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2009 H1N1 Influenza in Minnesota Epidemiology
Infectious Disease Epidemiology, Prevention and Control Division PO Box 64975 St. Paul, MN 55164-0975
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Week of Specimen Collection
Num
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f Hos
pita
lizat
ions
A/B (rapid test only)
B (rapid test only)
A (rapid test only)
Seasonal B
Untypeable A (likely 2009H1N1)2009 H1N1
Seasonal A
2008-2009 Influenza SeasonOctober 1, 2008 –
April 30, 2009
2009-2010 Influenza SeasonSeptember 1, 2009 –
April, 2010
Spring Influenza SurveillanceMay 1, 2009 –
August 31, 2009
1st
H1N1hospitalized case
Number of Hospitalized Cases of Influenza
by Influenza Type, Minnesota, October 2008 –
April 2010
Number of Hospitalized PCR-confirmed 2009 H1N1 Influenza Cases, Minnesota, April 2009 –
April 2010
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15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 1 3 5 7 9 11 13 15 17
Week of Specimen Collection
Num
ber o
f Hos
pita
lizat
ions
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb
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Week of Specimen Collection
Hos
pita
lizat
ions
per
100
,000
Per
sons
Cumulative Incidence of Hospitalized PCR-confirmed 2009 H1N1 Influenza Cases, Minnesota, April 2009 -
April 2010
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35 37 39 41 43 45 47 49 51 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35
Week of Clinic Visit
% o
f Out
patie
nt V
isits
for
ILI
07-08 Season 08-09 Season 09-10 Season
Percentage of Outpatient Visits for ILI*, Sentinel Surveillance Sites by Season, Minnesota,
September 2007 –
April 2010
*Influenza-like Illness
Spring Wave
2009
Fall Wave
2009
Normal Flu Surveillance October 1 –
April 30
Number and Percentage of Schools Reporting Outbreaks of ILI*, Minnesota, September 2009 –
April 2010
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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 Outbreak
Num
ber o
f Sch
ools
0%
5%
10%
15%
20%
25%
Number of Schools Reporting ILI
Percent of Eligible Schools Reporting ILI
*Influenza-like Illness
Number and Percentage of Culture-Confirmed Influenza Specimens, Minnesota Virology
Laboratories, September 2007 –
April 2010
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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
Num
ber o
f Pos
itive
Cul
ture
Tes
ts
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% o
f Pos
itive
Cul
ture
Tes
ts
Flu A/B+Flu B+Flu A+2007-2008 % +2008-2009 % +2009-2010 % +
Number and Percentage of Positive Influenza Rapid Test Results, Minnesota Rapid Testing Sites,
September 2007 –
April 2010
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
Num
ber o
f Pos
itive
Rap
id T
ests
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% o
f Pos
itive
Rap
id T
ests
Flu B+Flu A/B+Flu A+2007-2008 % +2008-2009 % +2009-2010 % +
Circulating Respiratory Viruses, Laboratory Influenza Surveillance Program, Minnesota, October 2009 –
April 2010
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40 42 44 46 48 50 52 2 4 6 8 10 12 14 16 18Week of Submission
Num
ber o
f Pos
itive
s
Adenovirus Enterovirus
Influenza A Influenza B
Human Metapneumovirus Parainfluenza – 1
Parainfluenza – 2 Parainfluenza – 3
Parainfluenza – 4 Rhinovirus
RSV
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0-4 5-18 19-24 25-49 50-64 65+
Age Group (yrs.)
Num
ber o
f Hos
pita
lizat
ions
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40
60
80
100
120
Hos
pita
lizat
ions
per
100
,000
Per
sons
Number of Hospitalizations
Hospitalizations per 100,000 Persons
Number and Incidence of Hospitalized PCR- confirmed 2009 H1N1 Influenza by Age Group,
Minnesota, April 2009 –
April 2010
Number and Incidence of Hospitalized PCR-confirmed 2009 H1N1 Influenza Cases by Race/Ethnicity,
Minnesota, April 2009 –
April 2010
Number of Cases Incidence per 100,000
White Black AsianHispanicNative American
43.2
73.9
68.0
26.2
104.2
1,179
45
83
140
259
White
Black
Hispanic
Unknown
Asian
Native American
Multi Race
White
Black
Hispanic
Asian
UnknownMulti RaceNative
American
Spring Wave Fall Wave
Proportion of Hospitalized PCR-confirmed 2009 H1N1 Influenza Cases by Race/Ethnicity,
Minnesota, April 2009 –
April 2010
Median Age of Hospitalized PCR-confirmed 2009 H1N1 Influenza Cases by Race/Ethnicity,
Minnesota, April 2009 –
April 2010
Race/Ethnicity Spring Wave Fall Wave
White 16.9 yrs. 30.0 yrs.
