Influenza UpdateInfluenza Update

Ariane Reeves, RN, BSN, MPH, CICAriane Reeves, RN, BSN, MPH, CIC

Influenza Surveillance CoordinatorInfluenza Surveillance Coordinator

Georgia Division of Public HealthGeorgia Division of Public Health

Influenza virus typesInfluenza virus types

Influenza AInfluenza A– Epidemics (seasonal) and pandemicsEpidemics (seasonal) and pandemics– Infects many species (e.g., avian, swine, equine)Infects many species (e.g., avian, swine, equine)

Influenza BInfluenza B– Epidemics onlyEpidemics only– Human reservoir onlyHuman reservoir only

Influenza CInfluenza C– Causes mild illness and is not included in surveillance Causes mild illness and is not included in surveillance

systemssystems

How viruses evolveHow viruses evolve

Antigenic Antigenic driftdrift– Influenza A and B virusesInfluenza A and B viruses– Result of an accumulation of small mutationsResult of an accumulation of small mutations– Can cause an epidemicCan cause an epidemic

Antigenic Antigenic shiftshift– Influenza A viruses onlyInfluenza A viruses only– ReassortmentReassortment– Can result in pandemicCan result in pandemic

Swine virus Avian/human

reassortantvirus

Avianvirus

Human virus

Rare – Pandemic Potential

Pandemic Potential

“Mixing vessel”

Interspecies Interspecies Transmission Genetic Transmission Genetic ReassortmentReassortment

Epidemiology of InfluenzaEpidemiology of Influenza

Highly infectious Highly infectious Transmission Transmission – primarily person-to-person via large and primarily person-to-person via large and

aerosolized small virus-laden dropletsaerosolized small virus-laden droplets– direct contact & indirect contact (fomites)direct contact & indirect contact (fomites)

Incubation period: 1-4 daysIncubation period: 1-4 daysInfectious period: 1 day prior to onset of Infectious period: 1 day prior to onset of symptoms to 3 days after symptoms to 3 days after – may be longer in childrenmay be longer in children

Impact of Seasonal InfluenzaImpact of Seasonal Influenza

Illness in 10-20 % population each yearIllness in 10-20 % population each year

Highest attack rates in childrenHighest attack rates in children

Average of 200,000 hospitalizations/yearAverage of 200,000 hospitalizations/year

Average of 36,000 deaths/yearAverage of 36,000 deaths/year

Highest rate of hospitalization and death in Highest rate of hospitalization and death in the elderlythe elderly

Laboratory TestingLaboratory Testing

• Viral cultureViral culture– Gold standardGold standard– Isolates for yearly vaccine developmentIsolates for yearly vaccine development

• Point-of-care tests (rapid tests)Point-of-care tests (rapid tests)– Generally 70+% sensitive, 90+% specificGenerally 70+% sensitive, 90+% specific– GDPH ordering for sentinels and districts!GDPH ordering for sentinels and districts!

• Other tests:Other tests:• ImmunofluorescenceImmunofluorescence• Serology (acute and convalescent)Serology (acute and convalescent)• RT-PCR – Currently used at GPHL for both seasonal RT-PCR – Currently used at GPHL for both seasonal

and avian influenza – results in 2-4 hoursand avian influenza – results in 2-4 hours

Influenza Surveillance OverviewInfluenza Surveillance OverviewMorbidityMorbidity– Sentinel Provider Network Syndromic SurveillanceSentinel Provider Network Syndromic Surveillance– EIP hospital surveillance (peds and adults)EIP hospital surveillance (peds and adults)

MortalityMortality– 122 Cities Mortality System122 Cities Mortality System– Pediatric deaths are reportablePediatric deaths are reportable

Virologic SurveillanceVirologic Surveillance– WHO/NREVSS Collaborating LaboratoriesWHO/NREVSS Collaborating Laboratories– Novel influenza A surveillance Novel influenza A surveillance

State assessmentState assessment– State & Territorial Epidemiologists Reports (that’s me)State & Territorial Epidemiologists Reports (that’s me)

Sentinel Provider NetworkSentinel Provider Network

Goal of 1 regularly reporting site per 250,000 Goal of 1 regularly reporting site per 250,000 populationpopulationTo date, we have 73 sentinel providers enrolledTo date, we have 73 sentinel providers enrolledEach week, report ILI activityEach week, report ILI activitySend specimens to the GA Public Health Lab 3 Send specimens to the GA Public Health Lab 3 times during the seasontimes during the season– Characterize the virus Characterize the virus – Able to determine changes in circulating virus Able to determine changes in circulating virus – Determines what flu vaccine will be made of for Determines what flu vaccine will be made of for

upcoming season!upcoming season!

