Influenza Influenza SurveillanceSurveillance

Lisa McHugh, MPHLisa McHugh, MPHInfluenza Surveillance Influenza Surveillance

CoordinatorCoordinatorNew Jersey Department of Health New Jersey Department of Health

and Senior Servicesand Senior Services

Seasonal InfluenzaSeasonal Influenza

5-20% infected yearly (15-60 million*)5-20% infected yearly (15-60 million*) >200,000 U.S. hospitalizations>200,000 U.S. hospitalizations

63% in persons age 63% in persons age >> 65 65 Hospitalization rate children <5Hospitalization rate children <5

With high-risk condition 500/100,000With high-risk condition 500/100,000 Without high-risk condition 100/100,000Without high-risk condition 100/100,000

~36,000 U.S. deaths ~36,000 U.S. deaths Greater than 90% of all deaths in adults Greater than 90% of all deaths in adults >>

65 years65 years Deaths among children uncommon but can Deaths among children uncommon but can

occuroccur

*Based on population of US Census estimate for 2007

Influenza SurveillanceInfluenza Surveillance

When and where influenza activity is When and where influenza activity is occurringoccurring

Determine types of influenza virus Determine types of influenza virus circulatingcirculating

Detect changes in influenza virusesDetect changes in influenza viruses Track influenza-related illnessTrack influenza-related illness Measure influenza’s impact on Measure influenza’s impact on

deaths in the United Statesdeaths in the United States

Influenza Surveillance in Influenza Surveillance in NJNJ

Disease surveillanceDisease surveillance Virologic surveillanceVirologic surveillance

Disease SurveillanceDisease SurveillanceInfluenza-like Illness (ILI)Influenza-like Illness (ILI)

Impossible to count all cases of influenzaImpossible to count all cases of influenza Use ILI to approximate true disease Use ILI to approximate true disease

burdenburden ILI combined with other more reliable ILI combined with other more reliable

information (i.e., laboratory testing) can information (i.e., laboratory testing) can provide a good estimate of disease provide a good estimate of disease burdenburden

Limitation: casts a wide net and will Limitation: casts a wide net and will capture other respiratory illnesscapture other respiratory illness

Disease SurveillanceDisease Surveillance

Influenza-like illness (ILI) Influenza-like illness (ILI) surveillancesurveillance Active surveillance- School, ED, LTCFActive surveillance- School, ED, LTCF

Sentinel provider surveillance Sentinel provider surveillance networknetwork

Pediatric influenza surveillancePediatric influenza surveillance

Active ILI SurveillanceActive ILI Surveillance

Weekly reports from ED, LTCF, and Weekly reports from ED, LTCF, and SchoolsSchools ED and LTCF - # ILI* and total censusED and LTCF - # ILI* and total census Schools - # absent and total censusSchools - # absent and total census

Currently enrolled in surveillanceCurrently enrolled in surveillance LTCF - 132LTCF - 132 ED - 87ED - 87 Schools - 719Schools - 719

Analysis done at state, county and regional Analysis done at state, county and regional levellevel* Patients with fever (* Patients with fever (>>100°F, oral or equivalent) AND cough and/or 100°F, oral or equivalent) AND cough and/or

sore throat (in the absence of a known cause).sore throat (in the absence of a known cause).

CDRSS ILI ModuleCDRSS ILI Module

Sentinel Provider Sentinel Provider Surveillance Network Surveillance Network

(SPSN)(SPSN) A collaborative effort between the public health A collaborative effort between the public health and medical communities to monitor influenza and medical communities to monitor influenza

State and local health department recruit State and local health department recruit providers to participateproviders to participate

Providers report weekly the number of patients Providers report weekly the number of patients seen and the number with ILI by 5 age seen and the number with ILI by 5 age categoriescategories

Reporting is from October 1 to mid-May Reporting is from October 1 to mid-May (MMWR week 40 to 20) of each year but year-(MMWR week 40 to 20) of each year but year-round reporting is encouragedround reporting is encouraged

SPSN GoalsSPSN Goals

Establish the beginning of the influenza season Establish the beginning of the influenza season to guide vaccination practicesto guide vaccination practices