Black 12.3 yrs. 20.3 yrs.
Hispanic 5.3 yrs. 8.4 yrs.
Asian 5.4 yrs. 11.7 yrs.
Native American 48.2 yrs. 36.3 yrs.
All Races 11.1 yrs. 26.8 yrs.
Incidence of Hospitalized PCR-confirmed 2009 H1N1 Influenza by Week, Minnesota, April 2009 –
April 2010
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18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 2 4 6 8 10 12 14 16
Week of Specimen Collection
Hos
pita
lizat
ions
per
100
,000
Per
sons
7-County Minneapolis-St. Paul MetroGreater Minnesota
Smoothed lines
“Spring Wave”
“Fall Wave”
Marti
nFaribaul
t
Olmste
dDodg
eSteel
e
Hennepi
n
t
Tod
d
Dougla
sGran
t
71
Northwest18
West Central
57
Southeast156South
Central92
Central 280
Southwest 67
Northeast 129
Metro 1025
Number of Hospitalized PCR-confirmed 2009 H1N1 Cases by District of Residence, April 2009 –
April 2010
Incidence of Hospitalized PCR-confirmed 2009 H1N1 Influenza by District of Residence,
Minnesota, April 2009 –
April 2010
11.7
40.2
24.9
39.136.5
32.1 30.6 32.1
0
10
20
30
40
50
Northwest
Northeas
tWest C
entral
Centra
l
Metro
South Centra
lSouthwest
SoutheastHos
pita
lizat
ions
per
100
,000
Per
sons
Incidence of Hospitalized PCR-confirmed 2009 H1N1 Influenza by District of Residence and Wave,
Minnesota, April 2009 –
April 2010
0
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20
30
40
50
Northwes
t
Northeas
tWest
Centra
l
Central
Metro
South C
entra
l
Southwest
Southeas
tH
ospi
taliz
atio
ns p
er 1
00,0
00 P
erso
ns
SpringFall
Hospitalized PCR-confirmed 2009 H1N1 Influenza Cases by Age Group and Presence of Underlying Medical
Conditions, Minnesota, April 2009 –
April 2010
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Pediatric
Adult
Percent of Cases
Without Underlying Medical Condition
With Underlying Medical Condition(s)
Underlying Medical Conditions of Hospitalized PCR- confirmed 2009 H1N1 Influenza Adult (≥
18 yrs.) Cases,
Minnesota, April 2009 –
April 2010
Underlying Medical Condition Total PercentAsthma 328 32%
Chronic Metabolic Disease 288 28%
Chronic Lung Disease 201 20%
Chronic Cardiovascular Disease 225 22%
Immunosuppressive Condition 108 11%
Cognitive Dysfunction 54 5%
Neuromuscular Disorder 62 6%
Cystic Fibrosis 7 1%
Chronic Renal Disease 92 9%
Cancer 30 3%
Underlying Medical Conditions of Hospitalized PCR- confirmed 2009 H1N1 Influenza Pediatric (<18 yrs.) Cases,
Minnesota, April 2009 –
April 2010
Underlying Medical Conditions Total PercentAsthma 228 28%
Chronic Metabolic Disease 26 3%
Chronic Lung Disease 30 4%
Chronic Cardiovascular Disease 24 3%
Immunosuppressive Condition 32 4%
Developmental Delay 65 8%
Neuromuscular Disorder 37 5%
Cystic Fibrosis 2 <1%
Seizure Disorder 39 5%
Proportion of Hospitalized PCR-confirmed 2009 H1N1 Influenza Cases Admitted to ICU by Age Group and Presence of Underlying Medical
Conditions, Minnesota, April 2009 –
April 2010
0%
10%
20%
30%
40%
50%
Pediatric Adult
% o
f Cas
es A
dmitt
ed to
ICU
Without Underlying Medical Condition
With Underlying Medical Condition(s)
19% All Cases
0%
10%
20%
30%
40%
50%
Pediatric Adult
% o
f Cas
