INFLUENZA SURVEILLACE IIIA

REPUBLIC OF THE PHILIPPIiES DURING 1976-1977

0

TG, KSIAZEK, J.G. OLSON, A.K. ALCANTARA & C.V. UYL.NGCO

REPORT NO. TR - 822

A,

UNITED STATES NA'ALMEDICAL RESEARCH UlIT NO. TWOMO0 SM PR AZSCO, CALIFIUImA 96 52

NAVAL MEDICAL RESEARCH AND DEVELOPMENT COMMAND

79 12 27 086

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Th~is study was su. ;c:rted by!ur.ds l rovided ~-yt~e NavelM'cdic 4a1 Rce.ezrch an~d rnevclop-mc.-.t Comman~d, N4avy Dciartnent,for Work Unit M~r5l.524.OO9-2O1O.

Distribution. of thisdocument is urimitcd

K. SORENSENtCAPTAIN MC VSN('OMMANDING OFFICER

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~Rtrirtc -,'1 h permission of the *ditor Ofjr hifl*tuiw. -2ojrnal of Microbiology 4nd Infectious Diseases

W, nazza ei~isfanoe in Manil, Republicof the. Philippines Durdng 1970-1977

i HOAS . KSAlkAi'RA

INTRODUC~TION M~AThRJAL8 AND METHODS

The recent emor rnce% of A/ Sample Population. Febrile 'pa.usslR77 ~t'HINI vlrun onCo: agtdni Ilents at Sanl Lasaro Hospital whotkamonstratea Lhat now strains of hadt clniciti signs and symptomsinfluenlo A vtrwi (i.en orislnate In 'rcrnpa'.ble with influenza were so.Sou&t Aqh'4 during the con-v !'rCtedj c virus ifoolatifl and seo*

tx:a&~r~.i~a ,CAi4i to -;: dien, The majority of pa.nmeits of tfie world and become epi. tUcnts entering the study were fromj4k)#w(: o o a4ri~ panctemic 'AeCt rc~osi tn ManiAla.

F'O~U1~ ~ ~N~i4 Mckal Virus [solution and Identification.I?*zwarcii UnIit No. 2 1110wW., To pntlcnts who had onsetsTi\tpi, sureilla. ne progra fo m.threo cl%.ys or less prior to report.

~CLV illnce rogrm fo ~nIng to the oUtpstient sWvlos Werer=~~z in the Western Pecifir 1 o vrs slain t

cluding the Phillppine3. rrnptedfrvrsisto

Scvers? -erods of Influoi act!.. it Nw~ ~~~rrv~ ~MM~I~ ~Cotto~n applicsitions wore Used to

in 17 imin :971~~7 The isolates rc swab the orophorynx of selectedcoveted during is period cover a~ Paflt na ad the, swabs wero thenbrood spectrum of a nt ige 0n IC c mm di a ow draMin W wn'

Stmns.talnfti 24 M1 brain bwtK Uinfiobroth having a &,WWco, nrtl~nof 200 units of penlWin/mi md

UH~ Na" 2. 200 ug of utrepton"WI. noe+ '"~ ~ ~ .vils~ Containin~g the swabe were

MR'A1%A1 "'&" ' IhW ' eeald w Ith Psaeftl film ad pleced** .,, I,.', ~~ s~ I~f' n #L mechankcal te'mr lit - WOC

