CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION Influenza Surveillance in Mainland of China Yuelong Shu Chinese National Influenza Center National Institute for Viral Disease Control and Prevention China CDC , Beijing

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION Management of Influenza Surveillance Network in Mainland China Influenza Surveillance Data Response to Pandemic H1N1 2009

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION Classification:  Seasonal Influenza: Class C Notifiable Infectious Disease  Pandemic A(H1N1) 2009 : Class B Notifiable Infectious Disease  H5N1: Class B Notifiable Infectious Disease Sentinel hospital-based surveillance:  ILI surveillance  Virological surveillance Influenza or ILI outbreak surveillance:  Outbreak report  Virological surveillance Influenza Surveillance in Mainland China

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION To monitor influenza activity in mainland China To monitor the antigenic and genetic characterization of influenza virus: for recommendation of representative strain and vaccine strain To monitor reassortant or mutation of the virus: more severe or/and transmissible? Drug resistance surveillance To monitor the novel influenza virus 4 Surveillance Objectives

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION 5 History Influenza research initiated in 1952 in mainland of China Influenza department of Institute of Virology was established in 1954 Chinese National Influenza Center was established in 1957 Rejoined WHO Global influenza surveillance network (GISN) in 1981

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION Structure of National Influenza Surveillance Network(NISN)

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION 63 network laboratories and 197 sentinel hospitals since Oct, 2005

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION 411 network laboratories and 556 sentinel hospitals since June, 2009

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION Network Laboratories Samples Collection Fill the Original Form For Delivery and Examination Fill the Original Form For Delivery and Examination Sentinel Hospitals CNIC Samples Identification Print the Delivery and Examination Form of Flu Virus Strain Print the Delivery and Examination Form of Flu Virus Strain Confirmation & Feedback Confirmation & Feedback Lab Results Entry ILI Report Updated Surveillance Information System for Influenza China Information System for Disease Control and Prevention Surveillance Information System for Influenza Information Management System for A (H1N1)

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION Influenza Surveillance Information System (continued) ILI report by sentinel hospitals Virological Surveillance Virological Surveillance

Influenza Surveillance Information System (3) No. of consultations ILI by age groups

Influenza Surveillance Information System (4) Patient’s Information Patient’s Information Specimen’s Information Specimen’s Information Laboratory Information Laboratory Information

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION Influenza Surveillance Information System (5) PCR Test for novel A(H1N1) 2009

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION Accelerating national and international cooperation and communication and continuing participation in the GISN English Weekly Report

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION Virus Database Add Search Sequence Database Add Search Download Multi-alignment & BLAST Developing Virus Information Database for NISN 15

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION Identification and confirmation of influenza virus in CNIC

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION Number of virus isolates sequenced in CNIC

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION

Trainings to the NISN 19 Every year CNIC organizes various training courses for the NISN, such as epidemiology workshop, laboratory detection techniuqe training, Biosafety training, GLP training and laboratory hands on training, etc. More than 2000 epidemiologists and laboratory technicians were trained in the last five years.

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION Supervision Supervision have been organized each year since 2000.

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION National Influenza Surveillance Quality Evaluation System To strengthen the management of the NISN. The evaluation system includes the following 4 parts:  Virological Surveillance  Epidemiological Surveillance  Outbreak Surveillance  Management of the Network Laboratory The Quality Evaluation includes about 20 indicators.

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION Quality Evaluation to the National Influenza Surveillance System The Quality Evaluation results

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION International Cooperation & Communication

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION International Cooperation & Communication Tabletop Exercise Symposium

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION Surveillance Data

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION Percentage of ILI Reported by Sentinel Hospitals during 2006 － 2009 in Southern Area

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION Percentage of ILI Reported by Sentinel Hospitals during 2006 － 2009 in Northern Area

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION H3 dominant H1 dominant H3 dominant

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION Composition of the type/subtype of influenza virus since June1 st,2009

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION *≥8 fold lower in HI titer Seasonal Influenza A(H1N1)NO.Percent WHO recommended Vaccine strain (2008/09North- 2009/10 North) In total 1400 isolates A/Brisbane/59/2007-like % A/Brisbane/59/2007-low* % WHO recommended Vaccine strain (2007/08North- 2008South) In total 1400 isolates A/Solomon islands/3/2006-like % A/Solomon islands/3/2006-low* % China Recommended Epidemic Reference Strain for Network labs (2008 Oct-2009 Sept) In total 1400 isolates A/Guangdong-baoan/51/2008- like % A/Guangdong-baoan/51/2008- low* % China Recommended Epidemic Reference Strain for Network labs (2009 Oct-2010 Sept) In total 802 isolates A/Tianjin-jinnan/15/2009-like % A/Tianjin-jinnan/15/2009-low* 496.1% Antigenic Analysis of Seasonal H1N1 –Tested at CNIC (Jan, 2009-July, 2009) (Chicken Antiserum)