Monitor the antigenic changes of circulating Monitor the antigenic changes of circulating influenza strains by collecting point of care influenza strains by collecting point of care specimensspecimens

Maintain a surveillance system that provides Maintain a surveillance system that provides early warning and adequate monitoring early warning and adequate monitoring capabilities in the event of a pandemic or capabilities in the event of a pandemic or outbreakoutbreak

Provide medical entities and other NJ residents Provide medical entities and other NJ residents with current and accurate information regarding with current and accurate information regarding the incidence and severity of disease in NJthe incidence and severity of disease in NJ

SPSNSPSN

SPSNSPSNNew Jersey Department of Health and Senior Services

Influenza-like Activity - Sentinel Providers

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

40 42 44 46 48 50 52 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38

MMWR Weeks

Pe

rce

nt

ILI

2007-2008 2006-2007

Pediatric Influenza Pediatric Influenza SurveillanceSurveillance

In the 2003-2004 influenza season, In the 2003-2004 influenza season, an increase in pediatric deaths an increase in pediatric deaths observed nationallyobserved nationally

CDC implemented pediatric CDC implemented pediatric mortality reportingmortality reporting

Subsequent years severe pediatric Subsequent years severe pediatric illness and mortality data collected illness and mortality data collected in NJin NJ

Pediatric Influenza Pediatric Influenza SurveillanceSurveillance

Case DefinitionCase Definition Pediatric patients (i.e., less than 18 years of age) with Pediatric patients (i.e., less than 18 years of age) with

laboratory confirmed influenza* laboratory confirmed influenza* ANDAND

Influenza-related deaths (in which there is no period of Influenza-related deaths (in which there is no period of complete recovery between illness and death); complete recovery between illness and death);

OROR Influenza encephalopathy (defined as altered mental Influenza encephalopathy (defined as altered mental

status, or personality changes in patients lasting more status, or personality changes in patients lasting more than 24 hours and occurring within 5 days of the onset of than 24 hours and occurring within 5 days of the onset of an acute febrile respiratory illness); an acute febrile respiratory illness);

OROR Severe illness defined as admission to an intensive care Severe illness defined as admission to an intensive care

unit for influenza-related illness (in previously health unit for influenza-related illness (in previously health children)children)

Pediatric Influenza Pediatric Influenza SurveillanceSurveillance

http://www.state.nj.us/health/flu/CaseReportForm.shtml

Pediatric Influenza Pediatric Influenza SurveillanceSurveillance

FindingsFindings

Season 2005-2006 2006-2007 2007-2008*

No. Reports 62 100 45

No. Meet Case Def. 25 17 19

Deaths 1 0 1

Vaccinated 4 1 3

Not Vaccinated 17 11 16

Unknown Vaccination

4 5 0

* As of March 11, 2008

New Jersey Pediatric Influenza Summary Report:2005-2006 Influenza Season can be found at: http://nj.gov/health/flu/documents/pediatric_flu_annual_report.pdf

Other Surveillance Other Surveillance ActivitiesActivities

122 City Mortality Report122 City Mortality Report ED Volume/Admission DataED Volume/Admission Data Real-time Outbreak and Disease Real-time Outbreak and Disease

Surveillance (RODS) Surveillance (RODS) Health Monitoring SystemHealth Monitoring System BioSense (Influenza Module)BioSense (Influenza Module) QuadraMedQuadraMed

Virologic SurveillanceVirologic Surveillance

GoalsGoals Identify and characterize circulating Identify and characterize circulating

strains for vaccine developmentstrains for vaccine development Identify and characterize strains with Identify and characterize strains with

pandemic potentialpandemic potential Monitor trends and compare season Monitor trends and compare season

differencesdifferences ParticipantsParticipants

Any laboratory conducting influenza testsAny laboratory conducting influenza tests NREVSSNREVSS

Types of Influenza Types of Influenza TestingTesting

Influenza Diagnostic Table

Procedure Influenza

Types Detected

Acceptable Specimens Time forResults

Rapid result

available

Viral culture (GOLD STANDARD)

A and B NP swab, throat swab, nasal wash, bronchial wash, nasal aspirate, sputum

3-10 days No

Immunofluorescence DFA Antibody Staining

A and B NP swab, nasal wash, bronchial wash, nasal aspirate, sputum

2-4 hours No

RT-PCR A and B NP swab, throat swab, nasal wash, bronchial wash, nasal aspirate, sputum

