Influenza Surveillance Lisa McHugh, MPH Influenza Surveillance Coordinator New Jersey Department of Health and Senior Services

Seasonal Influenza 5-20% infected yearly (15-60 million*) >200,000 U.S. hospitalizations 63% in persons age > 65 Hospitalization rate children <5 With high-risk condition 500/100,000 Without high-risk condition 100/100,000 ~36,000 U.S. deaths Greater than 90% of all deaths in adults > 65 years Deaths among children uncommon but can occur Uncomplicated influenza illness is characterized by the abrupt onset of constitutional and respiratory signs and symptoms (e.g., fever, myalgia, headache, malaise, nonproductive cough, sore throat, and rhinitis). Among children, otitis media, nausea, and vomiting are also commonly reported with influenza illness. The risks for complications, hospitalizations, and deaths from influenza are higher among persons aged > 65 years, young children, and persons of any age with certain underlying health conditions *Based on population of US Census estimate for 2007

Influenza Surveillance When and where influenza activity is occurring Determine types of influenza virus circulating Detect changes in influenza viruses Track influenza-related illness Measure influenza’s impact on deaths in the United States

Influenza Surveillance in NJ Disease surveillance Virologic surveillance When we look at influenza surveillance it can be broken down into 2 categories Disease Virologic

Disease Surveillance Influenza-like Illness (ILI) Impossible to count all cases of influenza Use ILI to approximate true disease burden ILI combined with other more reliable information (i.e., laboratory testing) can provide a good estimate of disease burden Limitation: casts a wide net and will capture other respiratory illness Looking at Disease Surveillance- we don’t actually count all cases of disease. This would be impossible Based on 5-20% infected yearly and about 8.5 million NJ residents – this equates to somewhere between 500,000 and 1.7 million NJ residents infected yearly. Instead we use ILI Above in slide

Disease Surveillance Influenza-like illness (ILI) surveillance Active surveillance- School, ED, LTCF Sentinel provider surveillance network Pediatric influenza surveillance In NJ we use 3 primary types of disease surveillance- ILI, SPSN, and Ped Surv We use several other secondary types of surveillance to back up these findings – more on this later.

Active ILI Surveillance Weekly reports from ED, LTCF, and Schools ED and LTCF - # ILI* and total census Schools - # absent and total census Currently enrolled in surveillance LTCF - 132 ED - 87 Schools - 719 Analysis done at state, county and regional level Data collected using our Communicable Disease Reporting and Investigation system called CDRSS. * Patients with fever (>100°F, oral or equivalent) AND cough and/or sore throat (in the absence of a known cause).

CDRSS ILI Module Here’s the report from our system. Broken down by county, region and the 3 reporting entities. Also see RSV – more on this later.

Sentinel Provider Surveillance Network (SPSN) A collaborative effort between the public health and medical communities to monitor influenza State and local health department recruit providers to participate Providers report weekly the number of patients seen and the number with ILI by 5 age categories Reporting is from October 1 to mid-May (MMWR week 40 to 20) of each year but year-round reporting is encouraged The second type of surveillance we use is the SPSN CDC runs the overall system with recruitment and management at state and local health department level. Participating providers for the past 2 seasons have received rapid test kits, free testing and free shipping. We will try to continue this program as funding permits.

SPSN Goals Establish the beginning of the influenza season to guide vaccination practices Monitor the antigenic changes of circulating influenza strains by collecting point of care specimens Maintain a surveillance system that provides early warning and adequate monitoring capabilities in the event of a pandemic or outbreak Provide medical entities and other NJ residents with current and accurate information regarding the incidence and severity of disease in NJ

SPSN

SPSN This is the 2007-2008 season compared to 2006-2007 season. See 2 peaks in the 06-07 data – to a lesser degree in 07-08 data. Why do we see this- more on this later.

