washington state department of health influenza surveillance update vivian hawkins, ms phd...

Washington State Department of Health Influenza Surveillance Update

Vivian Hawkins, MS PhDWashington State Department of Health

Communicable Disease Epidemiology Office206-418-5500

[email protected]

Influenza Update• Rates, Trends and Comparisons

– US and WA flu activity• Surveillance methodology and issues

– New directions in surveillance• Avian flu update• Discussion

– Suggestions welcome for how to improve influenza surveillance in WA

Rates, Trends and ComparisonsUS and WA Flu Activity

Influenza Laboratory Data, WA (WHO/NREVSS)2015-2016 Season, through Jan 9, 2016

Num

ber o

f Pos

itive

Spe

cim

ens

Percent Positive

A (subtyping not performed)

A (H1N1)

A (H3N2)

B (lineage not performed)

B (Victoria Lineage)

B (Yamagata Lineage)

From http://www.doh.wa.gov/Portals/1/Documents/5100/420-100-FluUpdate.pdf

http://www.doh.wa.gov/Portals/1/Documents/5100/420-100-FluUpdate.pdf

Courtesy of CDCCourtesy CDC

Influenza Laboratory Data (WHO/NREVSS), WA

2014-2015 Season

From http://www.doh.wa.gov/DataandStatisticalReports/DiseasesandChronicConditions/CommunicableDiseaseSurveillanceData/InfluenzaSurveillanceData

http://www.doh.wa.gov/DataandStatisticalReports/DiseasesandChronicConditions/CommunicableDiseaseSurveillanceData/InfluenzaSurveillanceData


2013-2014 Season






2012-2013 Season




ILINet


• Healthcare providers who provide a count of total number of patients seen each week, and the number of patient visits for ILI (fever of 100 or greater with cough and/or sore throat)

2014-2016 Seasons, through Jan 9, 2016


ILINet

• Healthcare providers who provide a count of total number of patients seen each week, and the number of patient visits for ILI (fever of 100 or greater with cough and/or sore throat)

2014-2016 Seasons, through Jan 9, 2016

Early indications that % ILI will be higher for week ending Jan 17



Courtesy CDC

Courtesy CDC

WA will be listed as having regional activity for week 2

Lab-Confirmed Influenza DeathsNumber and rate of reported laboratory-confirmed influenza-associated deaths by

age group, Washington, 2015-2016, through Jan 18, 2016

Number and rate of reported laboratory-confirmed influenza-associated deaths by age group, past season totals and current season to date


Age Group (in years)

Number of Deaths

Death Rate (per 100,000 population)

0–4 0 0.05–24 0 0.025–49 0 0.050–64 3 0.2265+ 5 0.53Total 8 0.12

Season Number of Deaths, All Ages

Death Rate (per 100,000 population), All Ages

2015-2016, season to date 8 0.12

2014-2015, total 157 2.28

2012-2013, total 54 0.80

2011-2012, total 18 0.27

2010-2011, total 36 0.53


Antigenic Testing

• So far this season, the circulating flu viruses CDC has tested have antigenically matched the 2015-2016 vaccine strains (source: CDC Flu View)

• So far only 11 H3N2 viruses collected in WA this season have been antigenically characterized, but all were the vaccine strain

Surveillance Methodology and IssuesNew Directions in Surveillance

What is Reportable in WA

• Lab-confirmed influenza deaths• ILI outbreaks in long-term care facilities

Additional Data StreamsThis means we need a lot of other ways to look at flu activity: • Sentinel labs• ILINet providers• Syndromic surveillance• Additional lab data:

• PHRAID (DOH system)• WHO/NREVSS (CDC)

Sentinel Labs• Network of labs across WA that send a subset of influenza

positive specimens to PHL for further characterization – Subtyping

• Subset of viruses are then sent to CDC:– Antigenic testing – Antiviral resistance testing

• Viruses are used in vaccine selection– WHO vaccine composition meeting to be held in February– Quiet flu activity so far has meant that CDC does not have as many

viruses on hand as would be ideal to inform the 2016-2017 vaccine– CDC has asked PHLs nationwide to send additional flu viruses

Influenza Sentinel Collaborating Labs

Courtesy Dr. Ailyn Perez-Osorio, WA DOH PHL

Influenza RT-PCR Subtyping Results

Sentinel Laboratory SiteTotal

Number of specimens

tested

Subtyping - Genotyping results (Cumulative)

InfA (H3N2) InfA (2009 pdmH1N1)

InfB - Victoria Lineage

InfB - Yamagata Lineage

Indeterminate Negative at WA PHL*

Peace Health Laboratories 35 30 4 1The Everett Clinic 50 37 8 5Evergreen 65 35 2 4 20 4Providence St Peters 27 24 2 1Tacoma General 100 68 1 3 11 17Olympic Medical Center 43 37 6 Tri-Cities 4 2 2 PAML 44 42 1 1 Pullman Regional Hosp Lab 12 12 Sacred Heart MC 46 31 1 13 1Cumulative 430 318 4 8 67 4 29

Influenza A (2009 pdmH1N1) Antiviral Pyrosequencing ResultsNone performed, 4 sent to CDC.

Influenza A (H3) Antiviral Pyrosequencing ResultsThis season the WAPHL is testing a very small proportion of all A (H3) influenza strains received.As of 6/9/15 58 out of 58 (100 %) of Influenza A(H3) screened by pyrosequencing have tested as wild type.