1-2 days No

Serology A and B paired acute and convalescent serum samples6

>2 weeks No

Enzyme Immuno Assay (EIA)

A and B NP swab, throat swab, nasal wash, bronchial wash

15-30 minutes

Yes

NREVSS/WHONREVSS/WHO

National Respiratory and Enteric National Respiratory and Enteric Virus Surveillance SystemVirus Surveillance System 24 participating laboratories in NJ24 participating laboratories in NJ Report directly to CDC on 16 Report directly to CDC on 16

respiratory and enteric viruses respiratory and enteric viruses NJ receives and analyzes data weeklyNJ receives and analyzes data weekly

Virologic SurveillanceVirologic Surveillance

Rapid antigen test kit projectRapid antigen test kit project 2006-2007 Season2006-2007 Season

64 sentinel laboratories (8 facilities returned 64 sentinel laboratories (8 facilities returned kits)kits)

35 sentinel providers35 sentinel providers

NJDHSS asked that all positive tests be NJDHSS asked that all positive tests be forwarded to NJPHEL for PCR and forwarded to NJPHEL for PCR and cultureculture

678 samples received from 29 (45%) 678 samples received from 29 (45%) facilities facilities

Virologic SurveillanceVirologic Surveillance

*Data as of MMWR week 20

Test Results

2005-2006 2006-2007

CDC/WHO(n=135,973)

Positive=17,997

NJ(n=139)

Positive=75

CDC/WHO(n=172,735*)

Positive=23,181

NJ(n=810)

Positive =611

A13,857 (81%)

A8,209 (59%)

73 (97%)

H113

(18%) 18,392 (80%)

A12,290(67%)

428 (70%)

A49 (11%)

H1420(3%)

H13,872 (21%)

H1144 (34%)

H35,228 (38%)

H360

(82%)

H32,230 (12%)

H3235 (55%)

B 3,642 (18%) 2 (3%) 4,789 (20%) 183 (30%)

Other Virus

2 9

NVI/QNS 62 190

Influenza Subtype by Test Type (NJPHEL)2006-2007 Influenza Season

0

50

100

150

200

250

300

A AH1 AH3 B NVI QNS Other virus

Influenza Subtype

Fre

qu

en

cy

Culture PCR

Influenza Type by Age Group (NJPHEL)2006-2007 Influenza Season

0

20

40

60

80

100

120

<1 1 to 18 19 to 64 65+

Age group

Nu

mb

er

of

Po

sit

ive

s

A H1 A H3 B

Positive Influenza Samples by MMWR Week and Subtype2006-2007 Influenza Season

0

10

20

30

40

50

60

70

80

90

40 41 42 43 44 45 46 47 48 49 50 51 52 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

MMWR Week

Num

ber P

ositi

ve

Positive B Positive A not typed positive A H1 Positive A H3

New Jersey Department of Health and Senior ServicesInfluenza Laboratory Report

Viral Culture Positive Specimens by MMWR Week

0

10

20

30

40

50

60

70

80

90

40 41 42 43 44 45 46 47 48 49 50 51 52 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

MMWR Week

Nu

mb

er P

osi

tive

A H1 A H3 A UNK B

2007-2008 Influenza Culture Results by Subtype

RSV SurveillanceRSV Surveillance

Minimum of one hospital per county Minimum of one hospital per county reports the number of RSV tests and reports the number of RSV tests and the number positivethe number positive

Surveillance is important because Surveillance is important because RSV infection can often be confused RSV infection can often be confused with influenzawith influenza

Assists providers with administration Assists providers with administration of of

RSV-IGIV and palivizumabRSV-IGIV and palivizumab

New Jersey Department of Health and Senior ServicesRespiratory Syncytial Virus (RSV) Suveillance by Week, 2006-2008

0

5

10

15

20

25

30

35

40

45

35 37 39 41 43 45 47 49 51 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33

MMWR Week

Pe

rce

nt

Po

sit

ive

% positive 2007-2008 % positive 2006-2007

RSV SurveillanceRSV Surveillance

2007-2008 Influenza Season

RSV, Sentinel Providers and Influenza Positive LabsMMWR week 40 (2005) to MMWR week 20 (2007)

