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1 MDH 2010 – 2011 Influenza Season Update for Laboratories Audio-conference MLS Laboratories October 11, 2010 Aaron DeVries Paula Vagnone David Boxrud.

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Presentation on theme: "1 MDH 2010 – 2011 Influenza Season Update for Laboratories Audio-conference MLS Laboratories October 11, 2010 Aaron DeVries Paula Vagnone David Boxrud."— Presentation transcript:

1 1 MDH 2010 – 2011 Influenza Season Update for Laboratories Audio-conference MLS Laboratories October 11, 2010 Aaron DeVries Paula Vagnone David Boxrud MN Department of Health

2 2 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

3 3 Hospitalized Cases of Influenza by Influenza Type, Minnesota, October 1, 2008 – March 27, 2010 2008-2009 influenza season 2009-2010 influenza season 2 nd H1N1 wave Summer surveillance 1 st H1N1 wave 1 st H1N1 hospitalized 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 Number of Hospitalizations A/B (rapid test only) B (rapid test only) A (rapid test only) Seasonal B Untypeable A Novel H1N1 Seasonal A

4 4 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

5 5 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

6 6 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 SUBMISSION 1.All hospitalized MN residents with laboratory positive influenza (including rapid testing) 2.Any suspected influenza death or critical illness 3.Any unusual case incidence or cluster (including LTC)

7 7 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

8 8 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

9 9 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

10 10 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

11 11 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.

12 12 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

13 13 Preventing Influenza Transmission: Vaccine No separate H1N1 vaccine ACIP recommendation 2010-11 Everyone >6 months age

14 14 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.

15 15 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

16 16 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

17 17 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

18 18 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

19 19 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

20 20 Submission of Specimens Forms are found on the MDH – PHL website at: http://www.health.state.mn.us/divs/phl/cli n/forms.html

21 21 Influenza Surveillance Programs that include specimen submission ProjectTesting Submission form HospitalizedFlu PCR Hospitalized (project 1492) Cluster investigation/special circumstances/lab surveillance Flu PCR, culture Standard (project 493) Sentinel SiteFlu PCR, culture Special (project 1494) Super sentinelRVP PCR Special (project 1399)

22 22 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

23 23

24 24 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)

25 25 Insert rapid/PCR results here

26 26 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

27 27 Influenza Surveillance Programs that include specimen submission ProjectTesting Submission form HospitalizedFlu PCR Hospitalized (project 1492) Cluster investigation/special circumstances/lab surveillance Flu PCR, culture Standard (project 493) Sentinel SiteFlu PCR, culture Special (project 1494) Super sentinelRVP PCR Special (project 1399)

28 28 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

29 29 –Critical Access Hospital –Emergency Medicine –Family Practice –Hospital –Infectious Disease –Internal Medicine –Pediatrics –Student Health –Urgent Care Influenza Surveillance – Sentinel surveillance sites

30 30 Influenza Sentinel Site Locations

31 31 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)

32 32 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)

33 33 Super Sentinel Sites Influenza Incidence Project Participants –ACMC (Willmar) –Boynton (U of MN, Minneapolis) –Open Cities Health Care (St Paul) –Fairview Lakes Pediatric

34 34 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

35 35 Super Sentinel Sites- Preliminary Results Dates# Tested# Rhino +Other + 8/16-8/22 1730 8/23-8/29 321 adeno 8/30-9/5 620 9/6-9/12 1961 para 4 9/13-9/19 33151 para 2 9/20-9/26 4416 1 adeno 5 coro OC43 1 para 3

36 36 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)

37 37 FDA Cleared PCR Assays for 2009 H1 Influenza CDC developed Prodesse ProFast+ Focus Simplexa

38 38 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

39 39 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

40 40 One more Surveillance Program – Paula Vagnone MLS Weekly Influenza/RSV Laboratory Surveillance

41 41 MLS Weekly Influenza & RSV Laboratory 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!

42 42 Southwest Region Wash- ing- ton Lake Cook Le Sueur Rice Goodhue NoblesRockJackson MartinFaribault Freeborn Mower FillmoreHouston Winona Olmsted Dodge Steele Waseca Blue Earth Watonwan Cottonwood Murray Pipestone Nicollet Wabasha Dakota Scott Chisago Isanti Brown Sibley Carver Hennepin WrightMeeker Kandiyohi Renville Redwood Sherburne LyonLincoln Yellow Medicine Lac Qui Parle Swift Big Stone PopeStevens Traverse Chippewa Stearns Benton Carlton Pine Kanabec Mille Lacs Aitkin Crow Wing Morrison Cass Hubbard Wadena Todd Douglas Grant Ottertail Wilkin Becker Clay Clear Water Mahnomen Norman Red Lake Pennington Polk Beltrami Marshall Itasca Koochiching Lake of the Woods RoseauKittson St. Louis McLeod 71 Anoka Hennepin Ram- sey MLS Influenza/RSV Lab Surveillance West Central Region Northeast Region Central Region Metro Region Southeast Region South Central Region Northwest Region

43 43 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 & RSV Laboratory Surveillance

44 44 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 & RSV Laboratory Surveillance

45 45 Number and Percentage of Positive Influenza Rapid Test Results, MN Laboratory System Rapid Testing Sites, Sept. 2007 – April 2010

46 46 MLS Weekly Influenza & RSV Laboratory Surveillance

47 47 MLS Weekly Influenza & RSV Laboratory Surveillance

48 48 MLS Weekly Influenza & RSV Laboratory Surveillance

49 49 QUESTIONS?

50 50 Dave Boxrud, MS Molecular Epidemiology/Virology Supervisor Phone: 651-201-5257 Email: dave.boxrud@state.mn.usdave.boxrud@state.mn.us Aaron DeVries, MD, MPH Medical Epidemiologist, Infectious Disease Epi. Prevention & Control Phone: 651-201-5080 Email: aaron.devries@state.mn.usaaron.devries@state.mn.us

51 51 Paula M. Vagnone, MT (ASCP) MN Laboratory System Program Advisor, Emergency Prep. & Response Phone: 651-201-5581 Email: paula.snippes@state.mn.uspaula.snippes@state.mn.us


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