Sentinel Provider Network, Sentinel Provider Network, 2007-20082007-2008

73 sentinel sites73 sentinel sites– Practice types:Practice types:

Emergency Departments Emergency Departments PediatricsPediatricsFamily MedicineFamily MedicineInternal MedicineInternal MedicineInfectious DiseaseInfectious DiseaseUniversity Health ServicesUniversity Health ServicesOccupational Health ServicesOccupational Health Services

– 35 to 40 report regularly35 to 40 report regularly

Athens Regional Medical Center Atlanta Medical CenterCandler County HospitalChildren's Healthcare of Atlanta at EglestonChildren's Healthcare of Atlanta at Scottish RiteColumbus Regional Hospital, DeKalb Medical Emory University HospitalGeorgia Public Health Laboratory Grady Memorial HospitalJasper Memorial Hospital Lab Medical Center of Central Georgia Medical College of GeorgiaMemorial HealthMemorial Medical CenterNE Georgia Medical CenterNewton Medical CenterPiedmont Newnan HospitalPolk Medical CenterSatilla Regional Medical Center Southern Regional Medical CenterStephens County HospitalTanner Medical CenterThe Medical CenterWellstar CobbWellstar DouglasWellstone Kennestone

National NREVSS DataNational NREVSS Data2007-20082007-2008

National NREVSS DataNational NREVSS Data 2006-2007 2006-2007

Influenza isolates GPHL, Influenza isolates GPHL, 2006-2007 (N=91)2006-2007 (N=91)

Influenza Virus IsolatesInfluenza Virus Isolates

No.No. (%)(%)

A (H1)A (H1) 3838 (41.8)(41.8)

A (H3)A (H3) 33 (3.3)(3.3)

A (not-typed)A (not-typed) 00 (0)(0)

BB 5050 (54.9)(54.9)

State assessmentsState assessments

We report to CDC each week We report to CDC each week – No activityNo activity– SporadicSporadic– LocalLocal– RegionalRegional– WidespreadWidespread

Based on components of influenza Based on components of influenza surveillance and syndromic surveillancesurveillance and syndromic surveillance

Weekly ActivityWeekly Activity

Influenza activ ity in Georgia, 2007-20081 2 3 4 1 2 3 4 5 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 5 1 2 3 4 1 2 3 4 5 1 2 3 4 1 2 3 4 1 2 3 4 5 1 2 3 4

Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep

week by month

Widespread

Regional

Local

Sporadic

None

Weekly activityWeekly activity

Influenza activity in Georgia, 2006-20071 2 3 4 1 2 3 4 5 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 5 1 2 3 4 1 2 3 4 5 1 2 3 4 1 2 3 4 1 2 3 4 5 1 2 3 4

Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep

week by month

Widespread

Regional

Local

Sporadic

None

Weekly ActivityWeekly Activity

Influenza activity in Georgia, 2005-20061 2 3 4 1 2 3 4 5 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 5 1 2 3 4 1 2 3 4 5 1 2 3 4 1 2 3 4 1 2 3 4 5 1 2 3 4

Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep

week by month

Widespread

Regional

Local

Sporadic

None

Sentinel ILI SurveillanceSentinel ILI Surveillance

Percent of Vis its for Influenza-like Illness Reported by Sentine l Provider Netw ork in Georgia

0.0

2.0

4.0

6.0

1 2 3 4 1 2 3 4 5 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 5 1 2 3 4 1 2 3 4 5 1 2 3 4 1 2 3 4 1 2 3 4 5 1 2 3 4

Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep

Month and week

% o

f V

isit

s

2007-2008

Sentinel ILI SurveillanceSentinel ILI Surveillance

Percent of Visits for Influenza-like Illness Reported by Sentinel Provider Network in Georgia

0.0

2.0

4.0

6.0

1 2 3 4 1 2 3 4 5 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 5 1 2 3 4 1 2 3 4 5 1 2 3 4 1 2 3 4 1 2 3 4 5 1 2 3 4

Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep

Month and week

% o

f V

isit

s

2006-2007

Sentinel ILI SurveillanceSentinel ILI SurveillancePercent of Visits for Influenza-like Illness

