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Influenza Update

Influenza Update. Ariane Reeves, RN, BSN, MPH, CIC Influenza Surveillance Coordinator Georgia Division of Public Health. Influenza virus types. Influenza A Epidemics (seasonal) and pandemics Infects many species (e.g., avian, swine, equine) Influenza B Epidemics only Human reservoir only

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Influenza Update

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  1. Influenza Update Ariane Reeves, RN, BSN, MPH, CIC Influenza Surveillance Coordinator Georgia Division of Public Health

  2. Influenza virus types • Influenza A • Epidemics (seasonal) and pandemics • Infects many species (e.g., avian, swine, equine) • Influenza B • Epidemics only • Human reservoir only • Influenza C • Causes mild illness and is not included in surveillance systems

  3. How viruses evolve • Antigenic drift • Influenza A and B viruses • Result of an accumulation of small mutations • Can cause an epidemic • Antigenic shift • Influenza A viruses only • Reassortment • Can result in pandemic

  4. Interspecies Transmission Genetic Reassortment Rare – Pandemic Potential Pandemic Potential Human virus Swine virus Avian virus Avian/human reassortant virus “Mixing vessel”

  5. Epidemiology of Influenza • Highly infectious • Transmission • primarily person-to-person via large and aerosolized small virus-laden droplets • direct contact & indirect contact (fomites) • Incubation period: 1-4 days • Infectious period: 1 day prior to onset of symptoms to 3 days after • may be longer in children

  6. Impact of Seasonal Influenza • Illness in 10-20 % population each year • Highest attack rates in children • Average of 200,000 hospitalizations/year • Average of 36,000 deaths/year • Highest rate of hospitalization and death in the elderly

  7. Laboratory Testing • Viral culture • Gold standard • Isolates for yearly vaccine development • Point-of-care tests (rapid tests) • Generally 70+% sensitive, 90+% specific • GDPH ordering for sentinels and districts! • Other tests: • Immunofluorescence • Serology (acute and convalescent) • RT-PCR – Currently used at GPHL for both seasonal and avian influenza – results in 2-4 hours

  8. Influenza Surveillance Overview • Morbidity • Sentinel Provider Network Syndromic Surveillance • EIP hospital surveillance (peds and adults) • Mortality • 122 Cities Mortality System • Pediatric deaths are reportable • Virologic Surveillance • WHO/NREVSS Collaborating Laboratories • Novel influenza A surveillance • State assessment • State & Territorial Epidemiologists Reports (that’s me)

  9. Sentinel Provider Network • Goal of 1 regularly reporting site per 250,000 population • To date, we have 73 sentinel providers enrolled • Each week, report ILI activity • Send specimens to the GA Public Health Lab 3 times during the season • Characterize the virus • Able to determine changes in circulating virus • Determines what flu vaccine will be made of for upcoming season!

  10. Sentinel Provider Network, 2007-2008 • 73 sentinel sites • Practice types: • Emergency Departments • Pediatrics • Family Medicine • Internal Medicine • Infectious Disease • University Health Services • Occupational Health Services • 35 to 40 report regularly

  11. Athens Regional Medical Center Atlanta Medical Center Candler County HospitalChildren's Healthcare of Atlanta at Egleston Children's Healthcare of Atlanta at Scottish Rite Columbus Regional Hospital, DeKalb Medical Emory University Hospital Georgia Public Health Laboratory Grady Memorial HospitalJasper Memorial Hospital Lab Medical Center of Central Georgia Medical College of Georgia Memorial HealthMemorial Medical Center NE Georgia Medical Center Newton Medical Center Piedmont Newnan HospitalPolk Medical CenterSatilla Regional Medical Center Southern Regional Medical Center Stephens County Hospital Tanner Medical Center The Medical Center Wellstar CobbWellstar DouglasWellstone Kennestone

  12. National NREVSS Data2007-2008

  13. National NREVSS Data 2006-2007

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

  15. State assessments • We report to CDC each week • No activity • Sporadic • Local • Regional • Widespread • Based on components of influenza surveillance and syndromic surveillance

  16. Weekly Activity

  17. Weekly activity

  18. Weekly Activity

  19. Sentinel ILI Surveillance

  20. Sentinel ILI Surveillance

  21. Sentinel ILI Surveillance

  22. Syndromic Surveillance • Began utilizing syndromic surveillance for influenza data collection • Syndrome based on ILI symptoms • Fever PLUS flu and Respiratory • 38 hospitals participating

  23. Syndromic Surveillance

  24. Syndromic Surveillance 2006-2007

  25. Pediatric Deaths • Influenza-associated pediatric influenza deaths became reportable during the 2003-04 season • 2006-2007, 5 cases were reported • 3 with MRSA • 1 with Strep A • 1 with an unusually high amount of influenza B virus noted in clinical/autopsy specimens

  26. Observations for 2006-2007 • Season had two distinct peaks in December and February • Epidemiology defined by school holiday closures at Thanksgiving and Christmas • Multiple school outbreaks were reported in November and December • No outbreaks were reported in LTCFs

  27. How is 2007-2008 shaping up? • Slow to start compared to previous years • Just now seeing local activity • Rapid tests are a mix of A and B • 23 patients hospitalized in metro Atlanta to date (no pediatrics – yet)

  28. ACIP Recommendations 2007-2008 • ALL persons, including school-aged children, who want to reduce the risk of illness or transmission to others • ALL children 6- 59 months • ALL adults 50 years of age and older • Children and adults on aspirin therapy • Women who will be pregnant during flu season • Adults/children with chronic illness, immunosuppression, ↓respiratory function • Residents of LTCFs • Household contacts of infants, sick kids and >50 • HEALTHCARE WORKERS!

  29. Influenza Vaccination Coverage Levels Persons Aged 65 and Over Source: Behavioral Risk Factor Surveillance System (BRFSS)

  30. Influenza 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.

  31. Vaccination rates among children 6-23 months Sept-Oct 2005 National Immunization Survey MMWR 56:37

  32. 2007-2008 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!

  33. Antivirals • Oseltamivir and Zanamivir • Prophylactic use can limit spread • People at high risk • People who care for those at high risk • People who cannot take the vaccine or who might have poor response • Use for treatment can decrease duration and severity uncomplicated influenza • Start within < 2 days (though recent studies have demonstrated effectiveness past 2 days) • Shown to reduce serious complications • For pandemic flu, a prioritization scheme will be used

  34. A word about pan flu • Info changes frequently! • www.pandemicflu.gov • Planning in GA continues • Statewide Pan Flu Planning Committee • Emergency Preparedness Steering Council • Revision of the State SOG, SOP and COOP • District Health Department planning, training and exercising • Seasonal flu planning, surveillance and response prepares us for pandemic flu!

  35. A word about avian flu • WHO website www.who.int • Pakistan is most recent country with human cases and human to human transmission • CIDRAP email http://www.cidrap.umn.edu/index.html • Georgia’s response • GDPH presenting “train-the-trainer” sessions for response to WHO phase 3 and 4 – next one is January 14, 2008 Tifton • Public health and Dept. of Ag collaboration • Georgia SART (State Agricultural Response Teams) – part of response in ICS

  36. Resources • ACIP prevention and control of influenzaMMWR 2007 http://www.cdc.gov/mmwr/pdf/rr/rr56e629.pdf • CDC’s new flu site http://www.cdc.gov/flu/ • GDPH flu page http://health.state.ga.us/epi/flu/ • Dept of Ag. HPAI Plan http://agr.georgia.gov/00/article/0,2086,38902732_0_98980644,00.html

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