Slide 1 of 25 Influenza Surveillance in the DoD: 2009 - 2010 Armed Forces Health Surveillance Center...
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Slide 1 of 25 Influenza Surveillance in the DoD: 2009 - 2010 Armed Forces Health Surveillance Center (AFHSC) United States Air Force School of Aerospace
Slide 1 of 25 Influenza Surveillance in the DoD: 2009 - 2010
Armed Forces Health Surveillance Center (AFHSC) United States Air
Force School of Aerospace Medicine (USAFSAM) Naval Health Research
Center (NHRC) DoD Global Influenza Network Partners (GEIS
Operations) Presentation to the Vaccines and Related Biological
Products Advisory Committee VRBPAC 22 February 2010 CAPT Kevin L.
Russell, MD, MTMH, FIDSA** **Representing the DoD CONUS and OCONUS
lab-based influenza surveillance activities
Slide 2
Slide 2 of 25 Briefing Outline PURPOSE : Provide a concise
update to the VRBPAC on DoD influenza surveillance activities,
2009-2010 1.AFHSC a)Defense Medical Surveillance SystemHealth care
utilization b)Laboratory network 2.Strain Circulation and Molecular
Analyses a)pH1N1, H3N2, B 3.Vaccine Effectiveness a)AFHSC, NHRC,
USAFSAM 4.Vaccine Safety 5.Population-Based Serology Studies
Slide 3
Slide 3 of 25 CAPT Russell//301-319-3041 DSN 285- AFHSC
Operating Structure DIRECTOR Armed Forces Health Surveillance
Center Dep Dir, AFHSC/ Director, GEIS DoD Serum Repository AFHSC HQ
Support Science Advisor Executive Officer Resource Mgr Chief,
Information Officer Chief, Epi and Analysis Chief, Communications,
Standards, & Training Chief, GEIS Operations Data Management
Epidemiology/ Analysis Surveillance Operations & Communications
Surveillance Standards & Training AI/PI Surveillance GEIS Core
Liaisons USPHS DHS WHO
Slide 4
Slide 4 of 25 Pre- Induction Post- Discharge MEPS 11.1 million
persons 23.1 million records Hospitalizations 2.7 million records
Ambulatory Data 162 million records Health Risk Assessments (Army)
575,000 records Immunizations 51.6 million records Casualty Data
40,600 AD Deaths Pre / Post-Deployment Health Assessments 6,336,114
forms Reportable Diseases 215,000 records Deployments 4.0 million
records Serum Specimens (DoD Serum Repository) 46.1 million
specimens Personnel Data 9.0 million persons 102.5 million records
Focus: Active Duty & Reserve Component / Surveillance DMSS:
Longitudinal Database
Slide 5
DoD Lab-based Influenza Surveillance - 2009
Slide 6
Slide 6 of 25 Breadth of AFHSC Influenza Surveillance Division
of Epidemiology and Analysis 1.4M AD records (health care
utilization, immunizations, deployment, reportable diseases, etc)
12 data feeds into DMSS, additional in house Medical Surveillance
Monthly Reports (MSMR), Adhoc requests, Studies/analyses, Routine
reports/summaries Weekly influenza reports Vaccine safety and
effectiveness studies Division of GEIS Operations Approximately 500
locations in over 75 countries globally Military ; Local
government/academic Extensive characterization capabilities within
the DoD Culture, HAI, PCR (battery), Sequencing Rapid sharing of
results with CDC and/or regional WHO reference centers Two DoD
laboratories reported first four cases of 2009 A/H1N1 in the U.S.
