1 mdh 2010 – 2011 influenza season update for laboratories audio-conference mls laboratories...
TRANSCRIPT
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MDH2010 – 2011 Influenza Season
Update for Laboratories
Audio-conference MLS LaboratoriesOctober 11, 2010
Aaron DeVriesPaula VagnoneDavid Boxrud
MN Department of Health
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Objectives
• Prepare the laboratory community for response to the current influenza season
• Update on influenza vaccine.• Describe the variety of surveillance
systems in place at MDH for monitoring influenza in Minnesota
• Apprise laboratorians on the current specimen acceptance criteria for influenza testing
• Describe the current influenza testing algorithm being used by the MDH – Public Health Laboratory
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Hospitalized Cases of Influenza by Influenza Type, Minnesota, October 1, 2008 – March 27, 2010
2008-2009 influenza season
2009-2010 influenza season2nd H1N1 wave
Summer surveillance1st H1N1 wave
1st H1N1hospitalized
case
0
25
50
75
100
125
150
175
200
225
250
275
300
325
350
375
400
425
450
OCT08
NOV08
DEC08
JAN09
FEB09
MAR09
APR09
MAY09
JUN09
JUL09
AUG09
SEP09
OCT09
NOV09
DEC09
JAN10
FEB10
MAR10
Month/Year of Specimen Collection
Nu
mb
er
of
Ho
sp
ita
liza
tio
ns
A/B (rapid test only)
B (rapid test only)
A (rapid test only)
Seasonal B
Untypeable A
Novel H1N1
Seasonal A
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Death
Critical Illness
Hospitalization
Moderate Outpatient Illness
Mild Outpatient Illness
Minimal or No Symptoms
1. Deaths with infectious hallmarks
2. Hospitalized patients with ILI
3. Virology Lab Reporting
Influenza Disease Burden
MDH Influenza Surveillance (Case Based)
6. School Absenteeism
5. Longterm Care Facility ILI
4. Sentinel site ILI
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1. Deaths with infectious hallmarks
2. Hospitalized patients with ILI
3. Virology Lab Reporting
6. School Absenteeism
5. Longterm Care Facility ILI
4. Sentinel site ILI
Influenza Disease Burden
MDH Influenza Surveillance (Non-case Based)Death
Critical Illness
Hospitalization
Moderate Outpatient Illness
Mild Outpatient Illness
Minimal or No Symptoms
No good surveillance for the bulk of influenza disease
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Hospital Based Influenza Surveillance: 2010-2011
• Specimen submission:– All hospitalized patients with ILI regardless of prior testing
results (includes those with a neg flu rapid test)– Similar to 2009-2010
• Reporting cases:– DIFFERENT THAN SPECIMEN SUBMISSION1. All hospitalized MN residents with laboratory positive
influenza (including rapid testing)2. Any suspected influenza death or critical illness3. Any unusual case incidence or cluster (including LTC)
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Early Season 2010-11 Laboratory Surveillance
• Establishing early cases is important• Laboratories performing rapid testing
methods – Submit up to two patient specimens that
are positive for influenza (both A and B) each week
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PHL and Influenza PCR testing
• In 2009, PHL performed clinical testing for the purposes of patient care
– PCR for 2009 H1N1 was not readily available
• In 2010-2011, PHL influenza PCR will be for surveillance purposes
– Cumulative reports– Critical for understanding disease activity and
trends over time
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Rapid Influenza Testing
• Can be a helpful tool in some circumstances
– Sensitivity is moderate (50-70%)– Specificity is high (90-95%)
• If negative, cannot be reassured that influenza is absent
– Particularly when disease prevalence is high
If positive and hospitalized, should prompt a disease report
http://www.cdc.gov/flu/professionals/diagnosis/rapidlab.htm
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CDC Infection Control Guidance for Influenza:Adhere to droplet precautions
• Droplet precautions for 7 days after symptom onset or 24 hours after resolution of fever and resp symptoms
• Airborne precautions (fit tested N95 or equivalent) during aerosol generating procedures– Bronchoscopy, sputum induction, intubation
and extubation, autopsies, cardiopulmonary resuscitation, and open suctioning of airways
http://www.cdc.gov/flu/professionals/infectioncontrol/healthcaresettings.htm
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2010 – 2011 Influenza Vaccine
• Reduces laboratory-confirmed influenza infections• Reduces influenza-associated mortality• Cost effective• Reduces HCW absenteeism• HCW vaccination leads to decreased mortality
among LTC residents
Talbot T, Babcock H, Caplan A, et al. Revised SHEA Position Paper: Influenza Vaccination of Healthcare Personnel. Infect Control Hosp Epidemiol 2010; 31(10):987-995
Bridges CB, Thompson WW, Meltzer MI, et al. Effectiveness and cost-benefit of influenza vaccination of healthy working adults: a randomized controlled trial. JAMA 2000;284(13):1655–1663.