es R
equi
ring
Mec
hani
cal V
entil
atio
n Without Underlying Medical Condition
With Underlying Medical Condition(s)
Proportion of Hospitalized PCR-confirmed 2009 H1N1 Influenza Cases Requiring Mechanical Ventilation by Age Group and Presence of Underlying Medical Conditions,
Minnesota, April 2009 –
April 2010
10% All Cases
0%
10%
20%
30%
40%
50%
Pediatric Adult
% o
f Cas
es w
ith P
neum
onia
Without Underlying Medical Condition With Underlying Medical Condition(s)
Proportion of Hospitalized PCR-confirmed 2009 H1N1 Influenza Cases Diagnosed with Pneumonia by Age Group and Presence of
Underlying Medical Conditions,
Minnesota, April 2009 –
April 2010
37% All Cases
0%
2%
4%
6%
8%
10%
Pediatric Adult
% o
f Cas
es w
ith B
acte
rial C
o-In
fect
ion
Without Underlying Medical Condition
With Underlying Medical Condition(s)
Proportion of Hospitalized PCR-confirmed 2009 H1N1 Influenza Cases with Bacterial Co-Infection* by Age Group and Presence of Underlying
Medical Conditions, Minnesota, April 2009 –
April 2010
1.6% All Cases
*Cultural confirmation of a bacterial pathogen from sterile site
within 3 days of admission.
Number and Percentage of Female Hospitalized PCR- confirmed 2009 H1N1 Influenza Cases Ages 13-49 Who
Were Pregnant, Minnesota, April 2009 –
April 2010
Spring Wave Fall Wave TotalFemales 13-49 Yrs. n=54 n=329 n=383
Pregnant Cases 20 (37%) 46 (14%) 66 (17%)
Hospitalized PCR-confirmed 2009 H1N1 Influenza Cases in Minnesota: Summary
From April 1, 2009 to April 30, 2010: 1,824 hospitalized PCR-
confirmed 2009 H1N1 Influenza cases; 1,564 since September 1, 2009
– In Spring wave:• Median age, 11.8 years• 17% in ICU• 81% Cases from Metro Area
– In Fall wave:• Median age, 26.5 years• 20% in ICU• 52% Cases from Metro Area
– Pregnancy among hospitalized women 13 -
49 years of age:• 17% (of 384)
Number of Deaths Related to Influenza A, Minnesota, April 2009 –
April 2010
67 Deaths Related to Influenza A
• 63 2009 H1N1 Influenza
• 4 Influenza A, Not Subtyped
• 55 Hospitalized
• 12 Non-hospitalized
Deaths Related to Influenza A by Wave and Age Group, Minnesota, April 2009 –
April 2010
Age Group (yrs.) Spring Fall Total
<18 2 6 8
18-64 1 45 46
65+ 1 12 13
Total Deaths 4 63 67
Deaths Related to Influenza A by Race/Ethnicity, Minnesota, April 2009 –
April 2010
(63=2009 H1N1; 4=unspecified Influenza A)
Native American
Black
Hispanic
Asian
White
Influenza A Deaths in Minnesota by Week of Collection, (N=67)Minnesota, April 2009 –
April 2010
South Central
Northwest
Northeast
Metro
Week of Collection
Num
ber o
f Dea
ths
24 2523 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47
Jun Jul Aug Sep Oct DecNov
1
2
3
4
5
6
48 49 50
7
8
9
10
11
12
West Central
Central
Southwest
Southeast
51 52 1 9
MarJan
13
2
Influenza A Crude Death Rates by District of Residence, Minnesota, April 2009 –
April 2010
(63=2009 H1N1; 4=unspecified Influenza A)
District Deaths n=67Crude Death Rate per
100,000 Persons
Northwest 2 1.34
Northeast 11 3.43
West Central 2 0.77
Central 7 0.99
Metro* 30 1.07
South Central 5 1.93
Southwest 2 0.91