ks. Vtr 114 and ai L ted on d17 toe to

~~~~~~.~NA-U In 0VM . mt.w lf O6yTj l~oltO St

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"-IBes Avaiiab Cop"IY 0 1 ) n190-V :Waf a t

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htwuicto, wooolayers of primary 77 antigen only after October 1977monkey kidney cells. In 1977, CE and testing for A/NJ/70 HAI antiand mnolayers of a continuoun line bodies was discontinued in 1977.of %anvc kedUivy (MDCK) cells Dengue HAI tests were also per.wcr, used for Isolation, Hemag- formed using standard techniques'Clutinattng (H1A) agents Isolated using kaolin absorbed aern and pro-wore ldeai~ficd by utandard hemag, totype DEN.1 and DE4.2 Sucrose.glutuiatlun inhibition (HAI) proce. acetone extracted suckling mouSudures'. Reference HA antigens and brain antigens. Criterion for saantiscra used in identification of logic eyiderm of recent intetmisolates were supplied by the World was a four-fold or greater rise inHealth Organlizatlon (WHO) Cola. HAI antibody titer.boruting Center for Influenza Vi-ruses, Center for Disease Control, RESUTSAtlanta, Georgia. U..A. Selectedisolates were sent to the WHO Col. Virus Isolation. The distribuUonlaborating Center for confirmation of isolates during 1976 Is preentedof identification. In Table I. Virus was isolated ina months of the yeur. All stlinmSerologie Studies. Acute phase isolated during the period were ofvenous blood specimens were taken the H3N2 subtype but were of twoat the same tme as throat swabs antigenically distinguishable strains:and also from patients whoso onset A/Victora/75-1ike and A/Texas/77,had been kvater than three days like. These two strains are cross.before presentation at the outpa, reactive in HAI tests but are nonetlent clinic. thele&3 distinguishable. The A/

Convalesvent bloods were drawn Toxas/77.Uke strains were first iso-lated by us In Manila In Augustfrom as many patients as posible 1976.after an Interval of 14 days or morefrom the time of onset. After clot. The distribution of isolates Inting, all blood samples were centrl. 1977 is presented In Table U1. Penerfused and the serum transferred to strains were Isolated during 177screw capped vials and stored at but fewer attempts at IsolatioN wN- 200C until they were transported made. The Isolation of strains Wason dry Ice to NAMRU.-2 for testing. again scattered Uroghout th

year. However, In 1977 the WItU&aTests for HAI antlibodie to In. tion was more oompila than 1976:fluenta viruses were performed both type A and typ B Isolatesusing standard techniques using were made a&d, furtherm o , tworeference HA antigens and r(',nlrol subtypes Of type A, HN diora supplied by the WHU Colla. HINI wet IsoAkte& te VMMMborating Center. The HA antigens of two iype A Whoim gubteused were A/Victoria/75 (H3N2), was further complested by theA/New Jersny (NJ)/70 (lswINlI), H;N2 sUalins bei of two distIng.B/H1K/72 and A/US8R/77 (HINI). uA,hable Strins, AlV~ltow'I ,BlkSera were tested ngninst AitUSSR/ and A/ftezad77.lke. j

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TempnpTrly, tbs 1971 At"anS OM We0e Dot obtaine In & fiMae iutftbats follows: the 2 form manner monith by nthW

were both A/Vkctilftlk. MWs In 1, 72 paired aen ware teat14B3142 stlm M Ol4td inJu ed for 1W! antibodles. Tron Jan*

* were *It A/T=UMS/TUkO. Tbr..drumof ypeB Wom ~kruary to October, onlY tests tor A/~~~rain5vitols7 of type 3 nlem imlrXIuM/7

to g/Min Kong/I wase isolated In RMN~od w waft. Aftrmay and urn TbS ra5wly UnrSifn Octobe all paired sar we a&s

or reUnargtw,3RINI stan was tete for A/170/77 HAI snUbD-tswtbted in Noveiber and Deosm dies Th eut o h ~

ba dthe isolates wer A/USSR/ tests ane prwted in Tabl IV.Neftiegy.Dur~ 196. ~Add Mialy, tIt"7, 24 pairs offteley. Drft 976,87 Pired a ware tested against VW-1 and

sm wer flmired using A/VO DEN-2 RA antigen. Nins Of thinrnS, A/New .ervey/10, &Md D/ s4 parellssowed a etfol or

1mW Xing/73 HA antigons (Tabl. poster rise in MAU antbody tite101. Of them 15 showed four-old from acute to convalscet serumrsim In RAI antibody tte. Paired samnples.

TA3IZ IIl

* REIULIR OW UMNWIZA MAI TKMTM ON lAlR19D I'VIIMTT MA~,VANIIA IM7

AIVICl5 (MRS) A/NJ/I halNI) W/NICt

* ubar4Ol or igreetet Hs frorn soute to couvslimt senum mecI.

IMUOMV "UI Stu"1 by man*~ at mew. a in jM 10 is in.

+ Onse aownd dhgrin August

40 INset omunrd daritg October.

AMAW

TAIILE I V

RESUI.TS OF INFLUIENZA AND DENGUE HIAI TESTS (W PAIREDl'ATII.NT SEIIA, 1977., MANILA

AntigenTest Re.sults ... . ... . . .. ..

A/VIC/75 A/USSR/77 B/HK/7 DEN.I & DEN-2

Positive'" "5 0

Negative 70 42 72 13

Total 72 47 72 24

Fourfold or g rcater i Iw from acute to convalescent serum specl.

men.%.

Patient's (inset wus in Sei)tember

- Numbet ,jf patients positive by minth of onset. October, 2, Deo.ember. 3.

SNumber of patients positive by month of onset: April, 1. June, 1;July. 1; August, 3; September, 1; October, 1. November. 1.

I)ISCUSSION Again in 1977 a new strain of in-o fluenza, this tme a now or recur-

Influenza strains were seen in rent subtype, HINI, #m isolated.Manila after they had been seen in November. This isolated closelyelsewhere in ti,, WestOrn Pacific resembled others which had causedregion. .S'pcxvically, in 1976, a epidcmic disease in the Sovietstrain of H3N2 inlluenza was 1s. Union and Hong Kong in October'.

