"2020.11.27.20238147","DOI":"10.1101\/2020.11.27.20238147","article-title":"Ethnicity, Household Composition and COVID-19 Mortality: A National Linked Data Study.","author":"V Nafilyan","year":"2020","journal-title":"medRxiv."},{"key":"ref-17","doi-asserted-by":"publisher","first-page":"1251-66","DOI":"10.1016\/j.socscimed.2004.07.016","article-title":"Inequity and inequality in the use of health care in England: An empirical investigation.","volume":"60","author":"S Morris","year":"2005","journal-title":"Soc Sci Med."},{"key":"ref-18","doi-asserted-by":"publisher","first-page":"141-7","DOI":"10.1136\/pgmj.2004.026237","article-title":"Access to health care for ethnic minority populations.","volume":"81","author":"A Szczepura","year":"2005","journal-title":"Postgrad Med J."},{"key":"ref-19","doi-asserted-by":"publisher","first-page":"fdaa196","DOI":"10.1093\/pubmed\/fdaa196","article-title":"The views of ethnic minority and vulnerable communities towards participation in COVID-19 vaccine trials.","author":"W Ekezie","year":"2020","journal-title":"J Public Health (Oxf)."}],"container-title":["Wellcome Open Research"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/wellcomeopenresearch.org\/articles\/6-49\/v3\/xml","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/wellcomeopenresearch.org\/articles\/6-49\/v3\/pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/wellcomeopenresearch.org\/articles\/6-49\/v3\/iparadigms","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2021,6,10]],"date-time":"2021-06-10T09:27:28Z","timestamp":1623317248000},"score":1,"resource":{"primary":{"URL":"https:\/\/wellcomeopenresearch.org\/articles\/6-49\/v3"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,6,10]]},"references-count":19,"URL":"https:\/\/doi.org\/10.12688\/wellcomeopenres.16620.3","relation":{"has-review":[{"id-type":"doi","id":"10.21956\/wellcomeopenres.18707.r44272","asserted-by":"object"},{"id-type":"doi","id":"10.21956\/wellcomeopenres.18707.r44368","asserted-by":"object"}]},"ISSN":["2398-502X"],"issn-type":[{"value":"2398-502X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,6,10]]},"assertion":[{"value":"Indexed","URL":"https:\/\/wellcomeopenresearch.org\/articles\/6-49\/v3#article-reports","order":0,"name":"referee-status","label":"Referee status","group":{"name":"current-referee-status","label":"Current Referee Status"}},{"value":"10.21956\/wellcomeopenres.18323.r42945, Benjamin\u00a0J. Cowling, WHO Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, The University of Hong Kong, Hong Kong, China, 08 Mar 2021, version 1, 1 approved, 1 approved with reservations","URL":"https:\/\/wellcomeopenresearch.org\/articles\/6-49\/v1#referee-response-42945","order":0,"name":"referee-response-42945","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"<b>Jennifer Davidson<\/b>; \n<i>Posted: 08 Apr 2021<\/i>; Dear Professor Cowling,&nbsp;  Thank you for&nbsp;your positive feedback and helpful comments.&nbsp;Below are&nbsp;our responses to each of your questions\/points:&nbsp;&nbsp;  \n<b><i>Point 1:&nbsp;Influenza\/ILI in CPRD is mainly ILI, so I am not sure your conclusion &quot;Our results suggest influenza infection risk...&quot; might be fairer to discuss ILI than influenza virus infection?&nbsp;<\/i><\/b> Response&nbsp;to point 1: Thank you for highlighting this, it would indeed be fairer to discuss ILI. We have updated the relevant text to \u201cOur results suggest the risk of clinical&nbsp;influenza\/ILI&nbsp;diagnosis differs between White and non-White groups\u201d. We have used&nbsp;\u201cinfluenza\/ILI\u201d&nbsp;in other&nbsp;sections of our discussion,&nbsp;so&nbsp;think&nbsp;the continued use of&nbsp;this&nbsp;phase&nbsp;adds consistency and acknowledges that some infections will be due to the influenza virus while others are not.&nbsp;&nbsp;  \n<b><i>Point 2:&nbsp;To what extent could access to care also affect comparisons?&nbsp;<\/i><\/b> Response to point 2: We have expanded our discussion of&nbsp;ethnic inequalities&nbsp;in&nbsp;access to care&nbsp;in our limitations section to include further&nbsp;consideration&nbsp;on inequalities in access to care: \u201cEthnic inequalities in the incidence of&nbsp;respiratory infections could arise because of differences in risk of exposure. Differences in exposure risk may be, driven by factors such as occupation, including working in frontline high-exposure occupations (including healthcare settings), and household composition, with large multigenerational households more common in non-White ethnic&nbsp;groups(16), as well as inequalities in access to care. Results from analysis of ethnic inequalities in access to care are mixed with the reasons for any inequalities complex, and likely due to multiple interlinked factors including; different cultural approaches to health, experiences of discrimination, and language&nbsp;barriers(17,18). Potentially ethnic differences in influenza\/ILI incidence could be greater than we have shown depending on the extent of access to care inequality. Unequal access to treatments will also affect the likelihood of adverse outcomes after infection.\u201d&nbsp;  \n<b><i>Point 3:&nbsp;You are not studying incidence of infections directly, but medically-attended illnesses?