Reported by Sentinel Provider Network in Georgia

0.0

2.0

4.0

6.0

1 2 3 4 1 2 3 4 5 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 5 1 2 3 4 1 2 3 4 5 1 2 3 4 1 2 3 4 1 2 3 4 5 1 2 3 4

Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep

Month and week

% o

f Vis

its

2005-2006

Syndromic SurveillanceSyndromic Surveillance

Began utilizing syndromic surveillance for Began utilizing syndromic surveillance for influenza data collectioninfluenza data collection

Syndrome based on ILI symptomsSyndrome based on ILI symptoms– Fever PLUS flu and RespiratoryFever PLUS flu and Respiratory

38 hospitals participating38 hospitals participating

Syndromic SurveillanceSyndromic Surveillance

Syndromic SurveillanceSyndromic SurveillancePercent of Visits for Influenza-like Illness

Reported by Emergency Departments and Ambulatory Care Centers in Georgia

0

5

10

15

20

25

30

35

1 2 3 4 1 2 3 4 5 1 2 3 4 1 2 3 4 5 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 5 1 2 3 4 1 2 3 4 1 2 3 4 5 1 2 3 4

Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep

Month and Week

% o

f V

isit

s

All Ages <2 2-4 5-17 18-64 65+

2006-2007

Pediatric DeathsPediatric Deaths

Influenza-associated pediatric influenza Influenza-associated pediatric influenza deaths became reportable during the deaths became reportable during the 2003-04 season2003-04 season

2006-2007, 5 cases were reported 2006-2007, 5 cases were reported – 3 with MRSA3 with MRSA– 1 with Strep A1 with Strep A– 1 with an unusually high amount of influenza 1 with an unusually high amount of influenza

B virus noted in clinical/autopsy specimensB virus noted in clinical/autopsy specimens

Observations for 2006-2007Observations for 2006-2007

Season had two distinct peaks in Season had two distinct peaks in December and FebruaryDecember and February

Epidemiology defined by school holiday Epidemiology defined by school holiday closures at Thanksgiving and Christmasclosures at Thanksgiving and Christmas

Multiple school outbreaks were reported in Multiple school outbreaks were reported in November and DecemberNovember and December

No outbreaks were reported in LTCFsNo outbreaks were reported in LTCFs

How is 2007-2008 shaping up?How is 2007-2008 shaping up?

Slow to start compared to previous yearsSlow to start compared to previous years

Just now seeing local activityJust now seeing local activity

Rapid tests are a mix of A and BRapid tests are a mix of A and B

23 patients hospitalized in metro Atlanta to 23 patients hospitalized in metro Atlanta to date (no pediatrics – yet)date (no pediatrics – yet)

ACIP Recommendations ACIP Recommendations 2007-20082007-2008

ALL persons, including school-aged children, who want ALL persons, including school-aged children, who want to reduce the risk of illness or transmission to othersto reduce the risk of illness or transmission to othersALL children 6- 59 monthsALL children 6- 59 monthsALL adults 50 years of age and olderALL adults 50 years of age and olderChildren and adults on aspirin therapyChildren and adults on aspirin therapyWomen who will be pregnant during flu seasonWomen who will be pregnant during flu seasonAdults/children with chronic illness, immunosuppression, Adults/children with chronic illness, immunosuppression, ↓respiratory function↓respiratory functionResidents of LTCFsResidents of LTCFsHousehold contacts of infants, sick kids and >50Household contacts of infants, sick kids and >50HEALTHCARE WORKERS!HEALTHCARE WORKERS!

Influenza Vaccination Coverage LevelsInfluenza Vaccination Coverage Levels Persons Aged 65 and Over Persons Aged 65 and Over

67.4 66.2 66.469.9 67.8 65.7

69.6

64.8

5763.6 62.2

59.3

67 64.460.8

90

30

40

50

60

70

80

90

10019

99

2000

2001

2002

2003

2004

2005

2006

2010

Per

cen

t

National

Georgia

HealthyPeople2010 goal

Source: Behavioral Risk Factor Surveillance System (BRFSS)

57.6 58.4 59 59.8 59.9 60.5 61 61.5 62 62.6 63.2 63.765.1 65.1 65.7 65.7 65.9 66.7

69.3

90

40

50

60

70

80

90

100Influenza Immunization for persons > 65 yrs,BRFSS Data 2000-2006

Behavioral Risk Factor Surveillance System (BRFSS)Individuals may have been vaccinated at public health departments, physician offices, hospitals, stores, or place of employment.