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION *≥8 fold lower in HI titer A(H3N2)NO.Percent WHO recommended Vaccine strain (2008South-2009/10 North) In total 396 isolates A/Brisbane/10/2007-like % A/Brisbane/10/2007-low* % WHO recommended Vaccine strain (2006/07North- 2007/08North) In total 396 isolates A/Wisconsin/67/2005-like 287.1% A/Wisconsin/67/2005 -low* % China Recommended Epidemic Reference Strain for Network labs (2007 Oct-2008 Sept) In total 399 isolates A/Jiangxi-donghu/312/2006-like % A/Jiangxi-donghu/312/2006-low* % China Recommended Epidemic Reference Strain for Network labs (2008 Oct-2009 Sept) In total 399 isolates A/Anhui-baohe/137/2008-like % A/Anhui-baohe/137/2008-low* % China Recommended Epidemic Reference Strain for Network labs (2009 Oct-2010 Sept) In total 75 isolates A/Fujian-tongan/196/2009-like % A/Fujian-tongan/196/2009-low* % Antigenic Analysis of H3N2 –Tested at CNIC (Jan, 2009-July, 2009) (Chicken Antiserum)

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION *≥8 fold lower in HI titer B(Victoria)NO.Percent WHO recommended Vaccine strain (2009South- ) In total 56 isolates(with Ferret Antiserum) BV/Brisbane/60/2008-like % BV/Brisbane/60/2008-low* % WHO recommended Vaccine strain (2006South-2007/8 North) In total 1292 isolates(with Chicken Antiserum) B/Malaysia/2506/2004-like 685.3% B/Malaysia/2506/2004-low* % China Recommended Epidemic Reference Strain for Network labs (2008 Oct-2009 Sept) In total 1343 isolates(with Chicken Antiserum) B/Jiangxi-Xinjian/39/2008-like523.9% B/Jiangxi-Xinjian/39/2008- low* % China Recommended Epidemic Reference Strain for Network labs (2009 Oct-2010 Sept) In total 949 isolates(with Chicken Antiserum) B/Jiangxi-xiushui/32/2009-like % B/Jiangxi-xiushui/32/2009- low* % Antigenic Analysis of B(Victoria) –Tested at CNIC (Jan, 2009-July, 2009)

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION *≥8 fold lower in HI titer B(Yamagata)NO.Percent WHO recommended Vaccine strain (2008South- 2009South) In total 115 isolates B/Florida/4/2006-like % B/Florida/4/2006-low* 65.2% China Recommended Epidemic Reference Strain for Network labs (2008Oct-2009Sept) In total 115 isolates B/Shanxi-beilin/127/2008-like % B/Shanxi-beilin/127/2008-low* % China Recommended Epidemic Reference Strain for Network labs (2007Oct-2008Sept) In total 115 isolates B/Fujian-Xinluo/54/2006-like % B/Fujian-Xinluo/54/2006-low* % China Recommended Epidemic Reference Strain for Network labs (2009Oct-2010Sept) In total 11 isolates B/Hubei-wujiagang/158/2009-like 11100% B/Hubei-wujiagang/158/2009- low* 00 Antigenic Analysis of B(Yamagata)–Tested at CNIC (Jan, 2009-July, 2009) (Chicken Antiserum)

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION Drug resistance surveillance for seasonal influenza (bioinformatics) ( Collection date from Jan2009 to July 2009) 39.0% (30/77) H1N1 viruses and 100% (49/49) H3N2 viruses isolated in mainland China from Jan2009 to July 2009 are resistant to adamantine. 61.0% (47/77) H1N1 viruses isolated in mainland China from Jan2009 to July 2009 are resistant to Oseltamivir. No Oseltamivir resistance viruses were found in H3N2(0/83) and B (0/49)viruses.

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION Response to 2009 H1N1 Pandemic

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION Support to Chinese Influenza Surveillance Network Special financial funds for Chinese Influenza Surveillance Network from Central finance Timely development of diagnostic method Enhanced Surveillance:  Expansion of network laboratories  Expansion of sentinel hospitals A series of trainings and meetings On site or by video/teleconference

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION Diagnostic method development timeline

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION Distribution of Diagnostic Kit to NISN and other countries/areas Country /areas RT PCR kits Real-time PCR kits Singapore5 Papua New Guinea5 Mongolia55 Cuba305 Macau10 Vietnam2 Laos2 Cambodia2 Brunei2 Indonesia2 Malaysia2 Philipine2 Thailand2 NISN in China Test for 45,200 specimens Test for 75,752 specimens

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION Rapid information exchange

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION China-ASEAN workshop for Pandemic A(H1N1) 2009

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION Illness onset date of the cases infected with the novel A(H1N1) influenza virus in Mainland China

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION Geographic distribution of the cases infected with the novel A(H1N1) influenza virus

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION Infection sources the cases infected with the novel A(H1N1) influenza virus in Mainland China

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION Composition of the type/subtype of influenza virus since June1 st,2009 Pandemic A(H1N1) A(Unsubtyped) B(Unsubtyped)

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION HA Isolates from China Novel A(H1N1) Seasonal H1N1 MP NA NP NS PA PB1 PB2 Phylogenetic Analysis

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION Drug Resistance Analysis by bioinformatics All the A(H1N1) viruses isolated in Mainland China are resistant to adamantine A/Hunan/SWL3/2009(H1N1) has a histamine to tyrosine mutation at residue 274 of the NA (N2 numbering; residue 275 by N1 numbering), which confers a high level of resistance to Oseltamivir. The case was imported case from US, and took Oseltamivir for prophylactic purpose 1~6 days before the onset of illness. The sequence was reported to Genebank. The other isolates are sensitive to Oseltamivir.

CHINESE CENTER FOR DISEASE CONTROL AND PREVENTION