More than 40,000 samples collected and analyzed in 2009
Slide 7
Slide 7 of 25 DoD Global Influenza Activity (1 Sept 2009 31 Jan
2010) New = previous two weeks
Slide 8
Slide 8 of 25 Global Influenza Circulation October pH1N1 H3N2
sH1N1 Flu B
Slide 9
Slide 9 of 25 Global Influenza Circulation November pH1N1 H3N2
sH1N1 Flu B
Slide 10
Slide 10 of 25 Global Influenza Circulation December pH1N1 H3N2
sH1N1 Flu B
Slide 11
Slide 11 of 25 Global Influenza Circulation January pH1N1 H3N2
sH1N1 Flu B
Slide 12
Slide 12 of 25 Global Influenza Circulation February pH1N1 H3N2
sH1N1 Flu B
Slide 13
Slide 13 of 25 Summary of Circulating Strain Activity
Laboratory confirmed influenza rates among US service members have
declined since peaking in the Fall of 2009 Regional differences in
virus co-circulation Samples from European sites have all been 2009
A/H1N1 Samples collected during the Fall of 2009 from Southeast
Asia showed co- circulation of Influenza B, A/H3N2, and 2009 A/H1N1
viruses The 2009 A/H1N1 virus is the predominant virus currently
circulating
Slide 14
Slide 14 of 25 Distribution of Sequenced A/H1N1 within the DoD,
2009 - 2010 CONUS OCONUS United States AfghanistanKorea
AlaskaKuwait GuamKyrgyzstan HondurasUnited Arab Emirates
IraqUkraine Japan CONUS OCONUS United States AfghanistanKorea
AlaskaKuwait GuamKyrgyzstan HondurasUnited Arab Emirates
IraqUkraine Japan 298 26 4 4 Distribution of Sequenced A/H1N1
Specimens within the DoD, 2009 - 2010 1 1 3 3 57 97 80 2 2 3 3 3 3
9
Slide 15
Amino Acid Substitutions (x100) 0 2.6 2 A/Florida/375/2009
A/South Carolina/3203/2009 A/Nevada/3460/2009 * A/Iraq/18529/2009
A/Nevada/143/2009 A/North Carolina/4358/2009 A/Texas/331/2009
A/Japan/3624/2009 A/Arizona/4156/2009 A/South Carolina/2260/2009
A/California/3770/2009 A/Florida/2412/2009 A/Connecticut/2033/2009
A/Georgia/3826/2009 A/United Arab Emirates/2757/2009
A/Guam/3656/2009 A/Korea/3163/2009 A/Colorado/1102/2009
A/Japan/4856/2009 A/Arizona/20285/2009 A/Florida/19340/2009
A/Korea/3619/2009 A/Arizona/3825/2009 A/Korea/1772/2009
A/Arizona/4887/2009 A/Texas/427/2009 A/Maryland/2635/2009
A/Maryland/2520/2009 A/Texas/732/2009 A/New Jersey/3792/2009
A/Colorado/653/2009 A/Iraq/4045/2009 A/Iraq/4051/2009
A/Ohio/4320/2009 A/Afghanistan/2953/2009 A/Ohio/674/2009
A/Japan/4372/2009 A/Japan/4081/2009 A/California/1763/2009
A/Japan/16700/2009 A/Japan/1888/2009 A/Maryland/3894/2009
A/Oklahoma/1631/2009 A/Maryland/2519/2009 A/Virginia/2393/2009
A/South Carolina/3652/2009 A/New Jersey/4768/2009 A/Texas/2465/2009
A/Illinois/4597/2009 A/Japan/3627/2009 A/Illinois/4877/2009
A/Massachusetts/2573/2009 A/Japan/4639/2009 A/Japan/4375/2009
A/Japan/4079/2009 A/Japan/4861/2009 A/Delaware/3213/2009
A/Delaware/3296/2009 A/District of Columbia/4386/2009
A/Nebraska/527/2009 A/Nebraska/4107/2009 A/Japan/3711/2009
A/Ohio/3660/2009 A/Texas/3852/2009 A/Korea/1751/2009
A/California/1879/2009 A/Korea/19735/2009 A/Texas/2253/2009
A/Kyrgyzstan/2926/2009 A/Nebraska/2630/2009
A/Massachusetts/3702/2009 A/Iraq/4697/2009 A/Iraq/4075/2009
A/Honduras/3234/2009 A/California/3784/2009 A/Kansas/1106/2009
A/Japan/3754/2009 A/North Dakota/19325/2009 A/Ohio/4319/2009
A/Oklahoma/3982/2009 A/North Carolina/4957/2009 A/Alabama/2395/2009
A/New Mexico/20448/2009 A/Massachusetts/3912/2009 A/Korea/3918/2009
A/Korea/4837/2009 A/Virginia/4518/2009 A/Utah/307/2009
A/Alaska/4171/2009 A/Alaska/3051/2009 A/Texas/4576/2009 A/United
