Texas Influenza Texas Influenza SurveillanceSurveillance

Lesley BullionLesley Bullion

Influenza Surveillance CoordinatorInfluenza Surveillance Coordinator

Infectious Disease Control UnitInfectious Disease Control Unit

Flu Surveillance BasicsFlu Surveillance Basics

Flu is not a notifiable condition*Flu is not a notifiable condition*

Participation in surveillance is voluntaryParticipation in surveillance is voluntary

““Official” flu season is approximately Official” flu season is approximately October to May (MMWR week 40 to October to May (MMWR week 40 to MMWR week 20)MMWR week 20)

Texas Flu SurveillanceTexas Flu SurveillanceU.S. Outpatient Influenza-Like Illness U.S. Outpatient Influenza-Like Illness Surveillance Network (ILINet)Surveillance Network (ILINet)

Influenza-like illness (ILI) Influenza-like illness (ILI) datadata

Culture Surveillance ‘Network’Culture Surveillance ‘Network’SpecimensSpecimens from clinics, hospitals, public health labs, health from clinics, hospitals, public health labs, health departmentsdepartmentsLimited Limited specimensspecimens from some ILINet providers from some ILINet providers

Research and Hospital LaboratoriesResearch and Hospital LaboratoriesFlu test Flu test resultsresults from NREVSS, WHO, TCH, S&W, from NREVSS, WHO, TCH, S&W, USAFSAMUSAFSAM

Regional Flu Surveillance Coordinator ReportsRegional Flu Surveillance Coordinator ReportsILI, school closures, institutional outbreaks, laboratory ILI, school closures, institutional outbreaks, laboratory results, rapid flu test results, pediatric flu deathsresults, rapid flu test results, pediatric flu deaths

U.S. Outpatient U.S. Outpatient Influenza-Like Illness Influenza-Like Illness Surveillance Network Surveillance Network

(ILINet)(ILINet)

ILINet BasicsILINet Basics

VoluntaryVoluntary nationwide network of healthcare providers nationwide network of healthcare providers sponsored by the Centers for Disease Control and sponsored by the Centers for Disease Control and Prevention (CDC)Prevention (CDC)

Recruited by each state health departmentRecruited by each state health department

Weekly reports of influenza-like illness (fever ≥100°F Weekly reports of influenza-like illness (fever ≥100°F AND cough and/or sore throat in the absence of a known AND cough and/or sore throat in the absence of a known cause other than influenza)cause other than influenza)

Some Texas providers also submit specimens to DSHSSome Texas providers also submit specimens to DSHS

ILINet Reporting FormsILINet Reporting Forms

ILINet DataILINet Data

U.S. Outpatient Influenza-Like Illness Surveillance Network U.S. Outpatient Influenza-Like Illness Surveillance Network (ILINet), Texas Participants (N=143), 2008-09(ILINet), Texas Participants (N=143), 2008-09

HSR Total

1 9

2/3 27

4/5N 8

6/5S 36

7 9

8 11

9/10 18

11 25

Grand Total 143

As of 7/13/09

Culture SurveillanceCulture Surveillance

Culture Surveillance Sites, Culture Surveillance Sites, 1998-19991998-1999

2008-09 Influenza Surveillance Specimens 2008-09 Influenza Surveillance Specimens Submitted to DSHS Austin Lab (N=1,419*)Submitted to DSHS Austin Lab (N=1,419*)

HSRHSR TotalTotal

11 4040

2/32/3 642642

4/5N4/5N 120120

6/5S6/5S 4848

77 246246

88 106106

9/109/10 4444

1111 173173

Grand TotalGrand Total 14191419

*through April 15, 2009

Additional Laboratory DataAdditional Laboratory Data

Weekly Reports by Individual LabsWeekly Reports by Individual Labs

Texas Children’s Hospital: +culturesTexas Children’s Hospital: +cultures

Scott & White Hospital Laboratory: +tests Scott & White Hospital Laboratory: +tests (culture, PCR, antigen) by patient county(culture, PCR, antigen) by patient county

USAFSAM: +cultures/PCR by baseUSAFSAM: +cultures/PCR by base

LRN laboratories: +PCRLRN laboratories: +PCR

NREVSS Laboratory DataNREVSS Laboratory DataNREVSS Flu Reporters in 2008-09 season:

Arlington Memorial HospitalChildren’s Hospital of AustinChildren’s Medical Center of DallasCook Children’s Medical CenterCovenant Medical CenterDriscoll Children’s HospitalHunt Memorial Hospital DistrictMedical Center of PlanoMedical City Dallas HospitalMethodist Children's HospitalMethodist HospitalMother Frances HospitalSanta Rosa Health CareScott & White Memorial HospitalSouth Texas Regional Medical CenterTarrant County Public HealthTexas Children’s HospitalTexas Department of State Health ServicesTomball Regional HospitalUniversity Hospital/South Texas Medical CenterUniversity of Texas Medical Branch – Children’s HospitalUniversity Medical Center

