Influenza Surveillance Danae Bixler, MD, MPH Infectious Disease Epidemiology Program

Influenza Influenza SurveillanceSurveillance

Danae Bixler, MD, MPHDanae Bixler, MD, MPH

Infectious Disease Infectious Disease Epidemiology ProgramEpidemiology Program

2Infectious Disease Epidemiology

Program

ObjectivesObjectives

Understand surveillance for… Understand surveillance for… Seasonal influenza Seasonal influenza

ILIILI Laboratory reportingLaboratory reporting Sentinel provider systemSentinel provider system Pediatric death reportingPediatric death reporting Hospital dataHospital data

Avian highly pathogenic H5N1Avian highly pathogenic H5N1 Pandemic influenzaPandemic influenza


Program

Seasonal InfluenzaSeasonal Influenza

US:US: 36,000 deaths36,000 deaths 226,000 hospitalizations226,000 hospitalizations

Symptoms (2-7 days)Symptoms (2-7 days) fever, chills, sweats headache, arthralgia, myalgia coryza, sore throat, and cough


Program

Seasonal InfluenzaSeasonal Influenza

Influenza-like illnessInfluenza-like illness Reportable from providers weeklyReportable from providers weekly Fever Fever >> 100 + cough or sore throat 100 + cough or sore throat Over - represents influenzaOver - represents influenza Under - reportedUnder - reported

Laboratory confirmedLaboratory confirmed Reportable from laboratories weekly Reportable from laboratories weekly

(aggregate)(aggregate) Highly sensitive and specificHighly sensitive and specific Under – represents influenzaUnder – represents influenza


Program


Program

Other Sources of DataOther Sources of Data

Sentinel ProvidersSentinel Providers Report ILI weekly to CDCReport ILI weekly to CDC

High maintenanceHigh maintenance 50% of providers report 50% of the time50% of providers report 50% of the time

Submit specimensSubmit specimens Vital records, hospital dataVital records, hospital data

Non-specific codingNon-specific coding DelayedDelayed


Program


Program

Deaths from Pneumonia and Influenza* by MMWR Week, West Virginia Residents, 2000-2005

Source: West Virginia Vital Records*Underlying Cause of Death = ICD-10 Codes J10 - J18

0

5

10

15

20

25

30

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53

MMWR Week

Nu

mb

er o

f D

eath

s

2000

2001

2002

2003

2004

2005


Program

Weekly Admissions to Hospital with a Primary Discharge Diagnosis of Influenza or Pneumonia,

West Virginia, 2000 - 2005; N=89,957Source: West Virginia Health Care Authority

0

100

200

300

400

500

600

700

800

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53

MMWR Week of Admission

Nu

mb

er o

f A

dm

issi

on

s 2000

2001

2002

2003

2004

2005


Program

Also Reportable … Pediatric Also Reportable … Pediatric Death from Influenza Death from Influenza

(Age<18)(Age<18)within 1 week to local health departmentwithin 1 week to local health department

Source: N Engl J Med 2005;

353:2559-67.


Program

MMWR Week of Onset of Influenza Among Hospitalized Patients by Influenza Type,

(N=305)

0

10

20

30

40

50

60

46 47 48 49 50 51 52 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

2007 2008MMWR Week

Nu

mb

er o

f Cas

es

Influenza B

Influenza A

2007-2008 Hospital 2007-2008 Hospital StudyStudy


Program

Risk Factors Among Hospitalized Influenza Cases, (N=305)

157

103

85

62

38

24

0 50 100 150 200

≥ 1 Risk Factor

Chronic Heart Disease

Diabetes

Chronic Lung Disease

Renal Disease

Asthma

Number of Cases

WVDHHR/BPH/DSDC/IDEP13


Program

Avian InfluenzaAvian Influenza

387 cases and 245 deaths as of 387 cases and 245 deaths as of 9/10/20089/10/2008 CFR = 63%CFR = 63%

Signs and Symptoms:Signs and Symptoms: High feverHigh fever Dyspnea, respiratory distressDyspnea, respiratory distress (+/-) GI symptoms (+/-) GI symptoms Pneumonia / ARDSPneumonia / ARDS Multi-organ failureMulti-organ failure


Program

Avian Influenza Screening Avian Influenza Screening Criteria*Criteria*

*Under revision (CDC)*Under revision (CDC) Severe respiratory illnessSevere respiratory illness AND AND Epidemiological evidenceEpidemiological evidence

TravelTravel to a country with human or animal to a country with human or animal cases ANDcases AND