' lated in Atigust. 11is strain rescm. Similar straln had appartIly beenbled i virus isolated earlier that circulating In China as early assane summer In Australiti, A/VIc- May of 1977'. This virus was laterIorin/71l (H3N2). Both the Minlla Implicated as a own of epidemici.olate and the Australian Ivolate ,tlI.em in the U.S. aW Westmclosely rtlsenlblh a strain ., Aiicb Europe'. e Isolat4on o hmwt' sutilwrliiently Isolated in Texas strins of Influta MTd one pe-in a a n u i r y 1977, A/TEX/77 vlontsly rQpt at An 011rly time4 113N21. A/TEX/77, In lutir in Maifla sttess the imtprtance ofmonths. becnme a cause tof opide this type of AjztvfWla frtfm bothrrl," (115.40%c iI li1t- U.SL a rftlonlW a global view..

Manila continues to experience persons not previulisly exposedoutbreaks of Influenza due to a va. would be expected to experience di.riety of influenza strains. The tem sent.,. Althuugh only two Isolatespomrl distribution of Isolates dur. were made, both wcre from per.ing this two year study demons- suns of less tivan r years of age.trates that Influenza virus can oc. This age distribution with A/USSRcur at any time of the year In Ma. /77.like viruses hs also been foundnila as opposed to the generally in other NAMRU.2 studies"." andheld concept of a "flu season" in outbreaks in the Western He-which occurs in more temperate mispherel.Clitels. Difficulties in obtaining paired

Although no data on wchool ab. sera have made this portion of thesenteeism or excess mortality due surveillnnce program le'ss thanto respiratory disease were collect. ideal. Nevertheless, serologic risesed during this study, no serious epi. generally confirm what isolationdemic of influenza seems to have data has already demonstrated:cxcurred during the reporting per. several 5lrain.s of influcnza virusiod. This can be partially explained hve ibecn uctive and they are rcs.by A/VIC/75 and A/TEX/77 being ponsible for febrile illness.variants within the H3N2 subtype- a subtype to which most persons ters o rihing an n-possesm antibodies. This herd body liers to both dengue and mn.munity effect tends to limit the ex. flucntst virusc5 among our studytent of outbreaks among the Ctn. population Indicatcs, thd non-spec.eral population and also the seve. fic nature of dengue and lnfluenr2rity of discase among individuals and the difficulty in making clinicalwho possess such antibody2. Also diagnoses of a delinitive naturethe A/USSR/V7.like viruses which without adequate laboratory sup.were Isolated in Manila are very port. Although the number of semsimilar to A/FlU/40 (HINI)*. This tested were small, the higher pro-similarity leads to a sinilar herd portion of pnired sera In which 4.immunity phenomenon but only In fold or grrater d unUc HAl anti.persons that wore born prior to or body titer rise omcurred may Indl.during the last HINI era. Thus, cats that mild dongue fever was aperson born after 105 would be more frequent cause of febrile I11.Immunologically naive to MINI vi. ness than influenza during 1977 Inruses and, therefore, If the viruses the patients of Son Lazaro Hoapi.aft fuffkcently similar, only those tal.

40 "Mw'

SUMMARY

Influenza surveillance was per in 1976) and a HINI virus similarfunned among patients admitted at to A/USSR/77 was first isolated InSan Lazaro Hospital In Manila from November 1977. Type B influenzaJanuary 1976 to December 1977. was also isolated from three ps-'wenty-seven lnfluua strais were tionts in May and June 1977.

6ulhtcd In 1976 and 16 In 1977. The Serologic tests on paired patient1976 stratns were all of the H3N2 aera confirmed the virus isolationsubtype although some were sinil findings. In addtion, several per-lor to A/Victoria/75 (H3N2) and sons admitted to the influenza stu.others to A/Texs/77 (H3N2). The dy had rising I antibody titers t4

1977 influenza solSt were more DEN.I and DEN.2 antigens. inxcatdiverse: Two subtypes of type A Ing that the probable cause Of thl~tinfluenza were Isolated, H3N2 (as febrile llnesses was dengue virus.

REFERENCES

1. US. Dcpt, HEW. P118. CDC. Mor. 7. US. De. HZW. PHS. CDO. MOPbidity and Mortality Weekly Report bkdty aM Mortality Weekly Report

12:410. 177. 27-24. IM7.

2. Kilbourne. ED. Enideomolois of In- S. U.S. Dept. 1fKW. PHl, CDC. Motfluenza. In The Influenta Virums and bidity a"d Mortality Weeky RepoInfluenma I/lbourns. LD, editr. 27:4, 171LAculemlc Prm Inc., New York, 1M

9. 019m, J.O, Rodriguan T.O., IYd3. US. Dept. HTW. PHS. Adymnced LA 08. and Uytlaungc O.V. Influam

boratory Tchniques for Inf luenza uvatlllame in Mmila, Public ofDagnos s. USPHS, Atlanta, Immtmo tl Philippin during IM75. PhfltploI Seres No. S. Procwdural Oude, pine J. irobiol Infec. Dia. .1975. I13.

4. Hhnuoa, W.McD. and Sathr, o.. 10. Olson, J.0., Klasnk. T.O., trwfgArbolrues. I Dign-ot'c Procedures O.. and XrK R.M. An nto*"2wfor Viral and Rickettsial Infetious outbrea& of Infiwas camed by A/Lanette, 1.H. and Schmidt, NJ, edl. USSRM .iw vnw an a U.S. Navaltore. ..netlcen Public Hnlth Asi Ship. Military Med. (In "ves)elation, Ie.. New York, mTS,12 Ksuk, T.O., Olson, J.., IrviNg

S. USA. Dept, XKW. PH. CDC. Mor OS. Wit, R. and Petraue. It. Anbidity and Mortality Weekly Report influmna outbteak duo to A/MASSR36:44. 19r. 77like (HINI) vru abatrd a U.S.

r. Us. 111w. Pts, CDC- Naval Ship. tManuscrlpt in prepars.

bldity and Mortality Weekly Report

771. 975

IU NCLASSIFLED

REPORT DOCUuEOTATION PAGE PL IT 3UC W* rois

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.S. Na a Medical Resear:h Unit o . 2A;P San Frarxisco 96528 T51.5-4o.009-2010

Ccr-. anig Officer, Nava: edical Research 1979a. Devetopment Comnand, !Naticnal Meical vsiGoat

FWAIN i wif 6N ' ~ 1W w C400..Jme4 OsoI¢ee It SeCus"v, CL( &li t e"j