NREVSS Flu Reporters in 2008-09 season:

Arlington Memorial HospitalChildren’s Hospital of AustinChildren’s Medical Center of DallasCook Children’s Medical CenterCovenant Medical CenterDriscoll Children’s HospitalHunt Memorial Hospital DistrictMedical Center of PlanoMedical City Dallas HospitalMethodist Children's HospitalMethodist HospitalMother Frances HospitalSanta Rosa Health CareScott & White Memorial HospitalSouth Texas Regional Medical CenterTarrant County Public HealthTexas Children’s HospitalTexas Department of State Health ServicesTomball Regional HospitalUniversity Hospital/South Texas Medical CenterUniversity of Texas Medical Branch – Children’s HospitalUniversity Medical Center

Regional Flu ReportsRegional Flu Reports

Flu Activity LevelsFlu Activity Levels

No Activity:No Activity: – Low clinical activity and no lab confirmationLow clinical activity and no lab confirmation

Sporadic:Sporadic: – ILI activity not increasedILI activity not increased– Isolated lab confirmed cases OR an institutional outbreak in a single institutionIsolated lab confirmed cases OR an institutional outbreak in a single institution

Local:Local: – Increase in ILI plus recent lab confirmation inIncrease in ILI plus recent lab confirmation in ONE ONE region of the stateregion of the stateOR OR – Recent lab confirmation AND two or more ILI or lab confirmed outbreaks inRecent lab confirmation AND two or more ILI or lab confirmed outbreaks in ONE ONE

regionregion

Regional:Regional:– Increased ILI OR institutional outbreaks in ≥2 but less than half of the regionsIncreased ILI OR institutional outbreaks in ≥2 but less than half of the regions– AND recent lab confirmation in affected regionsAND recent lab confirmation in affected regions

Widespread:Widespread: – Increased ILI OR institutional outbreaks in at least half of the regions Increased ILI OR institutional outbreaks in at least half of the regions – AND recent lab confirmed influenza in affected regionsAND recent lab confirmed influenza in affected regions

Flu activity levelFlu activity levelRegional reportsRegional reportsLab dataLab data

OutbreaksOutbreaks

SPSN ILI dataSPSN ILI data

Link to national reportLink to national report

Texas Texas Weekly Flu Weekly Flu

ReportReport

Texas Weekly Flu ReportTexas Weekly Flu Report

How does Texas How does Texas surveillance contribute to surveillance contribute to

national surveillance?national surveillance?

National Flu SurveillanceNational Flu Surveillance

Centers for Disease Control (CDC) Centers for Disease Control (CDC) components of influenza surveillance in components of influenza surveillance in the U.S.the U.S.– Viral Laboratory SurveillanceViral Laboratory Surveillance– Outpatient Illness DataOutpatient Illness Data– Mortality SurveillanceMortality Surveillance– Hospitalization SurveillanceHospitalization Surveillance– State and Territorial Epidemiologists ReportsState and Territorial Epidemiologists Reports

2008–2009 2008–2009 Influenza Season Influenza Season

in Texas in Texas (through April 15, 2009)(through April 15, 2009)

U.S. Outpatient Influenza-Like Illness Surveillance Network (ILINet), Data From Texas Participants, 2008-09

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October November December January February March April

MMWR Week

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Patients ILI %ILI

Texas Flu Summary, 2008–09Texas Flu Summary, 2008–09

First isolate of the season (DSHS Lab)First isolate of the season (DSHS Lab)– Flu A/unable to subtype!Flu A/unable to subtype!

Specimen collected October 15, 2008Specimen collected October 15, 2008Bell County Bell County Swine influenza A (H1N1) Swine influenza A (H1N1)

– Flu BFlu BSpecimen collected October 21, 2008Specimen collected October 21, 2008B/Malaysia/2506/2004-like (Victoria lineage)B/Malaysia/2506/2004-like (Victoria lineage)Webb CountyWebb County

Predominant type/subtype: A (H1N1)Predominant type/subtype: A (H1N1)

Percentage of Specimens Positive for Influenza and Types/Subtypes of Influenza Isolated at DSHS Austin Lab, 2008-09

0

20

40

60

80

100

120

140

160

40 41 42 43 44 45 46 47 48 49 50 51 52 53 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

October November December January February March April

2008 2009

MMWR Week

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A/H1 A/H3 A/Unable to subtype B %FLUPOS

Texas Flu Summary, 2008-09Texas Flu Summary, 2008-09

Early appearance of influenza B and A (H1N1)Early appearance of influenza B and A (H1N1)– Influenza A (H3N2) absent until week 52Influenza A (H3N2) absent until week 52

Seasonal peak: early FebruarySeasonal peak: early February– 221 specimens collected, 147 (67%) positive for flu 221 specimens collected, 147 (67%) positive for flu

during week 5 (week ending February 7, 2009)during week 5 (week ending February 7, 2009)– ILINet peak: 7.06% in week 6ILINet peak: 7.06% in week 6– NREVSS-Texas peak: 28.1% in week 5NREVSS-Texas peak: 28.1% in week 5– ““Widespread” designation for 7 weeksWidespread” designation for 7 weeks

