Dr Helen Carter

Specialist Registrar Public Health

Health Protection Agency

Regional Surveillance Unit

West Midlands

Influenza SurveillanceKey Health Data 2007

•Brief introduction to influenza

•Signpost sources of influenza surveillance information

•Consultation for proposed daily pandemic surveillance bulletin

Aims

Anyone involved with influenza planning?

Influenza

Influenza: A respiratory illness associated with infection by influenza virus.

Symptoms: Headache, fever, cough, sore throat, aching muscles and joints.

Pathogen: Virus first identified in 1933

Virus types: Two main types. Influenza A and B. Influenza A usually causes a more

severe illness

Illness: Wide spectrum of illness ranging from minor symptoms to pneumonia and death.

•Seasonal

Influenza

•Avian

Avian Influenza

First recognised in 1878, Italy

Current H5N1 outbreak started in 2003

Predominately affecting Indonesia

19th August 2007

Human cases n=321

Deaths n=194

Pandemic Influenza

•New strain of virus

•Easy to transmit between people

•No immunological resistance in people

•High mortality rate

Can happen at any time of year

Major influenza A sub-types of 20th Century

1920 1950 1980 2000

1918Spanish

1957 H1N1

19681957Asian

H2N2

1968Hong Kong

H3N2

H1N11977Russian

Shortest interval = 11 years Longest interval = 39 yearsCurrent interval = 37 years

1889-1892 ? H2N21900 ? H3N8

WHO Pandemic Influenza Phases

A pandemic is thought most likely to start outside the UK, and to become established in other countries before reaching the UK. For the UK, four alert levels are described in the DH and HPA Plans:

Alert level 1 Cases due to pandemic virus only outside the UKAlert level 2 New pandemic virus isolated in the UK (pandemic

imminent in the UK)Alert level 3 Outbreak(s) due to new pandemic subtype in the

UKAlert level 4 Widespread pandemic activity across UK

UK Alert Levels

Sources of surveillance information-animals

•Sampling of live caught wild birds

•Sampling of wild birds shoot dead during normal wildfowling activities

•Sampling of wild birds found dead

Sources of surveillance information-humans

•Royal College of General Practitioners

•QFLU

•NHS Direct

•Schools- Medical Officers for Schools & HPA pilot

•Death certificates

Royal College of General Practitioners

Established 1957

100 spotter GP practices

Consultations for influenza like illness

NICE utilise baseline for antivirals dispensing decisions

0

100

200

300

400

500

600

700

1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Rate

per

100,0

00

Epidemic activity (>400)

Higher than average seasonal activity (200-400)

Normal seasonal activity (50-200)

Epidemic activity (>200)

Normal seasonal activity (30-200)

Baseline activity (<50)

Baseline activity (<50)

RCGP new consultations for influenza-like illness

QFLU

Developed by EMIS and Nottingham University

Based upon GP computer systems

~3,300 practices participating

Population coverage ~25.5 million

PCT level data available

NHS Direct

Nurse-led telephone service, established 1997

Syndromic surveillance

Clinical algorithms

Answers half a million calls per month

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

16.0020

02/4

0

2003

/01

2003

/14

2003

/27

2003

/40

2004

/01

2004

/14

2004

/27

2004

/40

2005

/01

2005

/14

2005

/27

2005

/40

2006

/01

2006

/14

Year/week

Cold/flu call proportion of allcalls

Fever calls (5-14 yrs)proportion of all calls

NHS Direct Data

Schools

Medical Officers for Schools Association

400 members

HPA School absenteeism pilot

Death certificates

Depends upon doctor writing influenza as cause

Time delay

Information flows

Primary Care Surveillance Team based in

West Midlands Regional Surveillance Unit

Weekly bulletin: all ready produced

Background proposed daily bulletin; surveillance during a pandemic

Conjunction with:

•Health Protection Agency, West Midlands Regional Surveillance Unit,

•Government Office for the

West Midlands

•NHS West Midlands,

Strategic Health Authority

Purpose of bulletin

•To provide a region wide overview

•Provide comparisons to the national situation

•Manage the data demands and expectations of data providers during a pandemic

Who is it for?

Regional Civil Contingency Committee

Strategic Coordinating Groups

Primary Care Trusts

Health Protection Units

Acute Trusts

Local Authorities

&

potentially media and public

It is anticipated that PCT level data will be available via the Pandemic Influenza Portal and in a complementary weekly bulletin

Contents

•Health: GP and morbidity data

•NHS data

•Societal impacts

•Pragmatic approach

Consultation for daily surveillance bulletin

UK ALERT LEVEL: – Outbreak(s) in the UK

GP & Morbidity:

• NHS Direct ‘Cold/Flu’ Calls: Increasing (7-day rolling average = 16% of calls)

• QFlu (GP Consultations): Stable (7-day rolling average = 273 consultations for ILI per 100,000 practice population in West Midlands region compared to national rate of 300 consultations)

•RCGP Consultations Increasing to 270 per 100 000 •Laboratory Data: 9 Flu A and 2 Flu B reported (enter date)

(Total for last 7 days = 34 Flu A, 6 Flu B)

NHS:

•A&E Attendances: total for region (increasing from previous week)•Acute Trust bed occupancy rate proportion across region occupied•Proportion of NHS organisations reporting ‘severe’ pressure (escalation level 4)•Antiviral Prescriptions dispensed in West Midlands (no system in place currently)

Societal impact in the West Midlands:

• Mortality: cannot collect in a timely way at present. May be modeled data

• School closures: collected by Government Office via Children and Learners Directorate but not independent sector

• Care homes: no routine system in place currently

Exception reporting (free text)Petrol supplies disrupted in Staffordshire

500

480

460

440

420

400

380

360

340

320

300

280

260

240

220

200

180

160

140

120

100

80

60

40

20

Consultation Rate per 100 000 practice population

West Midlands Pandemic Flu Activity

Above Average Activity 100 - 200

Normal Seasonal Activity 30 - 100

Epidemic Activity >200

Data from RCGP / HPA West Midlands Weekly Returns

Baseline Activity <30

All Ages

5-14 yrs

This bulletin has been signed off by: Gillian Smith (Regional Epidemiologist)

West Midlands

Daily Update on the Impact of Pandemic Influenza across the West MidlandsDaily Update 1, Data for (enter date)This update will be sent out at 4pm every afternoon until further notice

Consultation

Who did we consult?

West Midlands Influenza Pandemic Planning Group;

all trust’s pandemic influenza leads & all LRFs.

Questions:

1. Does the concept of a daily surveillance bulletin appear useful to you?

2. Are the proposed contents items that would be helpful during a pandemic? If not then

3. If any different or additional information is required what information can be omitted to keep the bulletin to one side of A4?

Results (1)

•Responses so far n=15 covering all apart from one Local Resilience Forum area

•12 via e-mail

•2 verbal

•1 visit to a planning group meeting

[Responses encompassed multiple views]

Results (2) “We consider the bulletin of huge

importance” PCT

“Very positive start” Multi-agency planning group

“This is so straight forward and sensible no one could argue with it.”

PCT

All positive & supportive of the concept

Results (3)

Three most requested additional information:

1. Modelled data to aid forecasting demand over next 7-10 days

2. National call centre information

3. Timely mortality data

Summary

Variety of sources of influenza surveillance data: animal and human

Information for action

Daily bulletin consultation

More details, comments & questions

helen.carter@HPA.org.uk