Southeast 8 1.65
*All 4 deaths in spring wave occurred in Metro district residents
Deaths Related to Influenza A by Age Group and Presence of Underlying Medical Condition(s), Minnesota, April 2009 –
April 2010
(63=2009 H1N1; 4=unspecified Influenza A)
Age Group (yrs.) Total Deaths % With Underlying Medical Condition(s)
<18 8 75.0%
18-64 46 84.8%
≥65 13 92.3%
All Ages 67 87.7%
Underlying Medical Conditions among Deaths Related to Influenza A, Minnesota, April 2009 –
April 2010
(63=2009 H1N1; 4=unspecified Influenza A)
Underlying Medical Condition Total Percent
Obesity 30 46.9%
Chronic Cardiovascular Disease 27 42.2%
Chronic Metabolic Disease 21 32.8%
Immunosuppressive Condition 15 23.4%
Chronic Lung Disease 11 17.2%
Renal Disease 9 14.1%
Neuromuscular Disorder 7 10.9%
History of Lymphoma/Leukemia 6 9.4%
Cognitive Dysfunction 6 9.4%
Asthma 6 9.4%
Cancer Diagnosis in last 12 months 4 6.3%
Seizure Disorder 4 6.3%
Pregnant 0 0.0%
BMI of Adult Deaths Related to Influenza A, Minnesota, April 2009 –
April 2010
(55=2009 H1N1; 4=unspecified Influenza A)
17%
24%
5%
20%
12%
22%
Underweight:<18.5Normal:18.5–24.9Overweight:25.0–29.9Obese:30.0–39.9Morbidly Obese:≥40Unknown
Clinical Outcomes of Deaths Related to Influenza
A by Age Group, Minnesota, April 2009 –
April 2010
(63=2009 H1N1; 4=unspecified Influenza A)
Clinical OutcomePediatric <18 yrs.
n=8Adult 18+ yrs.
n=59
Hospitalized 5 (62.5%) 50 (84.7%)
ICU 5 (62.5%) 46 (78.0%)
Mechanical Ventilation 6 (75%) 40 (67.8%)
ARDS 1 (12.5%) 16 (27.1%)
Pneumonia 5 (62.5%) 48 (81.4%)Viral 0 10 (16.9%)
Bacterial 1 (12.5%) 3 (5.5%)Both 0 3 (5.5%)
Bacterial Co-Infections in Deaths Related to Influenza A, Minnesota,
April 2009 –
April 2010 (63=2009 H1N1; 4=unspecified Influenza A)
Sterile Non-sterile* Combined
Total (%) Total (%) Total (%)Persons with Bacterial Co-infection(s) 10 (15%) 10 (15%) 20 (30%)
Staphylococcus aureus 5 (7%) 4 (6%) 9 (13%)
MRSA 3 (4%) 2 (3%) 5 (7%)MSSA 0 1 (1%) 1 (1%)Unknown 2 (3%) 1 (1%) 3 (4%)
Streptococcus pneumoniae 3 (4%) 0 3 (4%)
Group B Streptococcus 2 (3%) 4 (6%) 6 (9%)
Pseudomonas aeruginosa 1 (1%) 1 (1%) 2 (3%)Bacterial Other** 2 (3%) 7 (10%) 9 (13%)
*Non-sterile sites include sputum, endotracheal aspirate, lung tissue, and stool **Stenotrophomonas maltophilia, Enterobacter cloacae, Staphylococcus saprophyticus, Staphylococcus coagulase negative, Enterococcal sepsis, Moraxella catarrhalis, Group A Streptococcus, Escherichia coli, VRE
Summary of Deaths Related to Influenza A, Minnesota, April 2009 –
April 2010
In Spring wave• 4 deaths (all PCR-confirmed 2009 H1N1) • 2 in children; 1 in an adult age 65 or older • 1 with no underlying conditions• 100% 7-county MSP area
In Fall wave• 63 deaths (59 2009 H1N1, 4 Influenza A-type
unspecified)• 6 in children; 12 >
65 y• 7 no underlying conditions• 41% (26/63) 7-county MSP area
For More Information Please Contact:
Minnesota Department of Health Acute Disease Investigation and Control
651-201-54141-877-676-5414
www.health.state.mn.us
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