Pediatric Influenza Surveillance In the 2003-2004 influenza season, an increase in pediatric deaths observed nationally CDC implemented pediatric mortality reporting Subsequent years severe pediatric illness and mortality data collected in NJ

Pediatric Influenza Surveillance Case Definition Pediatric patients (i.e., less than 18 years of age) with laboratory confirmed influenza* AND Influenza-related deaths (in which there is no period of complete recovery between illness and death); OR Influenza encephalopathy (defined as altered mental status, or personality changes in patients lasting more than 24 hours and occurring within 5 days of the onset of an acute febrile respiratory illness); Severe illness defined as admission to an intensive care unit for influenza-related illness (in previously health children)

Pediatric Influenza Surveillance Online entry form – used primarily by hospital Infection Control Professionals. Changed every year to adopt new epidemiologic questions. Questions added – daycare, travel, treatment, co-infection with bacterial agents. http://www.state.nj.us/health/flu/CaseReportForm.shtml

Pediatric Influenza Surveillance Findings Season 2005-2006 2006-2007 2007-2008* No. Reports 62 100 45 No. Meet Case Def. 25 17 19 Deaths 1 Vaccinated 4 3 Not Vaccinated 11 16 Unknown Vaccination 5 Following is brief overview of past 3 seasons. We know we are not capturing all cases of severe and fatal pediatric illness but can use collected data as a representative sample. We do have a report on the 05-06 pediatric data on our website – see bottom of slide. Plans to collate the 3 years of data and complete report. * As of March 11, 2008 New Jersey Pediatric Influenza Summary Report:2005-2006 Influenza Season can be found at: http://nj.gov/health/flu/documents/pediatric_flu_annual_report.pdf

Other Surveillance Activities 122 City Mortality Report ED Volume/Admission Data Real-time Outbreak and Disease Surveillance (RODS) Health Monitoring System BioSense (Influenza Module) QuadraMed I mentioned earlier that we have 3 primary surveillance systems that we use – but also some secondary comparison and here they are. This helps to validate the data we collect for ILI. 122 City- tracks deaths due to pneumonia and influenza (P&I) from 6 NJ cities ED volume – track increase in visits and admission from NJ hospitals – not specific syndromes RODS – over the counter data to track pruchase of cold/flu medications HMS- chief complaint data from hospitals in UASI region (area surrounding NYC) BioSense – Influenza module – evaluated SPSN data by using EARS flu analysis – compare provider to themselves and flag at threshold QuadraMed – Currently exploring – Hospital billing data – lag time but ICD-9 coded.

Virologic Surveillance Goals Identify and characterize circulating strains for vaccine development Identify and characterize strains with pandemic potential Monitor trends and compare season differences Participants Any laboratory conducting influenza tests NREVSS That conclude disease surveillance – now lets look at virologic surveillance

Types of Influenza Testing Influenza Diagnostic Table Procedure Influenza Types Detected Acceptable Specimens Time for Results Rapid result available Viral culture (GOLD STANDARD) A and B NP swab, throat swab, nasal wash, bronchial wash, nasal aspirate, sputum 3-10 days No Immunofluorescence DFA Antibody Staining NP swab, nasal wash, bronchial wash, nasal aspirate, sputum 2-4 hours RT-PCR 1-2 days Serology paired acute and convalescent serum samples6 >2 weeks Enzyme Immuno Assay (EIA) bronchial wash 15-30 minutes Yes In order to discuss virologic surveillance – need to understand a little bit about lab testing and what we use in virologic surveillance. Our primary focus is Culture, PCR and rapid testing methodologies. Where each conducted? Rapid – Range of sensitivities and specificities depending on product and prevalence of influenza in community When to use To guide patient management To determine the cause of an outbreak To support public health surveillance efforts

NREVSS/WHO National Respiratory and Enteric Virus Surveillance System 24 participating laboratories in NJ Report directly to CDC on 16 respiratory and enteric viruses NJ receives and analyzes data weekly How do we collect virologic data -