&nbsp;&nbsp;<\/i><\/b> Response to point 3: We have rephased the text in several places to emphasise that our incidence findings are based on illnesses which were medically-attended,&nbsp;including in the introduction where we state our study aim, in the opening sentence of our discussion, and in our limitations section of the discussion.&nbsp;&nbsp;  \n<b><i>Point 4:&nbsp;On a related note, if sick-notes are required in service sector but less frequently for white collar professions, would it lead to greater consultations among lower income professions?&nbsp;<\/i><\/b> Response to point 4:&nbsp;There are likely differences in the requirement of sick-notes within different professions in England. We are not able to comment on this directly but we did adjust for socio-economic status in our analyses to minimise the impact of any such differences.&nbsp;&nbsp;  \n<b><i>Point 5:&nbsp;I saw 12 references in the bibliography and wondered if there might be more (additional) similar studies that it would be relevant to cite here?&nbsp;<\/i><\/b> Response&nbsp;to point 5:&nbsp;We have expanded our bibliography to&nbsp;19&nbsp;references&nbsp;to include additional relevant literature.&nbsp;&nbsp;","URL":"https:\/\/wellcomeopenresearch.org\/articles\/6-49\/v3#referee-comment-4576","order":1,"name":"referee-comment-4576","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.21956\/wellcomeopenres.18537.r43676, Socorro Lupisan, Department of Health, Research Institute for Tropical Medicine, Muntinlupa, Philippines, 19 May 2021, version 2, indexed","URL":"https:\/\/wellcomeopenresearch.org\/articles\/6-49\/v2#referee-response-43676","order":2,"name":"referee-response-43676","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"<b>Jennifer Davidson<\/b>; \n<i>Posted: 04 Jun 2021<\/i>; Dear Dr Lupisan, &nbsp; Thank you for re-reviewing our article and for your positive feedback.&nbsp; &nbsp; In response to your specific points:  In the results section, who are the &quot;Other Asian&quot;? This is relevant to me as an Asian. Where will Filipinos, or other Asians fall under, other than Chinese which is specified? Does it mean, if not South Asian, they are &quot;Other Asian&quot;? \n<i>Response: To clarify, we based our categories of ethnicity on those used in the UK Census 2001, which was the most recent census prior to our study period. The 2001 Census groupings included an overall Asian category with sub-groupings of&nbsp;\u2018Indian\u2019, \u2018Pakistani\u2019, \u2018Bangladeshi\u2019 and 'Other Asian', and then collected 'Chinese' or 'Other' separately&nbsp;https:\/\/history.blog.gov.uk\/2019\/03\/07\/50-years-of-collecting-ethnicity-data\/. In order to make our results clinically interpretable, we grouped all South Asian ethnicities together (as 'Indian', 'Pakistani', 'Bangladeshi' and 'Other South Asian').&nbsp;Those reporting other specified Asian ethnicities that were not South Asian would form part of the 'Other' group, i.e. someone who was documented as Filipino would be grouped under 'Other'. We have updated the labels in our graphs and tables from 'Other Asian' to 'Other South Asian' for clarity. &nbsp;<\/i> Region of residence will not be relevant to readers who are not familiar, unless this is classified as urban, peri-urban or rural, which can be relatable. \n<i>Response: We used the 10 regional breakdowns in England available in CPRD, which are categorised geographically. There is substantial variation within each region so they are not able to be classified as urban, peri-urban and rural. However, our inclusion of the Townsend quintile gives further information about area-level deprivation, which is more relevant to our study question.<\/i> Still, the tables are too long. No comparison for significant difference has been done. May be added as supplement. \n<i>Response: We agree that the tables are long, but we think the<\/i>\n<i>&nbsp;importance of the information shown outweighs the issue of length.&nbsp;<\/i>\n<i>Wellcome Open Research do not permit supplementary material so we are unable to add the tables as an appendix. We acknowledge that we have not added a comparison of significant differences to the tables; due to the size of our dataset&nbsp;p-values can be uninformative.<\/i>","URL":"https:\/\/wellcomeopenresearch.org\/articles\/6-49\/v3#referee-comment-4638","order":3,"name":"referee-comment-4638","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"This work was supported in part by the British Heart Foundation [FS\/18\/71\/33938] who fund a Non-Clinical PhD Studentship for J.D., the Wellcome Trust [201440\/Z\/16\/Z] who fund an Intermediate Clinical Fellowship for C.W.-G, and the National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Immunisation at the London School of Hygiene and Tropical Medicine in partnership with Public Health England, who fund J.W., H.M., L.S. and M.R. The funders had no role in study design, data collection and analysis, preparation of the manuscript, or the decision to publish. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, the Department of Health and Social Care, or Public Health England. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.","order":4,"name":"grant-information","label":"Grant Information"},{"value":"This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.","order":0,"name":"copyright-info","label":"Copyright"}]}}