1

INFLUENZA (AND OTHER RESPIRATORY VIRUS) SURVEILLANCE IN WISCONSIN

Thomas Haupt M.S.Wisconsin Influenza Surveillance Coordinator

2

Greetings and Thank You From Wisconsin!

3

Population approximately 5.6 million

Average high temperature (July) 82 degrees

WISCONSIN THE “BADGER” STATE

4

Population approximately 5.6 million

>6,000 Confirmed and Probable Cases

WISCONSIN THE “SWINE-FLU” STATE

5

Surveillance MethodsCurrent and Future

Current• Virologic (Lab)• Rapid Test Site (RTS)• ILINET (Influenza-like illness)

Future• Enhanced ED monitoring• Hospitalizations• Enhance Antiviral Resistance Monitoring

6

PANDEMIC INFLUENZA VIROLOGIC SURVEILLANCEIN PERSPECTIVE

Confirmed % cases Cases (worldwide)

WORLDWIDE 94,500 100%

UNITED STATES 37,250 39%

WISCONSIN 6,300 7%

7

4 Labs Certified to do Pandemic Influenza Confirmation

8

Week Ending April 25th

"

Legend

APRIL 25MAY 2MAY 9MAY 16

MAY 23

MAY 30

JUNE 6JUNE 13

JUNE 20

9

Week Ending May 2nd

Legend

APRIL 25MAY 2MAY 9MAY 16

MAY 23

MAY 30

JUNE 6JUNE 13

JUNE 20

10

Week Ending May 9th

Legend

APRIL 25MAY 2MAY 9MAY 16

MAY 23

MAY 30

JUNE 6JUNE 13

JUNE 20

11

Week Ending May 16th

Legend

APRIL 25MAY 2MAY 9MAY 16

MAY 23

MAY 30

JUNE 6JUNE 13

JUNE 20

12

Week Ending May 23rd

Legend

APRIL 25MAY 2MAY 9MAY 16

MAY 23

MAY 30

JUNE 6JUNE 13

JUNE 20

13

Week Ending May 30th

Legend

APRIL 25MAY 2MAY 9MAY 16

MAY 23

MAY 30

JUNE 6JUNE 13

JUNE 20

14

Week Ending June 6th

Legend

APRIL 25MAY 2MAY 9MAY 16

MAY 23

MAY 30

JUNE 6JUNE 13

JUNE 20

15

Week Ending June 13th

Legend

APRIL 25MAY 2MAY 9MAY 16

MAY 23

MAY 30

JUNE 6JUNE 13

JUNE 20

16

Week Ending June 20th

Legend

APRIL 25MAY 2MAY 9MAY 16

MAY 23

MAY 30

JUNE 6JUNE 13

JUNE 20

17

0

500

1000

1500

2000

2500

3000

3500

2-May 9-May 16-May 23-May 30-May 6-Jun 13-Jun 20-Jun 27-Jun 4-Jul

week ending

# T

ests

0%

10%

20%

30%

40%

50%

60%

% P

osi

tive

Tested Confirmed % Positive

WISCONSIN PANDEMIC INFLUENZA LAB SURVEILLANCE

18

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

3-Ja

n

10-Ja

n

17-Ja

n

24-Ja

n

31-Ja

n

7-Feb

14-F

eb

21-F

eb

28-F

eb

7-Mar

14-M

ar

21-M

ar

28-M

ar

4-Apr

11-A

pr

18-A

pr

25-A

pr

2-May

9-May

16-M

ay

23-M

ay

30-M

ay

6-Ju

n

13-Ju

n

20-Ju

n

week ending

# T

ests

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

% P

osi

tive

Tested % Positive

WISCONSIN SEASONAL and PANDEMIC INFLUENZA LAB SURVEILLANCE

19

Virologic Surveillance

• Need to determine a median between testing everyone and those needed to be tested– Severely ill– High risk patients, and – Residents of LTC, Corrections and other Institutions

• Need a more streamline, accurate (yet simple) method of reporting data i.e..

“Electronic lab reporting”