~~~ ~~Unclassified O3i6Ou

Distribution of this docu,,,nt is unlimited

4.P ~ ~ ~ I C9OT Aseui m a? Ava"lMINT (00 0.4" e wmell a 01i 4 aclir to. a tlltl e& owe-Vl

Published in the Philippine Journal of Microbiology and InfectiousDiseases 8(l):33-40, 1979

I aS l ev *OuNG ( . 0,40ne - a w o" * 'influenza (0 Ao,~~s&Z AJ~A'%(. ~/~virusesPhilippines .IA

Influenza surveillance was performed among patients admitte -San Lazaro Hospital in Manila from January 1976 to December 1977.Twenty-seven influenza strains were isolated in 1976 and 16 in 1977.The 1976 strains were all of the 8312 subtype although some weresimilar to A/ictoria/7S (311W2) and others to A/Texaa/77 (H32). ta1977 influenza isolates were more diverse* Two subtypes of type A

" influenza were isolated, 132 (a in 1976) and M11 virus similar toO, .4W3 +. . . . . UNCLASSIFID "" (overl

,sco.,t+.y, '+. .' ot ". . I'& t r+,4t'-". P - 4k

UNCLASSIFIEDSicum?, CL&SOVIC&Y.. O ut Wins~euube oae f8

A/WSR/77 was first Isolated in M1vesier 1977. Yype 3 Wnluenza wasalso Isolated from three patients in May and June 1977. So

Serologic tests on paired patient sera confirmied the virusisolation findings. in addition, several persons admitted to theinfluenza study had rising MI antibody titers to DEN4-i and DEN-2...........antigens, Indicating that the probable cause of their febrileillnesses was dengue virus.

UNCLASSIFIED

.........-.. .....-