Nichol KL, Lind A, Margolis KL, et al. The effectiveness of vaccination against influenza in healthy, working adults. N Engl J Med 1995;333(14): 889–893.
Hayward AC, Harling R, Wetten S, et al. Effectiveness of an influenza vaccine programme for care home staff to prevent death, morbidity, and health service use among residents: cluster randomised controlled trial. BMJ 2006;333(7581):1241.
Lemaitre M, Meret T, Rothan-Tondeur M, et al. Effect of influenza vaccination of nursing home staff on mortality of residents: a cluster-randomized trial. J Am Geriatr Soc 2009;57(9):1580–1586.
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• UK• Those who received influenza vaccination had a
lower rate of acute myocardial infarction – Sept – Mid November - Adjusted OR 0.79 (95% CI 0.75–
0.83) – After mid-November - Adjusted OR 0.88 (95% CI 0.79–
0.97)• No reduction in MI with pneumococcal vaccination
– Adjusted OR 0.96, 95% CI 0.91–1.02)
CMAJ 2010. DOI:10.1503/cmaj.091891
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Preventing Influenza Transmission:Vaccine
• No separate H1N1 vaccine• ACIP recommendation 2010-11
Everyone >6 months age
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Preventing Influenza Transmission:Vaccine
“Therefore, for the safety of both patients and HCP, SHEA endorses a policy in which annual influenza vaccination is a condition of both initial and continued HCP employment and/or professional privileges.”
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Current Influenza Activity
June 13-Sept 25• 25,833 respiratory specimens, 326 (1.3%)
tested + for influenza• Pos specimens were from predominantly SE
US– 80% Flu A, (30% H1, 70% H3)
• 97% of H1 were 2009 H1N1 • 96% of H3 were H3N2/A/Perth/16/2009
– 20% Flu B• 88% of B were B/Brisbane/60/2008
MMWR October 8, 2010 / 59(39);1270-1273
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Current Influenza Activity
June 13-Sept 25• 25,833 respiratory specimens, 326 (1.3%)
tested + for influenza• Pos specimens were from predominantly SE
US– 80% Flu A, (30% H1, 70% H3)
• 97% of H1 were 2009 H1N1 • 96% of H3 were H3N2/A/Perth/16/2009
– 20% Flu B• 88% of B were B/Brisbane/60/2008
MMWR October 8, 2010 / 59(39);1270-1273
All part of 2010-11 Northern Hemisphere Vaccine
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Current Influenza Activity
June 13-Sept 25• 25,833 respiratory specimens, 326 (1.3%)
tested + for influenza• Pos specimens were from predominantly SE
US– 80% Flu A, (30% H1, 70% H3)
• 97% of H1 were 2009 H1N1 • 96% of H3 were H3N2/A/Perth/16/2009
– 20% Flu B• 88% of B were B/Brisbane/60/2008
MMWR October 8, 2010 / 59(39);1270-1273
NOT a part of the 2009-2010 vaccine
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Current Influenza Activity (cont.)
