Texas Influenza Texas Influenza SurveillanceSurveillance
Lesley BullionLesley Bullion
Influenza Surveillance CoordinatorInfluenza Surveillance Coordinator
Infectious Disease Control UnitInfectious Disease Control Unit
Flu Surveillance BasicsFlu Surveillance Basics
Flu is not a notifiable condition*Flu is not a notifiable condition*
Participation in surveillance is voluntaryParticipation in surveillance is voluntary
““Official” flu season is approximately Official” flu season is approximately October to May (MMWR week 40 to October to May (MMWR week 40 to MMWR week 20)MMWR week 20)
Texas Flu SurveillanceTexas Flu SurveillanceU.S. Outpatient Influenza-Like Illness U.S. Outpatient Influenza-Like Illness Surveillance Network (ILINet)Surveillance Network (ILINet)
Influenza-like illness (ILI) Influenza-like illness (ILI) datadata
Culture Surveillance ‘Network’Culture Surveillance ‘Network’SpecimensSpecimens from clinics, hospitals, public health labs, health from clinics, hospitals, public health labs, health departmentsdepartmentsLimited Limited specimensspecimens from some ILINet providers from some ILINet providers
Research and Hospital LaboratoriesResearch and Hospital LaboratoriesFlu test Flu test resultsresults from NREVSS, WHO, TCH, S&W, from NREVSS, WHO, TCH, S&W, USAFSAMUSAFSAM
Regional Flu Surveillance Coordinator ReportsRegional Flu Surveillance Coordinator ReportsILI, school closures, institutional outbreaks, laboratory ILI, school closures, institutional outbreaks, laboratory results, rapid flu test results, pediatric flu deathsresults, rapid flu test results, pediatric flu deaths
U.S. Outpatient U.S. Outpatient Influenza-Like Illness Influenza-Like Illness Surveillance Network Surveillance Network
(ILINet)(ILINet)
ILINet BasicsILINet Basics
VoluntaryVoluntary nationwide network of healthcare providers nationwide network of healthcare providers sponsored by the Centers for Disease Control and sponsored by the Centers for Disease Control and Prevention (CDC)Prevention (CDC)
Recruited by each state health departmentRecruited by each state health department
Weekly reports of influenza-like illness (fever ≥100°F Weekly reports of influenza-like illness (fever ≥100°F AND cough and/or sore throat in the absence of a known AND cough and/or sore throat in the absence of a known cause other than influenza)cause other than influenza)
Some Texas providers also submit specimens to DSHSSome Texas providers also submit specimens to DSHS
ILINet Reporting FormsILINet Reporting Forms
ILINet DataILINet Data
U.S. Outpatient Influenza-Like Illness Surveillance Network U.S. Outpatient Influenza-Like Illness Surveillance Network (ILINet), Texas Participants (N=143), 2008-09(ILINet), Texas Participants (N=143), 2008-09
HSR Total
1 9
2/3 27
4/5N 8
6/5S 36
7 9
8 11
9/10 18
11 25
Grand Total 143
As of 7/13/09
Culture SurveillanceCulture Surveillance
Culture Surveillance Sites, Culture Surveillance Sites, 1998-19991998-1999
2008-09 Influenza Surveillance Specimens 2008-09 Influenza Surveillance Specimens Submitted to DSHS Austin Lab (N=1,419*)Submitted to DSHS Austin Lab (N=1,419*)
HSRHSR TotalTotal
11 4040
2/32/3 642642
4/5N4/5N 120120
6/5S6/5S 4848
77 246246
88 106106
9/109/10 4444
1111 173173
Grand TotalGrand Total 14191419
*through April 15, 2009
Additional Laboratory DataAdditional Laboratory Data
Weekly Reports by Individual LabsWeekly Reports by Individual Labs
Texas Children’s Hospital: +culturesTexas Children’s Hospital: +cultures