Arab Emirates/1461/2009 A/Washington/4363/2009
A/Washington/2184/2009 A/Iraq/1309/2009 A/Korea/19741/2009
A/Mississippi/261/2009 A/South Dakota/339/2009 A/Iraq/2133/2009
A/California/7/2009/pH1N1 NYMC X181A A/California/07/2009 S203T
P83S I321V 2009 Vaccine *Reference Antigen July 09 (10) August 09
(5) September 09 (26) October 09 (299) November 09 (154) December
09 (74) ^ Create glycosylation motif & Loss of glycosylation
motif _ Parallel Mutation Site Protein identity compared to
A/California/07/2009- like virus, 97.9 99.4% (n=568) 99.1 - 99.4%:
(2-3 changes) 36% (201/568) 98.5 98.8%: (4-5 changes) 60% (341/568)
97.9 98.2%: (6-7 changes) 4% (25/568) Parallel amino acid changes
at 27 sites 20/27 within predicted epitope sites A/Iraq/18529/2009v
selected as CDC HI reference antigen All annotated aa changes are
comparisons of submitted specimens to HA1 region of
A/California/7/2009 (H1N1) like virus and do not relate to previous
vaccine strains. Q293H I321 L32I K36E E112K H273Y N129D K22R V47I
V47A T270A T270K T120A K283E A261D A197S A197T I116M D97N A48V A48S
N156K V19I S157L A197S I295V D35Y V272A I295T T72A T72I N31D P137L
P137H V199A V199I F114V D222E K54E 2009-10 DoD Influenza A/H1N1 HA1
- Phylogenetic Analysis
Slide 16
Protein identity compared to (n=7): A/Perth/16/2009 98.2 99.1%
A/Brisbane/10/2007 97.4 98.2% 99.1 - 99.4%: A/Perth 1A/Brisbane- 0
98.5 98.8%: A/Perth 5A/Brisbane- 0 97.4 98.2%: A/Perth 1A/Brisbane-
7 Parallel amino acid change at 261 (predicted epitope stie) 2009
10 Vaccine strain Previous Vaccine Strains July 09 August 09
October 09 December 09 ^ Create glycosylation motif & Loss of
glycosylation motif + Receptor Binding Site (RBS) _ Parallel
Mutation Site +V223I &N133D +P227H T212A K158N K173Q N189K
P194L E62K &N144K All annotated aa changes are comparisons of
submitted specimens to HA1 region of A/Brisbane/10/2007-like
viruses and do not relate to previous vaccine strains/ Amino Acid
Substitutions (x100) 0 6.2 246 A/Perth/16/2009 A/South
Carolina/10319/2009 A/Mississippi/15624/2009 A/Japan/3909/2009
A/Kuwait/4551/2009 A/Kuwait/4554/2009 A/Afghanistan/2950/2009
A/Kuwait/4562/2009 A/Brisbane/10/2007 A/Wisconsin/67/2005
A/California/7/2004 A/Wyoming/03/2003 A/Panama/2007/1999
A/Sydney/5/1997 R261Q 2009-10 DoD Influenza A/H3 HA1 - Phylogenetic
Analysis
Slide 17
Amino Acid Substitutions (x100) 0 5.9 24 B/California/2650/2009
B/California/2986/2009 B/District of Columbia/20691/2009
B/Texas/19095/2009 B/Maryland/18932/2009 B/Korea/18724/2009
B/Brisbane/60/2008 B/Japan/3280/2009 B/Malaysia/2506/2004NH B/Hong
Kong/330/2001 B/Florida/4/2006 B/Shanghai/361/2002 B/Sichuan/379/99
B/Beijing/184/93 Yamagata Lineage Victoria Lineage All DoD Flu B
specimens fall within Victoria Lineage Protein sequence identity
for DoD specimens (n=7) compared to B/Brisbane/60/2008 - 99.7%
Predicted loss of glycosylation motif for 6/7 specimens All
annotated aa changes are comparisons of submitted specimens to HA1
region of B/Brisbane/60/2008-like virus and do not relate to
previous vaccine strains. B/ 2009-10 Vaccine strain September 09
October 09 November 09 ^ Create glycosylation motif & Loss of
glycosylation motif L58P &N197D 2009-10 DoD Influenza B HA1 -
Phylogenetic Analysis
Slide 18
Slide 18 of 25 Vaccine Effectiveness AFHSC Retrospective
analysis, case/control (1:4) of seasonal influenza vaccine against
clinically apparent, laboratory-confirmed 2009 A/H1N1 associated