0

20

40

60

80

100

120

40 42 44 46 48 50 52 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 2 4 6 8 10 12 14 16 18 20

MMWR

% R

SV

and

# fl

u la

b po

sitiv

es

0

1

2

3

4

5

6

7

%IL

I Sen

tinel

pro

vide

rs

RSV Flu positives Sentinel ProviderFLU FLU

RSV RSV

Influenza Vaccine Influenza Vaccine 2007-20082007-2008

A/Solomon Islands/3/2006 (H1N1)-A/Solomon Islands/3/2006 (H1N1)-likelike

A/Wisconsin/67/2005 (H3N2)-like (or A/Wisconsin/67/2005 (H3N2)-like (or A/Hiroshima/52/2005 virus)A/Hiroshima/52/2005 virus)

B/Malaysia/2506/2004-like antigens B/Malaysia/2506/2004-like antigens (or B/Ohio/1/2005 virus)(or B/Ohio/1/2005 virus)

2007-2008 Circulating 2007-2008 Circulating StrainsStrains

A- H1N1 (191 specimens)A- H1N1 (191 specimens) 147 (77%) 147 (77%) A/Solomon Islands/3/2006-likeA/Solomon Islands/3/2006-like 19 (10%) Reduced titers to A/Solomon 19 (10%) Reduced titers to A/Solomon

Islands/3/2006-likeIslands/3/2006-like 25 (13%) 25 (13%) A/Brisbane/59/2007-likeA/Brisbane/59/2007-like

A- H3N2 (86 specimens)A- H3N2 (86 specimens) 12 (14%) 12 (14%) A/Wisconsin/67/2005-likeA/Wisconsin/67/2005-like 67 (78%) 67 (78%) A/Brisbane/10/2007-likeA/Brisbane/10/2007-like 7 (8%) Reduced titers to 7 (8%) Reduced titers to

A/Wisconsin/67/2005-likeA/Wisconsin/67/2005-like

CDC data as of MMWR week 9

2007-2008 Circulating 2007-2008 Circulating StrainsStrains

B (89 tested)B (89 tested) Victoria lineage (6)Victoria lineage (6)

4 (67%) 4 (67%) B/Ohio/01/2005-like B/Ohio/01/2005-like 2 (33%) Reduced titers to 2 (33%) Reduced titers to

B/Ohio/01/2005-like B/Ohio/01/2005-like Yamagata lineage (83)Yamagata lineage (83)

82 (99%) 82 (99%) B/Florida/04/2006-likeB/Florida/04/2006-like 1 (1%) Reduced titers to 1 (1%) Reduced titers to

B/Florida/04/2006-likeB/Florida/04/2006-likeCDC data as of MMWR week 9

Influenza Vaccine Influenza Vaccine 2008-20092008-2009

FDA recommends all three vaccine FDA recommends all three vaccine components to be changed for the components to be changed for the 2008-2009 influenza season2008-2009 influenza season A/Brisbane/59/2007-like (H1N1)A/Brisbane/59/2007-like (H1N1) A/Brisbane/10/2007- like (H3N2)A/Brisbane/10/2007- like (H3N2) B/Florida/4/2006-like B/Florida/4/2006-like

Proposed New Influenza Proposed New Influenza Vaccine Rule Vaccine Rule

The NJDHSS is proposing a new rule at The NJDHSS is proposing a new rule at N.J.A.C.8:57-19 to establish that all N.J.A.C.8:57-19 to establish that all children six through 59 months of age children six through 59 months of age entering or attending a licensed child care entering or attending a licensed child care center or preschool facility on or after center or preschool facility on or after September 1, 2008 shall annually receive September 1, 2008 shall annually receive at least one dose of influenza vaccine at least one dose of influenza vaccine between September 1 and December 31 between September 1 and December 31 of each year.of each year.