Virologic Surveillance Rapid antigen test kit project 2006-2007 Season 64 sentinel laboratories (8 facilities returned kits) 35 sentinel providers NJDHSS asked that all positive tests be forwarded to NJPHEL for PCR and culture 678 samples received from 29 (45%) facilities How does lab surveillance work. In the past we received around 130 samples for influenza. Sample submission was sporadic and did little to help track influenza (types and geographic spread). NJDHSS implemented Rapid test kit project in 2006-2007 influenza season. In the 07-08 season- project continued but reduced # of facilities to 16 with 2-3 samples per week. (reduced funding)

Virologic Surveillance Test Results 2005-2006 2006-2007 CDC/WHO (n=135,973) Positive=17,997 NJ (n=139) Positive=75 (n=172,735*) Positive=23,181 (n=810) Positive =611 A 13,857 (81%) 8,209 (59%) 73 (97%) H1 13 (18%) 18,392 (80%) 12,290 (67%) 428 (70%) 49 (11%) 420 (3%) 3,872 (21%) 144 (34%) H3 5,228 (38%) 60 (82%) 2,230 (12%) 235 (55%) B 3,642 (18%) 2 (3%) 4,789 (20%) 183 (30%) Other Virus 2 9 NVI/QNS 62 190 This is a table showing the 2005-2006 and 2006-2007 influenza season with regards to number of samples received and the type of influenza identified. See 7 fold increase in 06-07 Reverse of national picture more H3 than H1 – and lots of B *Data as of MMWR week 20

06-07 type breakdown Lots of H3 Not much difference in PCR and culture – EXCEPT in NVI where PCR excels at detecting virus in Old samples.

Very few samples in 65+ Many in 1-18 Not sure if that’s testing is ordered more or if really and increase in disease. SPSN – show similar trend – Could be overwhelming # of peds participating in SPSN program. Of note – few LTCF outbreaks.

National data for 06-07 season Peak in week 6- more H1 than H3

INFLUENZA ISOLATES FROM THE MID-ATLANTIC REGION Reported By WHO/NREVSS Collaborating Laboratories 2006-2007 Season

NJ for 06-07 our peak was week 12 Later than national and later than previous seasons.

2007-2008 Influenza Culture Results by Subtype Rapid test kit project 2007-2008 15 labs and 20 sentinel providers Asked to submit 2-3 specimens per week to PHEL 387 received as of MMWR week 9 Currently – looks like peak was week 5 but still looking at lab data and still seeing widespread flu around the state.

RSV Surveillance Minimum of one hospital per county reports the number of RSV tests and the number positive Surveillance is important because RSV infection can often be confused with influenza Assists providers with administration of RSV-IGIV and palivizumab Spoke earlier about how using ILI for surveillance casts a wide net and we pick up other respiratory disease – one of those is RSV. So we collect it – helps to extract data which is not ILI

RSV Surveillance 2007-2008 Influenza Season 2007-2008 data Peak week 52- usually earlier than influenza season – end of RSV is beginning of influenza so can miss the start of flu season.

RSV RSV Heres an example of how we can use disease and virologic data together. Sent pro – lots of noise- but overlay with lab data and you begin to see trends. FLU FLU

Influenza Vaccine 2007-2008 A/Solomon Islands/3/2006 (H1N1)-like A/Wisconsin/67/2005 (H3N2)-like (or A/Hiroshima/52/2005 virus) B/Malaysia/2506/2004-like antigens (or B/Ohio/1/2005 virus) Collect all this data – why Well see when flu is cicculating but also help with vaccine develop – Explain the process I am sure you have heard of the vaccine mis-match this year – so let’s discuss