illness Modest VE (22%): Many active duty with multiple prior
vaccinations and unique experience with respiratory pathogen
exposure Naval Health Research Center (NHRC) Population-based,
flu-confirmed, febrile-respiratory illness surveillance of recruits
at 8 training centers (since 2003)**( Russell 2004; Strickler 2007)
03/04--94%; 04/05--86%; 05/06--92%; 06/07--87%; 07/08--81%;
08/09--79%; 09/10--insufficient cases after vaccination instituted
USAF School of Aerospace Medicine (USAFSAM) Population-based of
observed as compared to expected influenza cases as determined by
vaccination coverage**( Orenstein 1985; Farrington 1993) Estimate
of vaccine effectiveness (not clinical VE) No VE demonstrated
Slide 19
Slide 19 of 25 Vaccine Effectiveness Unfortunately Unable to
examine pandemic 2009 H1N1 vaccine effectiveness due to high
seasonal vaccination coverage (~92%) and small case count occurring
after pandemic vaccination
Slide 20
Slide 20 of 25 H1N1 Vaccine Safety Collaboration between MILVAX
and AFHSC, in conjunction with the FDA's CBER and the CDC's
Immunization Safety Office AFHSCs DMSS searched weekly to identify
all H1N1 vaccinations Outcomes Anaphylaxis Bells palsy Idiopathic
thrombocytopenia Acute disseminated encephalomyelitis Guillain-Barr
Syndrome Acute transverse myelitis Optic neuritis Rapid cycle
statistical analysis of aggregated data Comparison to past 3
seasonal influenza vaccine campaigns Identify in near real-time
increased occurrences of outcomes
Slide 21
Slide 21 of 25 H1N1 Vaccine Safety Potential cases verified by
FDA and DoD neurologists and immunologists Safety surveillance
conducted on over 1 Million Service members receiving the Novel
A(H1N1) vaccine There continues to be no increase in safety
concerns compared to previous seasonal influenza vaccine
campaigns
Slide 22
Slide 22 of 25 Susceptibility Studies Utilize DoD serum
repository Determine existing rates of seroconversion True
incidence of 2009 H1N1 HAI and Microneutralization From 01 MayFeb
2010 Associate with Known 2009 H1N1 infection Medical care
Complications Co-morbidities Prior vaccinations
Slide 23
Slide 23 of 25 Summary The DoD maintains a global
laboratory-based influenza surveillance program military and
civilian populations underserved regions of the world Molecular
analysis of 2009 A/H1N1 specimens indicate an overall protein
identity of 97.9 99.4% compared to the vaccine strain Molecular
analysis of A/H3 specimens supports a change of vaccine composition
for the next season from A/Brisbane to A/Perth like strain We were
unable to perform 2009 H1N1 vaccine VE determinations Seasonal
vaccination studies suggest at most mild protection toward 2009
H1N1 No increase in vaccine safety concerns
Slide 24
Slide 24 of 25 Acknowledgements AFHSC Dr. Kelly Vest Dr. Jose
Toti Sanchez Dr. Angelia Eick LT Matthew Johns MAJ Ronald Burke CDR
David Blazes COL Robert DeFraites MILVAX Ms. Hayley Hughes LTC
Patrick Garman USAFSAM Ms. Alicia Guerrero Ms. Genny Maupin Major
Thomas Gibbons Lt Col Victor Macintosh Col Paul Sjoberg NHRC Mr.
Anthony Hawksworth Dr. Chris Myers CDR Patrick Blair CDR Dennis
Faix
Slide 25
Slide 25 of 25 Questions COL Robert DeFraites, MD, MPH,
Director, AFHSC Tel: 301-319-3245, E-mail:
[email protected]@us.army.mil CAPT Kevin
L. Russell, MD, MTMH, Director, DoD-GEIS Tel: 301-319-3041, E-mail:
[email protected]@us.army.mil