Late, small flu B wave (week 8)Late, small flu B wave (week 8)Mild compared to 2007-08Mild compared to 2007-08

Influenza Types and Subtypes Identified in Positive Specimens, Influenza Types and Subtypes Identified in Positive Specimens, DSHS Austin Laboratory, 2008-2009 SeasonDSHS Austin Laboratory, 2008-2009 Season

Virus Total

A H1 468

A H3 37

Unable to subtype 1

B/Florida/04/2006-like 15

B/Malaysia/2506/2004-like 248

Influenza B 7

Grand Total 776

2008-09 Flu Season in Texas (through April 15, 2009)

0%

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100%

40 41 42 43 44 45 46 47 48 49 50 51 52 53 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

October November December January February March April

2008 2009

MMWR Week

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%Flu Pos, DSHS Austin

%Flu Pos, NREVSS

%ILI, ILINet

Widespread flu activity reported to CDC

Influenza-Associated Pediatric Influenza-Associated Pediatric MortalityMortality

Reportable beginning in 2007 in TexasReportable beginning in 2007 in Texas

Laboratory-confirmed influenza death in a Laboratory-confirmed influenza death in a person under 18 years of ageperson under 18 years of age

11 deaths (through week 15)11 deaths (through week 15)– Age range: 7 months to 17 yearsAge range: 7 months to 17 years– 4 Flu A, 7 Flu B4 Flu A, 7 Flu B– Known MRSA or MSSA co-infection: 2/11 (18%)Known MRSA or MSSA co-infection: 2/11 (18%)– Significant underlying medical condition: 8/11 (73%)Significant underlying medical condition: 8/11 (73%)– Not vaccinated for flu: 4/6 (67%)Not vaccinated for flu: 4/6 (67%)

Review of 2008–09 Vaccine Review of 2008–09 Vaccine Components (Northern Hemisphere)Components (Northern Hemisphere)

All 3 were new components!All 3 were new components!– 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/Yamagata lineage)B/Florida/4/2006-like (B/Yamagata lineage)

Antigenic Characterization TestingAntigenic Characterization Testing

Performed on limited Texas isolates at Performed on limited Texas isolates at CDC laboratoryCDC laboratory20 A/H1 (seasonal) isolates: 100% match 20 A/H1 (seasonal) isolates: 100% match to vaccine strainto vaccine strain8 A/H3 isolates: 100% match8 A/H3 isolates: 100% match23 influenza B isolates:23 influenza B isolates:– 30% match to vaccine strain (Yamagata 30% match to vaccine strain (Yamagata

lineage)lineage)– 70% Victoria lineage70% Victoria lineage

Antiviral Resistance TestingAntiviral Resistance Testing

Performed on limited Texas isolates at CDC Performed on limited Texas isolates at CDC laboratorylaboratory1 swine influenza A/H1 tested (October 2008)1 swine influenza A/H1 tested (October 2008)– Sensitive to oseltamivir, zanamivir, adamantanesSensitive to oseltamivir, zanamivir, adamantanes

22 seasonal influenza A/H1’s tested22 seasonal influenza A/H1’s tested– 100% resistant to oseltamivir (sensitive to zanamivir 100% resistant to oseltamivir (sensitive to zanamivir

and adamantanes)and adamantanes)

7 influenza A/H3’s tested7 influenza A/H3’s tested– 100% resistant to adamantanes (sensitive to 100% resistant to adamantanes (sensitive to

oseltamivir and zanamivir)oseltamivir and zanamivir)

22 influenza B’s tested22 influenza B’s tested– 100% sensitive to oseltamivir and zanamivir100% sensitive to oseltamivir and zanamivir

2009-10 Vaccine Composition 2009-10 Vaccine Composition (Northern Hemisphere)(Northern Hemisphere)

Only the B strain will be changed:Only the B strain will be changed:– 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/Brisbane/60/2008-like (B/Victoria lineage)B/Brisbane/60/2008-like (B/Victoria lineage)

Texas Flu Surveillance Texas Flu Surveillance 2009-2010 Season2009-2010 Season

Continue funding all packaging, shipping, and Continue funding all packaging, shipping, and testing related to flu surveillance; however, testing related to flu surveillance; however, testing may be limited – how?testing may be limited – how?Increase ILINet participants & culture Increase ILINet participants & culture surveillance sites in selected areassurveillance sites in selected areasPCR to continue at LRNsPCR to continue at LRNsVTM ordering process? Limits?VTM ordering process? Limits?To sign up for automatic notification of new flu To sign up for automatic notification of new flu reports:reports:http://www.dshs.state.tx.us/idcu/disease/http://www.dshs.state.tx.us/idcu/disease/influenza/surveillance/2009/influenza/surveillance/2009/