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The 2009 H1N1 "swine flu" epidemic killed up to 203,000 people across the world, 10 times greater than initially estimated by the World Health Organisation, researchers say.
In a study published in the journal PLOS Medicine, epidemiologists used data on respiratory deaths in 20 nations to calculate a global mortality rate.
Prior to this research, the WHO counted just 18,631 laboratory-confirmed cases of H1N1, a viral infection of the air ways.
"This study confirms that the H1N1 virus killed many more people globally than originally believed," read a statement from Lone Simonsen, a research professor at George Washington University in Washington, DC.
"We also found that the mortality burden of this pandemic fell most heavily on younger people and those living in certain parts of the Americas."
The relatively modest number of deaths estimated by the WHO prompted some to question whether the overall response to the 2009 outbreak was excessive. However, Simonsen and her colleagues argued that laboratory-confirmed influenza deaths would underestimate the broad reach of the illness.
"Many influenza-related deaths result from secondary bacterial infections or from exacerbation of pre-existing chronic conditions, and are not recorded as related to influenza infection," the authors wrote.
Among the findings that surprised researchers was the age and geographic distribution of deaths. Between 62 per cent and 85 per cent of victims were younger than age 65. Traditionally, seasonal influenza hits seniors the hardest.
Researchers also calculated that flu-related deaths were 20 times greater in Central America and South America than in European countries. That finding stood in sharp contrast to an earlier United States Centres for Disease Control and Prevention estimate that heaviest mortality rates occurred in Africa and Southeast Asia, and that death rates in the Americas were lower.


H1N1 flu epidemic 'killed 203,000' according to WHO study

A man walks past a graffiti on a wall featuring a crying woman wearing a mask marked with H1N1 in Beijing in 2009. Photo: AP

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