20

Rapid Test Site (RTS) Surveillance

• Done for several years very informally

• 2008-09 CSTE Grant to Enhance Influenza Surveillance

21

Geographic Distribution of Laboratory Surveillance Contributors

Douglas Bayfield

Ashland

SawyerWashburnBurnett

Polk Barron Rusk

Price

Iron

Vilas

Oneida

Lincoln

TaylorChippewaSt. Croix

Pierce

Dunn

Pepin

Eau Claire

BuffaloTrempealeau

Jackson

Monroe

Clark Marathon

Wood Portage

Juneau Adams

Sauk

LaCrosse

Vernon

Crawford

Richland

Grant

LaFayetteGreen

Rock

Dane

Iowa

Columbia Dodge

Jefferson Waukesha

Walworth

Kenosha

Racine

Ozaukee

SheboyganFond du Lac

Green Lake

Marquette

Waushara Winnebago

Calumet

Manitowoc

Kewaunee

Brown

OutagamieWaupaca

Shawano

Menominee

OcontoLanglade

Forest

Marinette

Florence

Door

Milwaukee

Washington

Virology Laboratory

Rapid Test Site

Green Bay

Milwaukee

22

Wisconsin

0

500

1000

1500

2000

2500

#Tes

ts

0%

10%

20%

30%

40%

% P

osi

tive

Flu Tests RSV Tests

% Flu + % RSV +

23

Percent Positive Lab Tests

0%

10%

20%

30%

40%

50%

40 43 46 49 52 3 6 9 12 15

week

% P

osi

tive

Culture PCR Rapid

24

Rapid Test Site (RTS) Surveillance

Advantages• Many more sites (Data)• Consistent with both PCR and Culture• Can be easily broken down by regions of

the state Disadvantage• Use early and late in season (Low PVP)• Use during Pandemic Influenza

25

• Wisconsin had 66 Sentinel Clinicians, 50 of which were regular reporters– 30 of which do year-round surveillance

• Data analyzed by Public health Region and statewide– Baseline and threshold levels of ILI

• “Traditional” state– Limited electronic ILI, more syndromic

ILINet – WI Outpatient ILI surveillance

26

ILINet – WI Outpatient ILI surveillance network, through Jun 27

27

ILINet – WI Outpatient ILI surveillance network, through Jun 27

Wisconsin

0%

2%

4%

6%

8%

WI ILI WI BaselineWI Threshold Region V %Regional Baseline %

Southeastern Region

0%

2%

4%

6%

8%

10%

% IL

I

ILI % Baseline Threshold Milwaukee City

28

• Continue to recruit/maintain clinicians

• Gear toward more electronic ILI reporting– Hospital ED surveillance– Validate criteria for surveillance

• Chief Complaint/ discharge diagnosis etc

ILINet – WI Outpatient ILI surveillance network

29

Future Surveillance

• Enhance and develop “severity” surveillance

– Hospitalizations from flu

– ED data

– Deaths

• Antiviral Resistance

30

Hospitalizations and ED Data

• Intra –state pilot program to identify admissions due to ILI and ED visits due to ILI on a daily/weekly basis– By age group (0-4,5-24,25-49,50-64, >64)– Web based reporting system (WI-Trac)– early results varied

• 10 minutes to 1 hour of ICP time• ability of hospitals to do it also varied

31

32

Wisconsin Health Information Exchange (WHIE) Network

Currently in Milwaukee County only• 16 hospitals

Plan to expand to larger hospitals, hospital corporations this fall

Uses chief complaint “Fever” or “Flu”

Daily, weekly monthly

Hospital Death reporting being considered

33

Weekly ED visits with chief complaint of “fever” or “flu” at 11 Milwaukee area hospitals, by age-group, Jan 2008 – Jul 4, 2009

Wisconsin Health Information Exchange (WHIE) data

34

Wisconsin Health Information Exchange (WHIE) Network

Use in local areas is better than ILINet

Use in statewide or regional areas is being reviewed

Data needs to be validated for use in ILINet

35

Wisconsin Health Information Exchange (WHIE) Network

Chief Complaint Categories

Fever Flu

Respiratory Asthma Sepsis

DiarrheaRash

Other

36

Antiviral Resistance

• Wisconsin State Lab currently tests for seasonal influenza resistance to adamantanes and neuraminidase inhibitors

• Beginning July 2009 will test Pandemic H1N1 for resistance to adamantanes and neuraminidase inhibitors using CDC methodology

37

What we don’t do

• Statewide school absenteeism– Some local surveillance that varies greatly

• Large Business absenteeism

• Long term care (Except for clusters)

38

“Other” Respiratory Viruses Surveillance

Statewide and Regionally• RSV (Rapid tests)

Statewide• Parainfluenza (1-4)• Adenovirus• Rhinovirus• Human metapneumovirus• Coronavirus (OC-43 and others)• Enterovirusus

39

VIRUS CULTUREBased on 206 tests

RAPID TESTS SELECT PCR TESTS

Virus % Positive

Virus #Tests

% Positive

Virus Positive/total

number

Total % Positive 16.0% Influenza A & B 44/206

Influenza (Tot.) Influenza A Influenza B hMPV

9.7%1.5%8.2%0%

Influenza (Tot) 957 13.6%

Influenza A 3.6% # A/H1 8

Influenza B 9.9% # A/H3 0

Influenza Unk.* 0.1% # B 34

RSV 1.9% RSV 207 9.2% RSV 6/122

Adenovirus 1.0% Adenovirus 55 0.0% Adenovirus 1/38

Parainfluenza 3.4% Parainfluenza 6/76

Rhinovirus 0.0% *Influenza unknown (Unk) are positive influenza test results that cannot be distinguished between Type A and B

Rhinovirus 3/38

Enterovirus

0.0% Enterovirus 0/38

40

Again…

Thank you for invitation and hospitality !!

Questions and comments … Please