ExposureExposure:: Direct contact with Direct contact with

Sick or dead poultry Sick or dead poultry Poultry fecesPoultry feces Sick or dead birdsSick or dead birds A person hospitalized or deceased from severe A person hospitalized or deceased from severe

unexplained respiratory illnessunexplained respiratory illness Consumption of raw / undercooked poultryConsumption of raw / undercooked poultry


Program


Program


Program


Program

Areas reporting confirmed H5N1 Areas reporting confirmed H5N1 avian influenza in poultry and wild avian influenza in poultry and wild

birds since 2003birds since 2003

status as of 23.09.2008 (latest available update from WHO)status as of 23.09.2008 (latest available update from WHO)


Program

Pandemic InfluenzaPandemic Influenza

1918-1919 pandemic Typical onset of influenza, Rapid progression

fever cough dyspnea cyanosis

CXR: widespread infiltrates Pneumonia / ARDS


Program

Annual Average Mortality in Annual Average Mortality in Pandemic and Pandemic and

Interpandemic Years, Interpandemic Years, United States, 1918 - 1991United States, 1918 - 1991


Program

Age-Specific Attack Rates for Pandemic (1918) and Interpandemic (1928-1929)

Influenza

0

5

10

15

20

25

30

35

40

45

<11

to 4

5 to

9

10 to

14

15 to

19

20 to

24

25 to

29

30 to

34

35 to

39

40 to

44

45 to

49

50 to

54

55 to

59

60 to

64

65 t

o 69

70 to

74

>75

Age Group

Att

ack

Rat

e (%

) 1918 Pandemic

1928 - 1929Interpandemic


Program

Current WHO phase of Current WHO phase of pandemic alert pandemic alert

current as of 9/30/2008 (WHO)current as of 9/30/2008 (WHO)


Program

Early Outbreak Early Outbreak Reporting RequirementsReporting Requirementshttp://www.wvidep.org/Portals/31/PDFs/IDEP/influenza/http://www.wvidep.org/Portals/31/PDFs/IDEP/influenza/

APPENDIX%202%20Pandemic%20Influenza%20SurveillanceAPPENDIX%202%20Pandemic%20Influenza%20Surveillance%20and%20Response_.pdf%20and%20Response_.pdf

Immediately report: Individual cases of pandemic strain

influenza: Fever > 100 ºC; and Cough or sore throat or shortness of breath;

and Laboratory evidence of pandemic strain

infection (criteria TBD). Deaths from pandemic strain influenza.


Program

Established OutbreakReporting Requirementshttp://www.wvidep.org/Portals/31/PDFs/IDEP/influenza/http://www.wvidep.org/Portals/31/PDFs/IDEP/influenza/

APPENDIX%202%20Pandemic%20Influenza%20SurveillanceAPPENDIX%202%20Pandemic%20Influenza%20Surveillance%20and%20Response_.pdf%20and%20Response_.pdf

Individual providers- report aggregate cases of influenza-like illness: Fever > 100° F (36°C) and Cough or sore throat or shortness of breath

without another identified cause. Hospitals shall report (daily):

New admissions for pandemic influenza Fever > 100 ºC; and Cough or sore throat or shortness of breath without

another identified cause. New admissions for pneumonia or influenza. New deaths from pandemic influenza


Program

For more information…For more information…

IDEP: IDEP: http://www.wvidep.org/AZIndexofInfectiousDiseases/Influenza/tabid/1518/Default.aspx Protocols – please review / commentProtocols – please review / comment Surveillance data Surveillance data Information sheetsInformation sheets Avian and pandemic guidanceAvian and pandemic guidance

CDC: CDC: http://www.cdc.gov/flu/ WHO: WHO:

http://www.who.int/topics/influenza/en/


Program

AcknowledgementAcknowledgement Flu Study team members, 2008 - Flu Study team members, 2008 -

20092009 West Virginia Bureau for Public HealthWest Virginia Bureau for Public Health

Kay Shamblin, RN, BSN Kay Shamblin, RN, BSN Caroline Williams, MD Caroline Williams, MD Carolyn Winkler, RN Carolyn Winkler, RN Mary Myers, RN Mary Myers, RN Allie Clay, RN Allie Clay, RN Thein Shwe, MPH, MS, MBBSThein Shwe, MPH, MS, MBBS

Charleston Area Medical CenterCharleston Area Medical Center Deana Samms, BS, MA, CICDeana Samms, BS, MA, CIC

Microsoft Office PowerPoint 97-2003 Pres

Documents

Influenza Surveillance Danae Bixler, MD, MPH Infectious Disease Epidemiology Program