Scott & White Hospital Laboratory: +tests Scott & White Hospital Laboratory: +tests (culture, PCR, antigen) by patient county(culture, PCR, antigen) by patient county
USAFSAM: +cultures/PCR by baseUSAFSAM: +cultures/PCR by base
LRN laboratories: +PCRLRN laboratories: +PCR
NREVSS Laboratory DataNREVSS Laboratory DataNREVSS Flu Reporters in 2008-09 season:
Arlington Memorial HospitalChildren’s Hospital of AustinChildren’s Medical Center of DallasCook Children’s Medical CenterCovenant Medical CenterDriscoll Children’s HospitalHunt Memorial Hospital DistrictMedical Center of PlanoMedical City Dallas HospitalMethodist Children's HospitalMethodist HospitalMother Frances HospitalSanta Rosa Health CareScott & White Memorial HospitalSouth Texas Regional Medical CenterTarrant County Public HealthTexas Children’s HospitalTexas Department of State Health ServicesTomball Regional HospitalUniversity Hospital/South Texas Medical CenterUniversity of Texas Medical Branch – Children’s HospitalUniversity Medical Center
NREVSS Flu Reporters in 2008-09 season:
Arlington Memorial HospitalChildren’s Hospital of AustinChildren’s Medical Center of DallasCook Children’s Medical CenterCovenant Medical CenterDriscoll Children’s HospitalHunt Memorial Hospital DistrictMedical Center of PlanoMedical City Dallas HospitalMethodist Children's HospitalMethodist HospitalMother Frances HospitalSanta Rosa Health CareScott & White Memorial HospitalSouth Texas Regional Medical CenterTarrant County Public HealthTexas Children’s HospitalTexas Department of State Health ServicesTomball Regional HospitalUniversity Hospital/South Texas Medical CenterUniversity of Texas Medical Branch – Children’s HospitalUniversity Medical Center
Regional Flu ReportsRegional Flu Reports
Flu Activity LevelsFlu Activity Levels
No Activity:No Activity: – Low clinical activity and no lab confirmationLow clinical activity and no lab confirmation
Sporadic:Sporadic: – ILI activity not increasedILI activity not increased– Isolated lab confirmed cases OR an institutional outbreak in a single institutionIsolated lab confirmed cases OR an institutional outbreak in a single institution
Local:Local: – Increase in ILI plus recent lab confirmation inIncrease in ILI plus recent lab confirmation in ONE ONE region of the stateregion of the stateOR OR – Recent lab confirmation AND two or more ILI or lab confirmed outbreaks inRecent lab confirmation AND two or more ILI or lab confirmed outbreaks in ONE ONE
regionregion
Regional:Regional:– Increased ILI OR institutional outbreaks in ≥2 but less than half of the regionsIncreased ILI OR institutional outbreaks in ≥2 but less than half of the regions– AND recent lab confirmation in affected regionsAND recent lab confirmation in affected regions
Widespread:Widespread: – Increased ILI OR institutional outbreaks in at least half of the regions Increased ILI OR institutional outbreaks in at least half of the regions – AND recent lab confirmed influenza in affected regionsAND recent lab confirmed influenza in affected regions
Flu activity levelFlu activity levelRegional reportsRegional reportsLab dataLab data
OutbreaksOutbreaks
SPSN ILI dataSPSN ILI data
Link to national reportLink to national report
Texas Texas Weekly Flu Weekly Flu
ReportReport
Texas Weekly Flu ReportTexas Weekly Flu Report
How does Texas How does Texas surveillance contribute to surveillance contribute to
national surveillance?national surveillance?
