U.S. Influenza Activity and Vaccine Effectiveness Update

Lisa Grohskopf, MD MPH

Vaccine and Related Biologic Products Advisory Committee Meeting28 February 2014

National Center for Immunization and Respiratory Diseases

Influenza Division

Influenza Activity Update

Lyn Finelli, DrPH, MSInfluenza Surveillance and Outbreak Response Team

Epidemiology and Prevention BranchInfluenza Division

ACIPFebruary 26, 2013

VIROLOGIC SURVEILLANCE

0

1,000

2,000

3,000

4,000

5,000

0

5

10

15

20

25

30

40 50 10 20 30 40 50 10 20 30 40 500

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

0

10

20

30

40

50

60

70

80

90

100H3N2v

A(2009 H1N1)

A(H3)

A(Subtyping not performed)

B

Percent Positive

Num

ber o

f Pos

itive

Spe

cim

ens

Per

cent

Pos

itive

2012 2013 2014

2011

14%

31%

U.S. World Health Organization and National Respiratory and Enteric Virus Surveillance System Collaborating Laboratories,

National Summary, 2010-14

Antiviral ResistanceOctober 1, 2013 – February 15, 2014

High levels of resistance to the adamantanes (amantadine and rimantadine) persist among pH1N1 and influenza A (H3N2) viruses currently circulating globally.

Neuraminidase Inhibitor Resistance Testing Results Samples Collected Since October 1, 2013

Oseltamivir ZanamivirVirus

Samples tested

(n)

Resistant Viruses, Number

(%)

Virus Samples tested

(n)

Resistant Viruses, Number

(%)Influenza A (H3N2) 186 0 (0.0) 186 0 (0.0)

Influenza B 73 0 (0.0) 73 0 (0.0)2009 H1N1 3,471 26 (0.7) 1,259 0 (0.0)

ILI SYNDROMIC SURVEILLANCE

Percentage of Visits for Influenza-like Illness (ILI) Reported by the U.S. Outpatient Influenza-like Illness Surveillance Network (ILINet),

Weekly National Summary, 2013-14 and Selected Previous Seasons

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

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

0

1

2

3

4

5

6

7

8

2013-14 season

2012-13 season

2011-12 season

2009-10 season

2007-08 season

2002-03 season

National Baseline

Week

% o

f Vis

its fo

r IL

I

6.1%

4.6%

HOSPITALIZATION SURVEILLANCE

Rates of Lab-Confirmed Influenza Hospitalization FluSurvNet, October 1, 2013 –

February 15, 2014

55/100K

41/100K

38/100K

18/100K

7/100K

Overall Rate26.1/100K pop

MORTALITY SURVEILLANCE

40 50 10 20 30 40 50 10 20 30 40 50 10 20 30 40 500

5

10

15

20

25

30

35

40

Week of Death

Num

ber o

f dea

ths

2010-11Number of Deaths

Reported = 123

2011-12Number of Deaths

Reported = 35

2012-13Number of Deaths

Reported = 171

2013-14Number of Deaths

Reported = 52

Number of Influenza-Associated Pediatric Deaths

by Week of Death: 2010-11 to February 15, 2014

40 50 10 20 30 40 50 10 20 30 40 50 10 20 30 40 50 10 20 30 40 504

6

8

10

12

Weeks

% o

f All

Dea

ths

Due

to P

&I

Epidemic Threshold

Seasonal Baseline

Pneumonia and Influenza Mortality 122 U.S. Cities Surveillance System

National Summary, 2009-2014

2009 2010 2011 2012 2013 2014

8.7%

9.9%

Influenza Deaths by Age Group122 Cities Mortality Reporting System,

Number of Influenza Deaths by Age Group and Year

2009-10 2010-11 2011-12 2012-13 2013-140%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

16941 19 59 25

555

190 37

138

352

160

17566

556

194

>64 years25-64 years0-24 years

*

**Data as of week 6, 2014

***Data from week 15, 2009 – week 39, 2010

Influenza Activity Summary Influenza activity in the US during the 2013–14

season began approximately 4 weeks earlier than usual, and occurred at moderate levels Activity peaked in late December/early January Influenza A (H1N1) viruses predominated

There are higher rates of influenza-associated hospitalization in 2013-14 in persons 18-64 years of age than during the past several seasons

There were higher numbers of influenza deaths in the 122 Cities Mortality Surveillance System in 2013-14 in persons 25-64 years than during past several seasons

Acknowledgements

Joseph BreseeScott EppersonLenee BlantonKrista KnissRosaline DharaDesiree MustaquimAlejandro PerezMichelle LeonAndrea GiorgiCraig SteffensAshley FowlkesJulie VillanuevaSophie Smith

Michael JhungCarrie ReedAlicia FrySeema JainAnna BramleyVictoria JiangSandra Dos Santos ChavesDaniel JerniganJoe GreggLarissa GubarevaTerri WallaceXiyan XuNancy Cox

Interim Estimates of 2013-14 Seasonal Influenza Vaccine Effectiveness — United States,

February 2014

Data from the U.S. Flu VE NetworkDecember 2, 2013-January 23, 2014

Brendan Flannery, PhDInfluenza Division

Presentation to the ACIP Influenza Working GroupFebruary 18, 2014

National Center for Immunization & Respiratory DiseasesInfluenza Division

US Flu VE Network: Five Study Sites and Principal Investigators

Lisa JacksonMike Jackson

Ed Belongia

Arnold MontoSuzanne Ohmit

Rick ZimmermanPatricia Nowalk

Manju Gaglani

US Flu VE Network: Methods

Enrollees: All persons aged >6 months with medically attended acute respiratory illness (MAARI) – ambulatory care visits from Dec 2, 2013-Jan 23, 2014Methods : Prospective case-control study (test negative design) Influenza infection confirmed with CDC RT-PCR