WA State Sentinel Laboratory Network: 2014-2015 Season


Also send a subset of viruses to CDC for antigenic testing

Influenza RT-PCR Subtyping Results

Sentinel Laboratory SiteTotal

Number of specimens

tested

Subtyping - Genotyping results (Cumulative)

CommentsInfA (H3N2) InfA (2009 pdmH1N1)

InfB - Victoria Lineage

InfB - Yamagata Lineage

Indeterminate Negative at WA PHL*

Peace Health Laboratories 5 3 1 1 Pending B Genotype

Evergreen 4 4

Tacoma General 15 4 1 6 4 Pending B Genotype

Olympic Medical Center 5 5 PAML 2 1 1 Sacred Heart MC 5 4 1 1Cumulative 36 21 3 7

Influenza A (2009 pdmH1N1) Antiviral Pyrosequencing ResultsNone performed, 3 sent to CDC.

Influenza A (H3) Antiviral Pyrosequencing ResultsNone performed, 21 sent to CDC.

WA State Sentinel Laboratory Network: 2015-2016 Season

Also send a subset of viruses to CDC for antigenic testing


Sentinel Laboratories• Aware of a lab that may want to participate?

• Please let me know!

Syndromic SurveillanceSyndromic Surveillance, Percentage of Hospital Visits for a Chief Complaint of ILI by CDC Week, Western Washington, 2013-2016



Thinking beyond flu• What else is circulating in the community that

could result in ILI symptoms?

Thinking beyond flu• WHO/NREVSS collects data on several respiratory

(as well as enteric) viruses:– RSV, parainfluenza, adenovirus, rotavirus,

metapneumovirus, rhinovirus, enterovirus, and influenza

• Working to move more WA labs into WHO/NREVSS• Plan to feature information about non-flu

respiratory viruses in weekly flu report– Useful for situational awareness– Crucial when respond to emerging threats (what are

our baselines?)

WHO/NREVSS labs

Courtesy CDC

WA WHO/NREVSS Labs

• Children's Hospital and Regional Medical Center, Seattle, WA

• Laboratories Northwest at Multicare, Tacoma, WA• Overlake Hospital Medical Center, Bellevue, WA• Pathology Associates Medical Laboratories, Spokane, WA• Seattle King County Public Health Laboratory, Seattle, ‐

WA• Southwest Washington Medical Center, Vancouver, WA• University of Washington, Seattle, WA

Moving from PHRAID to NREVSS

• Would like to move labs reporting influenza results in PHRAID (Public Health Reporting of Aggregate Influenza Data) to NREVSS

• PHRAID– Web portal where labs report:

• Number of flu tests run each week• Number positive for influenza A, influenza B, or flu type

unknown • Can also enter RSV testing data

PHRAID, 2015-2016



PHRAID, 2015-2016


No subtyping data!

Some labs DO have subtype, and can enter that in NREVSS.


Flu Prediction

• When does the flu season start and stop?• How severe will the season be?

Flu Prediction

• When does the flu season start and stop?• How severe will the season be?

Working with UW Institute for Health Metrics and Evaluation assistant professor who is experienced in modeling to try to address these questions.

• More to come!

Avian Influenza Update

Highly Pathogenic Avian Influenza (HPAI)• H5NX (H5N2, H5N8, H5N1 reassortant)

viruses were identified in North American birds in late winter 2014-spring 2015.– No human illnesses identified to date– However, potential does exist for human illness– Similar viruses have caused human illness and

death elsewhere

More info from CDC: http://www.cdc.gov/flu/avianflu/h5/index.htm

http://www.cdc.gov/flu/avianflu/h5/index.htm


Highly Pathogenic Avian Influenza (HPAI)• H5NX (H5N2, H5N8, H5N1 reassortant)

viruses were identified in North American birds in late winter 2014-spring 2015.– No human illnesses identified to date– However, potential does exist for human illness– Similar viruses have caused human illness and

death elsewhere• H7N8 identified in Indiana turkey farm in Jan

2016.

More info from CDC: http://www.cdc.gov/flu/avianflu/h5/index.htm



USDA Avian Flu Tracking

• 219 HPAI detections in US flocks from Dec 2014-June 2015

• Last detection in WA flocks: Feb 2015 (backyard flocks, game bird farm, also some wild birds).

• 48 MILLION birds depopulated nationwide

From USDA APHIS

USDA Avian Flu Tracking

• 219 HPAI detections in US flocks from Dec 2014-June 2015

• Last detection in WA flocks: Feb 2015 (backyard flocks, game bird farm, also some wild birds).

• 48 MILLION birds depopulated nationwide

H7N8 confirmed Jan 16, 2016 in Indiana commercial turkey farm.

From USDA APHIS

Courtesy USDA

Minnesota National Guard

Image courtesy Wikipedia

CDC/USDA Joint Planning

• In response to the HPAI outbreaks of 2015, CDC/USDA have worked together on a monitoring plan for exposed people– During the 2015 outbreaks, there was not a

uniform plan by which state/local health departments were made aware of USDA staff and federal contractors involved in depopulations


• HPAI-exposed people monitored during exposure and for 10 days after exposure

• Antiviral prophylaxis can be considered• Low threshold for testing at PHL• Prompt treatment with antivirals• Infection control guidelines




WA DOH has prepared detailed materials for LHJs to use




WA DOH has prepared detailed materials for LHJs to use

WA DOH working closely with local, state and federal agencies on avian flu planning

Courtesy Seattle Times

Acknowledgements

• All Influenza Surveillance Network partners– LHJs– Healthcare providers– Laboratories– Patients– Other state agencies (Fish and Wildlife, WSDA,

Ecology)– DOH PHL, EPH, OICP– National partners: CDC, USDA

Discussion

• Ideas for how to improve flu surveillance in WA? • Please contact me at 206-418-5500 or

[email protected]

mailto:[email protected]