National Flu SurveillanceNational Flu Surveillance
Centers for Disease Control (CDC) Centers for Disease Control (CDC) components of influenza surveillance in components of influenza surveillance in the U.S.the U.S.– Viral Laboratory SurveillanceViral Laboratory Surveillance– Outpatient Illness DataOutpatient Illness Data– Mortality SurveillanceMortality Surveillance– Hospitalization SurveillanceHospitalization Surveillance– State and Territorial Epidemiologists ReportsState and Territorial Epidemiologists Reports
2008–2009 2008–2009 Influenza Season Influenza Season
in Texas in Texas (through April 15, 2009)(through April 15, 2009)
U.S. Outpatient Influenza-Like Illness Surveillance Network (ILINet), Data From Texas Participants, 2008-09
0
5000
10000
15000
20000
25000
30000
35000
40000
45000
5000020
0840
2008
41
2008
42
2008
43
2008
44
2008
45
2008
46
2008
47
2008
48
2008
49
2008
50
2008
51
2008
52
2008
53
2009
01
2009
02
2009
03
2009
04
2009
05
2009
06
2009
07
2009
08
2009
09
2009
10
2009
11
2009
12
2009
13
2009
14
2009
15
October November December January February March April
MMWR Week
Nu
mb
er o
f P
atie
nt
Vis
its
0%
1%
2%
3%
4%
5%
6%
7%
8%
Per
cen
tag
e o
f V
isit
s F
or
ILI
Patients ILI %ILI
Texas Flu Summary, 2008–09Texas Flu Summary, 2008–09
First isolate of the season (DSHS Lab)First isolate of the season (DSHS Lab)– Flu A/unable to subtype!Flu A/unable to subtype!
Specimen collected October 15, 2008Specimen collected October 15, 2008Bell County Bell County Swine influenza A (H1N1) Swine influenza A (H1N1)
– Flu BFlu BSpecimen collected October 21, 2008Specimen collected October 21, 2008B/Malaysia/2506/2004-like (Victoria lineage)B/Malaysia/2506/2004-like (Victoria lineage)Webb CountyWebb County
Predominant type/subtype: A (H1N1)Predominant type/subtype: A (H1N1)
Percentage of Specimens Positive for Influenza and Types/Subtypes of Influenza Isolated at DSHS Austin Lab, 2008-09
0
20
40
60
80
100
120
140
160
40 41 42 43 44 45 46 47 48 49 50 51 52 53 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
October November December January February March April
2008 2009
MMWR Week
Nu
mb
er o
f F
lu I
sola
tes
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Pe
rce
nta
ge
of
Sp
ec
ime
ns
Po
sit
ive
fo
r F
lu
A/H1 A/H3 A/Unable to subtype B %FLUPOS
Texas Flu Summary, 2008-09Texas Flu Summary, 2008-09
Early appearance of influenza B and A (H1N1)Early appearance of influenza B and A (H1N1)– Influenza A (H3N2) absent until week 52Influenza A (H3N2) absent until week 52
Seasonal peak: early FebruarySeasonal peak: early February– 221 specimens collected, 147 (67%) positive for flu 221 specimens collected, 147 (67%) positive for flu
during week 5 (week ending February 7, 2009)during week 5 (week ending February 7, 2009)– ILINet peak: 7.06% in week 6ILINet peak: 7.06% in week 6– NREVSS-Texas peak: 28.1% in week 5NREVSS-Texas peak: 28.1% in week 5– ““Widespread” designation for 7 weeksWidespread” designation for 7 weeks
Late, small flu B wave (week 8)Late, small flu B wave (week 8)Mild compared to 2007-08Mild compared to 2007-08
Influenza Types and Subtypes Identified in Positive Specimens, Influenza Types and Subtypes Identified in Positive Specimens, DSHS Austin Laboratory, 2008-2009 SeasonDSHS Austin Laboratory, 2008-2009 Season
Virus Total
A H1 468
A H3 37
Unable to subtype 1
B/Florida/04/2006-like 15
B/Malaysia/2506/2004-like 248
Influenza B 7
Grand Total 776
2008-09 Flu Season in Texas (through April 15, 2009)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
40 41 42 43 44 45 46 47 48 49 50 51 52 53 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
October November December January February March April
2008 2009
MMWR Week
Per
cen
tag
e o
f S
pec
imen
s P
osi
tive
fo
r In
flu
enza
0%
2%
4%
6%
8%
10%
12%
Per
cen
tag
e o
f V
isit
s D
ue