• IA clusters - early July,– 4 of 13 members of a college sports team; Flu A
(H3)– 9 of 12 children and one parent with ILI in a child
care setting; Flu A (H3)– Neither were associated with recent travel nor
had epidemiologic links• MN
– One nursing home outbreak – Flu A, H3 - Subtype pending
MMWR October 8, 2010 / 59(39);1270-1273
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Dave Boxrud - Objectives
• Apprise laboratorians on the current specimen acceptance criteria for influenza testing
• Describe the current influenza testing algorithm being used by the MDH – Public Health Laboratory
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Submission of Specimens
Forms are found on the MDH – PHL website at:
http://www.health.state.mn.us/divs/phl/clin/forms.html
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Influenza Surveillance Programs that include specimen submission
Project TestingSubmission
form
Hospitalized Flu PCRHospitalized
(project 1492)
Cluster investigation/special circumstances/lab
surveillance
Flu PCR, cultureStandard (project 493)
Sentinel Site Flu PCR, cultureSpecial
(project 1494)
Super sentinel RVP PCRSpecial
(project 1399)
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• Hospitalized with ILI (fever >100°F and cough or sore throat)
• Please submit specimen even if positive for influenza in your facility by culture or PCR
• Please submit hospitalized with ILI specimens regardless of rapid results
• MDH performs flu PCR
Hospitalized Surveillance
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Cluster investigation/special circumstances/lab surveillance
• Cluster investigation/unusual circumstances (consult with MDH epi 651-201-5414)
• Laboratory surveillance (2 positive flu/wk early in season)
• Include testing results, methods used (DFA, rapid EIA, PCR, etc.) and name of test kit(s) in the comment section at the bottom of the form
• Send positive influenza viral culture• MDH performs flu PCR and culture
(serotyping on culture pos for vaccine compatibility)
25Insert rapid/PCR results here
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• FDA cleared real-time PCR from CDC• Screen for influenza A, B and RNP• If type A PCR +
– Then type for H1, H3 and 2009 H1
• Influenza RT-PCR takes ~5 hrs• TAT ~1 week (surveillance vs Dx)
MDH-PHL Influenza PCR Testing
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Influenza Surveillance Programs that include specimen submission
Project TestingSubmission
form
Hospitalized Flu PCRHospitalized
(project 1492)
Cluster investigation/special circumstances/lab
surveillance
Flu PCR, cultureStandard (project 493)
Sentinel Site Flu PCR, cultureSpecial
(project 1494)
Super sentinel RVP PCRSpecial
(project 1399)
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Sentinel Provider Network
• 26 participating out-patient clinics in Minnesota
• Part of a CDC national program • Weekly reporting – ILI visits/total
patient visits• 2 specimens/week submitted for
confirmatory testing at MDH PHL
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– Critical Access Hospital– Emergency Medicine– Family Practice– Hospital– Infectious Disease– Internal Medicine– Pediatrics– Student Health– Urgent Care
Influenza Surveillance – Sentinel surveillance sites
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Influenza Sentinel Site Locations
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Sentinel Surveillance Sites
ACMC Wilmar
Adams Clinic - Mayo Health System
Alexandria Clinic
Allina Medical Clinic Shoreview
Altru Clinic
Bois Forte Medical Clinic
Boynton Health Service
Brainerd Medical Center
Edina Family Physicians
Fairview Lakes Pediatric Clinic
Glenwood Medical Center (Glacial Ridge)
Infectious Diseases - Minneapolis LTD
Innovis-Park Rapids
Johnson Memorial Health Services
Kittson Memorial Health Center
Mankato Clinic, LTD
Merit Care Clinic - Mahnomen
Minnesota State University
Open Cities Health Center
Park Nicollet Clinic - Creekside
Rainy Lake Medical Center and Hospital
Regina Medical Group
Saint Mary's University of MN
Sawtooth Mountain Clinic
St. Mary's Innovis Health Clinic - Detroit Lakes
Student Health (Marshall)
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“Super” Sentinel Sites Influenza Incidence Project
• CDC led program • Project runs 8/1/10-7/31/11• 4 providers submit to MDH
– Up to 10 specimens with ILI – Up to 10 specimens with ARI (2 of the
following-rhinorrhea or nasal congestion, sore throat, cough or fever)
• Collect illness data (symptoms)
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“Super” Sentinel Sites Influenza Incidence Project
• Participants – ACMC (Willmar)– Boynton (U of MN, Minneapolis)– Open Cities Health Care (St Paul)– Fairview Lakes Pediatric
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“Super” Sentinel Sites Influenza Incidence Project
• Real-time PCR for:– Influenza A and B (results reported)– RSV– Adenovirus– MPV– Rhinovirus– Coronavirus (229E, OC43, NL63, HKU1)– Parainfluenza virus (PIV) 1-4
• PCR TAT 1-2 weeks• Cumulative weekly results posted to website
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“Super” Sentinel Sites-Preliminary Results
Dates # Tested # Rhino + Other +
8/16-8/22 17 3 0
8/23-8/29 3 2 1 adeno
8/30-9/5 6 2 0
9/6-9/12 19 6 1 para 4
9/13-9/19 33 15 1 para 2
9/20-9/26
44 16
1 adeno
5 coro OC43
1 para 3
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Other Testing at MDH
• Pyrosequencing to detect anti-viral (oseltamivir) resistance in 2009 H1 (H275Y)
• Mutations that may indicate increased virulence (D222G)
• 1 H275Y mutation and 1 D222G mutation (same specimen)
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FDA Cleared PCR Assays for 2009 H1 Influenza
• CDC developed • Prodesse ProFast+• Focus Simplexa
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MDH Guidance for Lab - Developed Influenza Assays
• Labs should validate tests according to their SOPs
• MDH requires submission of clinical samples and result reporting for surveillance activities
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How MDH-PHL Can Help for Lab - Developed H1N1 Tests
• MDH-PHL can help validate tests as resources permit– Sharing of confirmed positive or negative
samples– Confirmatory testing on positive and
negative samples – Provide cultured virus
• MDH cannot make recommendations regarding specific regulatory requirements for individual laboratories
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One more Surveillance Program – Paula Vagnone
• MLS Weekly Influenza/RSV Laboratory Surveillance
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MLS Weekly Influenza & RSVLaboratory Surveillance
What is it?• 115 hospital- and clinic-based labs (8
viral culture labs)• Weekly data submission• Influenza and RSV• Rapid tests, PCR and culture data• Voluntary!
