Volume 390, Issue 10098, Pages 946-958 (September 2017) Global, regional, and national disease burden estimates of acute lower respiratory infections due to respiratory syncytial virus in young children in 2015: a systematic review and modelling study  Ting Shi, PhD, David A McAllister, MD, Prof Katherine L O'Brien, MD, Prof Eric A F Simoes, MD, Prof Shabir A Madhi, PhD, Bradford D Gessner, MD, Prof Fernando P Polack, MD, Evelyn Balsells, MPH, Sozinho Acacio, MD, Claudia Aguayo, MD, Issifou Alassani, MD, Asad Ali, MD, Prof Martin Antonio, PhD, Prof Shally Awasthi, MD, Juliet O Awori, MBBCh, Eduardo Azziz-Baumgartner, MD, Henry C Baggett, MD, Vicky L Baillie, PhD, Angel Balmaseda, MD, Alfredo Barahona, MD, Sudha Basnet, PhD, Prof Quique Bassat, MD, Wilma Basualdo, MD, Godfrey Bigogo, MPH, Prof Louis Bont, MD, Prof Robert F Breiman, MD, W Abdullah Brooks, MD, Prof Shobha Broor, MD, Prof Nigel Bruce, PhD, Dana Bruden, MS, Philippe Buchy, PhD, Stuart Campbell, MBChB, Phyllis Carosone-Link, MS, Mandeep Chadha, MD, James Chipeta, PhD, Monidarin Chou, PhD, Wilfrido Clara, MSc, Cheryl Cohen, PhD, Elizabeth de Cuellar, MD, Prof Duc- Anh Dang, PhD, Budragchaagiin Dash-yandag, MD, Maria Deloria-Knoll, PhD, Mukesh Dherani, PhD, Tekchheng Eap, MD, Bernard E Ebruke, MD, Marcela Echavarria, PhD, Carla Cecília de Freitas Lázaro Emediato, RN, Rodrigo A Fasce, BSc, Daniel R Feikin, MD, Luzhao Feng, MD, Prof Angela Gentile, MD, Aubree Gordon, PhD, Doli Goswami, MBBS, Sophie Goyet, PhD, Michelle Groome, PhD, Natasha Halasa, MD, Siddhivinayak Hirve, PhD, Nusrat Homaira, PhD, Stephen R C Howie, PhD, Jorge Jara, MD, Imane Jroundi, MD, Prof Cissy B Kartasasmita, PhD, Prof Najwa Khuri-Bulos, MD, Prof Karen L Kotloff, MD, Prof Anand Krishnan, MD, Romina Libster, MD, Olga Lopez, MD, Marilla G Lucero, MD, Florencia Lucion, MD, Socorro P Lupisan, MD, Debora N Marcone, PhD, John P McCracken, ScD, Mario Mejia, MD, Jennifer C Moisi, PhD, Joel M Montgomery, PhD, David P Moore, FCPaeds, Cinta Moraleda, MD, Jocelyn Moyes, MBBCh, Patrick Munywoki, PhD, Kuswandewi Mutyara, MD, Prof Mark P Nicol, PhD, Prof D James Nokes, PhD, Pagbajabyn Nymadawa, MD, Maria Tereza da Costa Oliveira, MD, Histoshi Oshitani, MD, Nitin Pandey, MD, Gláucia Paranhos-Baccalà, PhD, Lia N Phillips, MD, Valentina Sanchez Picot, DVM, Mustafizur Rahman, PhD, Mala Rakoto-Andrianarivelo, MD, Zeba A Rasmussen, MD, Prof Barbara A Rath, PhD, Prof Annick Robinson, MD, Candice Romero, MD, Prof Graciela Russomando, PhD, Vahid Salimi, PhD, Pongpun Sawatwong, MSc, Nienke Scheltema, MD, Brunhilde Schweiger, PhD, Prof J Anthony G Scott, FRCP, Phil Seidenberg, MD, Prof Kunling Shen, MD, Rosalyn Singleton, MD, Viviana Sotomayor, MPH, Prof Tor A Strand, PhD, Agustinus Sutanto, MD, Prof Mariam Sylla, MD, Milagritos D Tapia, MD, Somsak Thamthitiwat, MD, Elizabeth D Thomas, MPH, Rafal Tokarz, PhD, Claudia Turner, PhD, Prof Marietjie Venter, PhD, Sunthareeya Waicharoen, MSc, Prof Jianwei Wang, PhD, Wanitda Watthanaworawit, MSc, Prof Lay-Myint Yoshida, MD, Hongjie Yu, MD, Prof Heather J Zar, PhD, Prof Harry Campbell, MD, Prof Harish Nair, PhD  The Lancet  Volume 390, Issue 10098, Pages 946-958 (September 2017) DOI: 10.1016/S0140-6736(17)30938-8 Copyright © 2017 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license Terms and Conditions

Figure 1 Approaches for estimation of global RSV associated morbidity and mortality in children aged 0–4 years In this study, we report four different sets of estimates—number of episodes of (severe) RSV-ALRI at global and national levels, global RSV-ALRI hospital admissions, and global estimates of RSV-ALRI deaths in hospital and overall (in community). This figure summarises our approach for each of these categories and also shows how they relate to (and feed into each other). Global estimates of hospital admissions for RSV-ALRI have been estimated using two independent approaches and datasets (after ensuring all included studies satisfy the common case definition that hospital admission was based on a physician diagnosis of ALRI). Similarly, the in-hospital deaths due to RSV-ALRI are based on studies reporting in-hospital CFR for RSV and RSV-ALRI hospital admissions (again ensuring that all included studies satisfy the common case definition). RSV=respiratory syncytial virus. ALRI=acute lower respiratory infection. hCFR=in-hospital case fatality ratio. VA=verbal autopsy. DHS=demographic and health survey. *For details description of imputation see appendix p 7. †For detailed description of risk-factor based model see appendix pp 54–57. The Lancet 2017 390, 946-958DOI: (10.1016/S0140-6736(17)30938-8) Copyright © 2017 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license Terms and Conditions

Figure 2 Flow diagram for selection of studies RSV=respiratory synctical virus. Studies could have contributed data to more than one category. The Lancet 2017 390, 946-958DOI: (10.1016/S0140-6736(17)30938-8) Copyright © 2017 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license Terms and Conditions

Figure 3 Location of studies reporting incidence, hospital admission, and in-hospital case fatality in children with RSV-ALRI RSV-ALRI=RSV-associated acute lower respiratory infection. The Lancet 2017 390, 946-958DOI: (10.1016/S0140-6736(17)30938-8) Copyright © 2017 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license Terms and Conditions

Figure 4 Global burden of RSV-associated severe ALRI including burden on hospital services RSV=respiratory syncytial virus. ALRI=acute lower respiratory infection. Understanding the contribution of RSV to burden on hospital services and the proportion of “severe” cases not accessing hospital care or deaths outside of hospital is relevant for development of health policies to reduce global (RSV-associated) ALRI mortality. The orange boxes show the estimated number of “severe cases” and overall RSV-related deaths in LMICs that are based on relatively limited data. The green boxes show estimated burden on hospital inpatient services that are based on robust data. The blue boxes reflect the inferred (derived) burden estimates for severe cases and deaths that have no access to hospital care. The Lancet 2017 390, 946-958DOI: (10.1016/S0140-6736(17)30938-8) Copyright © 2017 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license Terms and Conditions