to I
LI
%Flu Pos, DSHS Austin
%Flu Pos, NREVSS
%ILI, ILINet
Widespread flu activity reported to CDC
Influenza-Associated Pediatric Influenza-Associated Pediatric MortalityMortality
Reportable beginning in 2007 in TexasReportable beginning in 2007 in Texas
Laboratory-confirmed influenza death in a Laboratory-confirmed influenza death in a person under 18 years of ageperson under 18 years of age
11 deaths (through week 15)11 deaths (through week 15)– Age range: 7 months to 17 yearsAge range: 7 months to 17 years– 4 Flu A, 7 Flu B4 Flu A, 7 Flu B– Known MRSA or MSSA co-infection: 2/11 (18%)Known MRSA or MSSA co-infection: 2/11 (18%)– Significant underlying medical condition: 8/11 (73%)Significant underlying medical condition: 8/11 (73%)– Not vaccinated for flu: 4/6 (67%)Not vaccinated for flu: 4/6 (67%)
Review of 2008–09 Vaccine Review of 2008–09 Vaccine Components (Northern Hemisphere)Components (Northern Hemisphere)
All 3 were new components!All 3 were new components!– A/Brisbane/59/2007-like (H1N1)A/Brisbane/59/2007-like (H1N1)– A/Brisbane/10/2007-like (H3N2)A/Brisbane/10/2007-like (H3N2)– B/Florida/4/2006-like (B/Yamagata lineage)B/Florida/4/2006-like (B/Yamagata lineage)
Antigenic Characterization TestingAntigenic Characterization Testing
Performed on limited Texas isolates at Performed on limited Texas isolates at CDC laboratoryCDC laboratory20 A/H1 (seasonal) isolates: 100% match 20 A/H1 (seasonal) isolates: 100% match to vaccine strainto vaccine strain8 A/H3 isolates: 100% match8 A/H3 isolates: 100% match23 influenza B isolates:23 influenza B isolates:– 30% match to vaccine strain (Yamagata 30% match to vaccine strain (Yamagata
lineage)lineage)– 70% Victoria lineage70% Victoria lineage
Antiviral Resistance TestingAntiviral Resistance Testing
Performed on limited Texas isolates at CDC Performed on limited Texas isolates at CDC laboratorylaboratory1 swine influenza A/H1 tested (October 2008)1 swine influenza A/H1 tested (October 2008)– Sensitive to oseltamivir, zanamivir, adamantanesSensitive to oseltamivir, zanamivir, adamantanes
22 seasonal influenza A/H1’s tested22 seasonal influenza A/H1’s tested– 100% resistant to oseltamivir (sensitive to zanamivir 100% resistant to oseltamivir (sensitive to zanamivir
and adamantanes)and adamantanes)
7 influenza A/H3’s tested7 influenza A/H3’s tested– 100% resistant to adamantanes (sensitive to 100% resistant to adamantanes (sensitive to
oseltamivir and zanamivir)oseltamivir and zanamivir)
22 influenza B’s tested22 influenza B’s tested– 100% sensitive to oseltamivir and zanamivir100% sensitive to oseltamivir and zanamivir
2009-10 Vaccine Composition 2009-10 Vaccine Composition (Northern Hemisphere)(Northern Hemisphere)
Only the B strain will be changed:Only the B strain will be changed:– A/Brisbane/59/2007-like (H1N1)A/Brisbane/59/2007-like (H1N1)– A/Brisbane/10/2007-like (H3N2)A/Brisbane/10/2007-like (H3N2)– B/Brisbane/60/2008-like (B/Victoria lineage)B/Brisbane/60/2008-like (B/Victoria lineage)
Texas Flu Surveillance Texas Flu Surveillance 2009-2010 Season2009-2010 Season
Continue funding all packaging, shipping, and Continue funding all packaging, shipping, and testing related to flu surveillance; however, testing related to flu surveillance; however, testing may be limited – how?testing may be limited – how?Increase ILINet participants & culture Increase ILINet participants & culture surveillance sites in selected areassurveillance sites in selected areasPCR to continue at LRNsPCR to continue at LRNsVTM ordering process? Limits?VTM ordering process? Limits?To sign up for automatic notification of new flu To sign up for automatic notification of new flu reports:reports:http://www.dshs.state.tx.us/idcu/disease/http://www.dshs.state.tx.us/idcu/disease/influenza/surveillance/2009/influenza/surveillance/2009/