Vaccination rates among children Vaccination rates among children 6-23 months Sept-Oct 20056-23 months Sept-Oct 2005

GeorgiaGeorgia

N = 372N = 372

Vaccinated with Vaccinated with at least 1 doseat least 1 dose

Fully vaccinatedFully vaccinated

Fulton and Fulton and DeKalb DeKalb

N = 184N = 184

33.3% 33.3% 21.2%21.2%

Rest of stateRest of state

N = 188N = 188

31.1%31.1% 21.0%21.0%

National Immunization Survey MMWR 56:37

2007-2008 Vaccine2007-2008 Vaccine

A/Solomon Islands/3/2006 (H1N1)-like (new for this season), A/Wisconsin/67/2005 (H3N2)-like, and B/Malaysia/2506/2004-like viruses.

132 million doses from 6 manufacturers

FluMist now OK for children 2-5 years

National Influenza Immunization Week was November 27 – December 2, 2007– First “Vaccinate Children Day” – CHOA receives award from CDC for high rate of

HCW flu vaccination rate!

AntiviralsAntivirals

Oseltamivir and Zanamivir Oseltamivir and Zanamivir Prophylactic use can limit spread Prophylactic use can limit spread – People at high riskPeople at high risk– People who care for those at high riskPeople who care for those at high risk– People who cannot take the vaccine or who might have poor People who cannot take the vaccine or who might have poor

responseresponse

Use for treatment can decrease duration and severity Use for treatment can decrease duration and severity uncomplicated influenzauncomplicated influenza– Start within Start within << 2 days (though recent studies have demonstrated 2 days (though recent studies have demonstrated

effectiveness past 2 days)effectiveness past 2 days)– Shown to reduce serious complicationsShown to reduce serious complications

For pandemic flu, a prioritization scheme will be usedFor pandemic flu, a prioritization scheme will be used

A word about pan fluA word about pan flu

Info changes frequently! Info changes frequently! – www.pandemicflu.govwww.pandemicflu.gov

Planning in GA continuesPlanning in GA continues– Statewide Pan Flu Planning CommitteeStatewide Pan Flu Planning Committee– Emergency Preparedness Steering CouncilEmergency Preparedness Steering Council– Revision of the State SOG, SOP and COOPRevision of the State SOG, SOP and COOP– District Health Department planning, training and District Health Department planning, training and

exercisingexercising

Seasonal flu planning, surveillance and Seasonal flu planning, surveillance and response prepares us for pandemic flu!response prepares us for pandemic flu!

A word about avian fluA word about avian flu

WHO website WHO website www.who.intwww.who.int– Pakistan is most recent country with human cases Pakistan is most recent country with human cases

and human to human transmissionand human to human transmission

CIDRAP email CIDRAP email http://www.cidrap.umn.edu/index.htmlhttp://www.cidrap.umn.edu/index.htmlGeorgia’s responseGeorgia’s response– GDPH presenting “train-the-trainer” sessions for GDPH presenting “train-the-trainer” sessions for

response to WHO phase 3 and 4 – next one is response to WHO phase 3 and 4 – next one is January 14, 2008 TiftonJanuary 14, 2008 Tifton

– Public health and Dept. of Ag collaborationPublic health and Dept. of Ag collaboration– Georgia SART (State Agricultural Response Teams) Georgia SART (State Agricultural Response Teams)

– part of response in ICS– part of response in ICS

ResourcesResources

ACIP prevention and control of influenzaACIP prevention and control of influenzaMMWR 2007 MMWR 2007 http://www.cdc.gov/mmwr/pdf/rr/rr56e629.pdfhttp://www.cdc.gov/mmwr/pdf/rr/rr56e629.pdf CDC’s new flu site CDC’s new flu site http://www.cdc.gov/flu/http://www.cdc.gov/flu/

GDPH flu page GDPH flu page http://health.state.ga.us/epi/flu/http://health.state.ga.us/epi/flu/

Dept of Ag. HPAI Plan Dept of Ag. HPAI Plan http://agr.georgia.gov/00/article/0,2086,3890273http://agr.georgia.gov/00/article/0,2086,38902732_0_98980644,00.html2_0_98980644,00.html