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Southwest Southwest RegionRegion
Wash-ing-ton
Lake
Cook
Le Sueur Rice Goodhue
NoblesRock Jackson Martin Faribault Freeborn Mower Fillmore Houston
WinonaOlmstedDodgeSteeleWaseca
Blue EarthWatonwanCottonwoodMurrayPipestone
Nicollet Wabasha
DakotaScott
Chisago
Isanti
Brown
Sibley
Carver
Hennepin
WrightMeeker
Kandiyohi
Renville
Redwood
Sherburne
LyonLincoln
Yellow Medicine
Lac Qui Parle
Swift
Big Stone
PopeStevensTraverse
Chippewa
StearnsBenton
Carlton
Pine
KanabecMilleLacs
Aitkin
Crow Wing
Morrison
CassHubbard
Wadena
Todd
DouglasGrant
OttertailWilkin
BeckerClay
ClearWater
MahnomenNorman
Red Lake
PenningtonPolk Beltrami
Marshall
Itasca
Koochiching
Lakeof theWoods
RoseauKittson
St. Louis
McLeod
71Anoka
HennepinRam-sey
MLS Influenza/RSV Lab Surveillance
West Central West Central RegionRegion
Northeast Region
Central Region
Metro Region
Southeast RegionSouth Central RegionSouth Central Region
Northwest Region
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Weekly Data Submission• # of tests performed• # of positives• Based on influenza week (Sat – Sun)• No MDH-PHL testing associated with this
surveillance
http://www.health.state.mn.us/divs/idepc/diseases/flu/stats/index.html
MLS Weekly Influenza & RSVLaboratory Surveillance
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Why is this data Important?• Assists healthcare providers with
patient diagnosis of ILI• Provides an indicator as to the
progression of the influenza season
• Indicator of prevalence of disease in
the community
MLS Weekly Influenza & RSVLaboratory Surveillance
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0
250
500
750
1000
1250
1500
35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Week of Specimen Collection
Nu
mb
er
of
Po
sit
ive
Ra
pid
Te
sts
0
10
20
30
40
50
60
70
80
90
100
% o
f P
os
itiv
e R
ap
id T
es
ts
Flu B+
Flu A/B+
Flu A+
2007-2008 % +
2008-2009 % +
2009-2010 % +
Number and Percentage of Positive Influenza Rapid Test Results, MN Laboratory System Rapid Testing Sites, Sept. 2007 – April 2010
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MLS Weekly Influenza & RSVLaboratory Surveillance
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MLS Weekly Influenza & RSVLaboratory Surveillance
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MLS Weekly Influenza & RSVLaboratory Surveillance
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QUESTIONS?
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• Dave Boxrud, MS Molecular Epidemiology/Virology SupervisorPhone: 651-201-5257 Email: [email protected]
• Aaron DeVries, MD, MPHMedical Epidemiologist, Infectious Disease Epi. Prevention & ControlPhone: 651-201-5080Email: [email protected]
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• Paula M. Vagnone, MT (ASCP) MN Laboratory System Program Advisor, Emergency Prep. & Response
Phone: 651-201-5581Email: [email protected]