2007-2008 Circulating Strains A- H1N1 (191 specimens) 147 (77%) A/Solomon Islands/3/2006-like 19 (10%) Reduced titers to A/Solomon Islands/3/2006-like 25 (13%) A/Brisbane/59/2007-like A- H3N2 (86 specimens) 12 (14%) A/Wisconsin/67/2005-like 67 (78%) A/Brisbane/10/2007-like 7 (8%) Reduced titers to A/Wisconsin/67/2005-like In green – current vaccine In yellow- future vaccine CDC data as of MMWR week 9

2007-2008 Circulating Strains B (89 tested) Victoria lineage (6) 4 (67%) B/Ohio/01/2005-like 2 (33%) Reduced titers to B/Ohio/01/2005-like Yamagata lineage (83) 82 (99%) B/Florida/04/2006-like 1 (1%) Reduced titers to B/Florida/04/2006-like CDC data as of MMWR week 9

Influenza Vaccine 2008-2009 FDA recommends all three vaccine components to be changed for the 2008-2009 influenza season A/Brisbane/59/2007-like (H1N1) A/Brisbane/10/2007- like (H3N2) B/Florida/4/2006-like

Proposed New Influenza Vaccine Rule The NJDHSS is proposing a new rule at N.J.A.C.8:57-19 to establish that all children six through 59 months of age entering or attending a licensed child care center or preschool facility on or after September 1, 2008 shall annually receive at least one dose of influenza vaccine between September 1 and December 31 of each year.

Antiviral Resistance Neuraminidase inhibitors Adamantanes* 45 (8.7%)of 519 H1N1 viruses tested were resistant to Oseltamivir Adamantanes* 111 (21.7%) of 511 influenza A viruses were resistant 98.9% of H3N2 4.3% H1N1 Four approved for influenza treatment Two adamantane derivatives Amantadine (Symmetrel®), rimantadine (Flumadine®) Older drugs approved 1966 and 1993 respectively Interferes with function of protein channels Two neurominidase inhibitors Oseltamivir (Tamiflu®), zanamivir (Relenza®) Both approved in 1999 Neurominidase inhibitors *CDC and ACIP recommend that neither amantadine nor rimantadine be used for the treatment or chemoprophylaxis of influenza A in the United States

Weekly Influenza Report All surveillance data is analyzed on a weekly basis (MMWR weeks) Influenza activity level is evaluated for both the state and 5 public health regions

Activity Levels No Activity- At least 2 of 3 parameters at or below state baseline AND no lab confirmed cases Sporadic – At least 2 of 3 parameters above state baseline AND confirmed laboratory cases anywhere in the state OR at least one laboratory confirmed outbreak in an institution anywhere in the state Local – At least 2 or 3 parameters above state baseline in a single county AND confirmed laboratory cases from that same county within the previous 3 weeks (other counties may be above baseline without lab confirmed cases) OR confirmed outbreaks in 2 or more institutions in a single county

Activity Levels Regional – At least 2 of 3 parameters above state baseline in > 2 but < 10 counties AND laboratory confirmed cases from these same counties in past 3 weeks OR confirmed outbreaks institutions in more than 2 but less than or equal to 10 counties Widespread – At least 2 of 3 parameters above state baseline in more than 10 counties OR institutional outbreaks in more than 10 counties AND lab confirmed influenza cases in previous 3 weeks.

NE Region (Bergen, Essex, Hudson) CE Region (Middlesex, Monmouth, Ocean, Union) NW Region (Morris, Passaic, Sussex, Warren) CW Region (Hunterdon, Mercer, Somerset) South Region (Atlantic, Burlington, Camden, Cape May, Cumberland, Gloucester, Salem)

Weekly Influenza Report

Weekly Influenza Activity New Jersey 0=No report/activity 1=Sporadic 2=Local 3= Regional 4=Widespread

Weekly Influenza Activity United States http://www.cdc.gov/flu/weekly/usmap.htm

Questions? Lisa McHugh, MPH Infectious & Zoonotic Disease Program Influenza Surveillance Program New Jersey Department of Health & Senior Services 609-588-7500 lisa.mchugh@doh.state.nj.us