Antiviral ResistanceAntiviral Resistance

Neuraminidase inhibitorsNeuraminidase inhibitors 45 (8.7%)of 519 H1N1 viruses tested 45 (8.7%)of 519 H1N1 viruses tested

were resistant to Oseltamivirwere resistant to Oseltamivir Adamantanes*Adamantanes*

111 (21.7%) of 511 influenza A viruses 111 (21.7%) of 511 influenza A viruses were resistantwere resistant 98.9% of H3N298.9% of H3N2 4.3% H1N14.3% H1N1

*CDC and ACIP recommend that neither amantadine nor rimantadine be used for the treatment or chemoprophylaxis of influenza A in the United States

Weekly Influenza ReportWeekly Influenza Report

All surveillance data is analyzed on a All surveillance data is analyzed on a weekly basis (MMWR weeks)weekly basis (MMWR weeks)

Influenza activity level is evaluated Influenza activity level is evaluated for both the state and 5 public for both the state and 5 public health regionshealth regions

Activity LevelsActivity Levels No ActivityNo Activity-- At least 2 of 3 parameters at or At least 2 of 3 parameters at or

below state baseline below state baseline ANDAND no lab confirmed cases no lab confirmed cases SporadicSporadic – At least 2 of 3 parameters above – At least 2 of 3 parameters above

state baseline state baseline ANDAND confirmed laboratory cases confirmed laboratory cases anywhere in the state anywhere in the state OROR at least one laboratory at least one laboratory confirmed outbreak in an institution anywhere in confirmed outbreak in an institution anywhere in the statethe state

LocalLocal – At least 2 or 3 parameters above state – At least 2 or 3 parameters above state baseline in a single county baseline in a single county ANDAND confirmed confirmed laboratory cases from that same county within laboratory cases from that same county within the previous 3 weeks (other counties may be the previous 3 weeks (other counties may be above baseline without lab confirmed cases) above baseline without lab confirmed cases) OROR confirmed outbreaks in 2 or more institutions in confirmed outbreaks in 2 or more institutions in a single countya single county

Activity LevelsActivity Levels

RegionalRegional – At least 2 of 3 parameters above – At least 2 of 3 parameters above state baseline in state baseline in >> 2 but 2 but << 10 counties 10 counties ANDAND laboratory confirmed cases from these same laboratory confirmed cases from these same counties in past 3 weeks counties in past 3 weeks OROR confirmed confirmed outbreaks institutions in more than 2 but less outbreaks institutions in more than 2 but less than or equal to 10 countiesthan or equal to 10 counties

WidespreadWidespread – At least 2 of 3 parameters – At least 2 of 3 parameters above state baseline in more than 10 counties above state baseline in more than 10 counties OROR institutional outbreaks in more than 10 institutional outbreaks in more than 10 counties counties ANDAND lab confirmed influenza cases lab confirmed influenza cases in previous 3 weeks.in previous 3 weeks.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

South Region

CW Region

NW Region

CE Region

NE Region

0

1

2

3

Activity Level

MMWR Week

Public Health Region

South Region CW Region NW Region CE Region NE Region

NE Region (Bergen, Essex, Hudson)CE Region (Middlesex, Monmouth, Ocean, Union)NW Region (Morris, Passaic, Sussex, Warren)CW Region (Hunterdon, Mercer, Somerset)South Region (Atlantic, Burlington, Camden, Cape May, Cumberland, Gloucester, Salem)

Weekly Influenza ReportWeekly Influenza Report

New Jersey Department of Health and Senior ServicesStatewide Influenza Activity Levels

0

1

2

3

4

5

40 41 42 43 44 45 46 47 48 49 50 51 52 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

MMWR Week

Act

ivit

y L

evel

2007-2008 2006-2007 2005-2006

Weekly Influenza ActivityWeekly Influenza ActivityNew JerseyNew Jersey

0=No report/activity 1=Sporadic 2=Local 3= Regional 4=Widespread

Weekly Influenza ActivityWeekly Influenza ActivityUnited StatesUnited States

http://www.cdc.gov/flu/weekly/usmap.htm

Questions?Questions?

Lisa McHugh, MPHLisa McHugh, MPH

Infectious & Zoonotic Disease ProgramInfectious & Zoonotic Disease ProgramInfluenza Surveillance ProgramInfluenza Surveillance Program

New Jersey Department of New Jersey Department of Health & Senior ServicesHealth & Senior Services

609-588-7500609-588-7500lisa.mchugh@doh.state.nj.uslisa.mchugh@doh.state.nj.us