Cases: Outpatient ARI and influenza PCR-positive Controls: Outpatient ARI and influenza PCR-negative

Vaccination status: receipt of ≥1 dose of 2013-14 seasonal flu vaccine confirmed by medical records and registries (2 sites) and self-report and medical records (3 sites)

Analysis: VE = (1 – adjusted OR) x 100% Adjustment for study site, age, sex, race/ethnicity,

self-rated health and days from illness onset to enrollment

US Flu VE Network: Results

Influenza test result No. (%)Influenza A 778 (99%) H1N1pdm09 742 H3N2 13 Not subtyped 23Influenza B 6 (1%)

• 2,319 enrolled from 2 December, 2013-23 January, 2014

• 1,535 (66%) influenza RT-PCR negative• 784 (34%) influenza RT-PCR positive

Adjusted VE* and 95% CIs against influenza A and B for ≥1 dose of 2013-14 seasonal influenza vaccine, by age

group

6 mos-17 yrs 18-49 yrs 50-64 yrs ≥65 yrs0

10

20

30

40

50

60

70

80

90

100

Age group

Vacc

ine

Effec

tive

ness

(%

)

* Vaccine effectiveness was estimated as 100% X (1 – odds ratio [ratio of odds of vaccination among flu-positive cases to odds of vaccination among flu-negative controls]) using multivariable logistic

regression including study site, age, sex, race/ethnicity, self-rated health status and days from illness onset to enrollment.

Comparison of adjusted VE estimates against H1N1pdm09 associated outpatient ARI over several

influenza seasons

* Adjusted VE and 95% CI for primary healthcare patients: 42% (-97%-83%). Source: Castilla J, Eurosurveillance 2014 .

US Flu V

E, 20

13-14

Canad

a, 20

13-14

Spain*,

2013

-14

US Flu V

E, 20

11-12

Canad

a, 20

11-12

US Flu V

E, 20

10-11

Marsh

field, W

I, 20

10-11

Euro

pe, 20

10-11

US Flu V

E, 20

09-10

Pregnan

t wom

en, U

S, 10-1

1/11-1

20

102030405060708090

100

Study, Influenza Season

Vacc

ine

Effec

tive

ness

(%

)

Conclusions 2009 H1N1pdm virus predominated among influenza

viruses identified from Dec 2, 2013-Jan 23, 2014 in U.S.

Interim adjusted VE against H1N1pdm09 associated medically attended ARI = 62% (95% CI: 53-69) Similar for all age groups Similar to VE estimates from previous seasons Consistent with laboratory data

Final analyses for 2013-14 season will investigate effects of prior vaccination

Ability to estimate VE for H3N2 or B infections will depend upon final sample size

US Flu VE Network• University of Michigan and Henry Ford Health System: Arnold S. Monto, MD, Suzanne E.

Ohmit, DrPH, Joshua G. Petrie, MPH, Emileigh Johnson, Rachel T. Cross, MPH, Casey Martens, Marcus Zervos, MD, Lois Lamerato, PhD, Mary Ann Aubuchon, William Fredrick; 

• University of Pittsburgh Schools of the Health Sciences and UPMC: Richard K. Zimmerman, MD, Mary Patricia Nowalk, PhD, Jonathan M. Raviotta, MPH, Heather Eng, Stephen R. Wisniewski, PhD, Charles R. Rinaldo, Jr, MD, Arlene Bullotta, Joe Suyama, MD, Evelyn Reis, MD, Donald B. Middleton, MD, Rhett H. Lieberman, MD, Michael Susick, MPH, Krissy K. Moehling, MPH, Mallory Schaffer, BS;

• Baylor Scott and White Health, Texas A&M University Health Science Center College of Medicine: Manjusha Gaglani, Lydia Clipper, RN, Anne Robertson, AA, Kempapura Murthy, MPH, Monica Weir, Hope Gonzales, Martha Zayed,  Teresa Ponder, Virginia Gandy, RN, Patricia Sleeth, RN, Sophia V James, MS, , Michael Reis, MD, Cathleen Rivera, MD, David Morgan, MD, and Baylor College of Medicine : Pedro Piedra, MD, Vasanthi Avadhanula, PhD;

• Group Health Research Institute : Michael L. Jackson, PhD, Lisa A. Jackson, MD, C. Hallie Phillips, MEd, Joyce Benoit, RN, Lawrence T. Madziwa, MS, Matt B. Nguyen, MPH, Julia P. Anderson, MA;

• Marshfield Clinic Research Foundation: Edward A. Belongia, MD, Huong Q. McLean, PhD, Deanna Cole, Donna David, Sarah Kopitzke, MS, Tamara A. Kronenwetter Koepel, Jennifer K. Meece, PhD, Carla Rottscheit, Sandra K. Strey, Maria E. Sundaram, MSPH, Laurel A. Verhagen;

• CDC: Alicia M. Fry, MD, Swathi N. Thaker, PhD, Jessie Clippard, MPH, Ivo Foppa, PhD, Jill Ferdinands, PhD, LaShondra Berman, MS, Angie Foust, MS, Wendy Sessions, MPH, Sarah Spencer, PhD, Erin Burns, MA, Joseph Bresee, MD, Nancy Cox, PhD.