1. Influenza Surveillance Danae Bixler, MD, MPH Infectious Disease Epidemiology Program

2. 2 Objectives Understand surveillance for… Understand surveillance for… Seasonal influenza Seasonal influenza ILI ILI Laboratory reporting Laboratory reporting Sentinel provider system Sentinel provider system Pediatric death reporting Pediatric death reporting Hospital data Hospital data Avian highly pathogenic H5N1 Avian highly pathogenic H5N1 Pandemic influenza Pandemic influenza

3. 3 Infectious Disease Epidemiology Program Seasonal Influenza US: US: 36,000 deaths 36,000 deaths 226,000 hospitalizations 226,000 hospitalizations Symptoms (2-7 days) Symptoms (2-7 days) fever, chills, sweats headache, arthralgia, myalgia coryza, sore throat, and cough

4. 4 Infectious Disease Epidemiology Program Seasonal Influenza Influenza-like illness Influenza-like illness Reportable from providers weekly Reportable from providers weekly Fever > 100 + cough or sore throat Fever > 100 + cough or sore throat Over - represents influenza Over - represents influenza Under - reported Under - reported Laboratory confirmed Laboratory confirmed Reportable from laboratories weekly (aggregate) Reportable from laboratories weekly (aggregate) Highly sensitive and specific Highly sensitive and specific Under – represents influenza Under – represents influenza

5. 5 Infectious Disease Epidemiology Program

6. 6 Other Sources of Data Sentinel Providers Sentinel Providers Report ILI weekly to CDC Report ILI weekly to CDC High maintenance High maintenance 50% of providers report 50% of the time 50% of providers report 50% of the time Submit specimens Submit specimens Vital records, hospital data Vital records, hospital data Non-specific coding Non-specific coding Delayed Delayed

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10. 10 Infectious Disease Epidemiology Program Also Reportable … Pediatric Death from Influenza (Age<18) within 1 week to local health department Source: N Engl J Med 2005; 353:2559-67.

11. 11 Infectious Disease Epidemiology Program 2007-2008 Hospital Study

12. 12 Infectious Disease Epidemiology Program

13. WVDHHR/BPH/DSDC/IDEP13

14. 14 Infectious Disease Epidemiology Program Avian Influenza 387 cases and 245 deaths as of 9/10/2008 387 cases and 245 deaths as of 9/10/2008 CFR = 63% CFR = 63% Signs and Symptoms: Signs and Symptoms: High fever High fever Dyspnea, respiratory distress Dyspnea, respiratory distress (+/-) GI symptoms (+/-) GI symptoms Pneumonia / ARDS Pneumonia / ARDS Multi-organ failure Multi-organ failure

15. 15 Infectious Disease Epidemiology Program Avian Influenza Screening Criteria* *Under revision (CDC) Severe respiratory illness AND Severe respiratory illness AND Epidemiological evidence Epidemiological evidence Travel to a country with human or animal cases AND Travel to a country with human or animal cases AND Exposure: Exposure: Direct contact with Direct contact with Sick or dead poultry Sick or dead poultry Poultry feces Poultry feces Sick or dead birds Sick or dead birds A person hospitalized or deceased from severe unexplained respiratory illness A person hospitalized or deceased from severe unexplained respiratory illness Consumption of raw / undercooked poultry Consumption of raw / undercooked poultry

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19. 19 Infectious Disease Epidemiology Program Areas reporting confirmed H5N1 avian influenza in poultry and wild birds since 2003 status as of 23.09.2008 (latest available update from WHO)

20. 20 Infectious Disease Epidemiology Program Pandemic Influenza 1918-1919 pandemic Typical onset of influenza, Rapid progression fever cough dyspnea cyanosis CXR: widespread infiltrates Pneumonia / ARDS

21. 21 Infectious Disease Epidemiology Program Annual Average Mortality in Pandemic and Interpandemic Years, United States, 1918 - 1991

22. 22 Infectious Disease Epidemiology Program

23. 23 Infectious Disease Epidemiology Program Current WHO phase of pandemic alert current as of 9/30/2008 (WHO)

24. 24 Infectious Disease Epidemiology Program Early Outbreak Reporting Requirements http://www.wvidep.org/Portals/31/PDFs/IDEP/influenza/APPENDIX%202%20Pan demic%20Influenza%20Surveillance%20and%20Response_.pdf Immediately report: Individual cases of pandemic strain influenza: Fever > 100 ºC; and Cough or sore throat or shortness of breath; and Laboratory evidence of pandemic strain infection (criteria TBD). Deaths from pandemic strain influenza.

25. 25 Infectious Disease Epidemiology Program http://www.wvidep.org/Portals/31/PDFs/IDEP/influenza/APPENDIX%202%20Pan demic%20Influenza%20Surveillance%20and%20Response_.pdf Established Outbreak Reporting Requirements http://www.wvidep.org/Portals/31/PDFs/IDEP/influenza/APPENDIX%202%20Pan demic%20Influenza%20Surveillance%20and%20Response_.pdf Individual providers- report aggregate cases of influenza-like illness: Fever  > 100° F (36°C) and Cough or sore throat or shortness of breath without another identified cause. Hospitals shall report (daily): New admissions for pandemic influenza Fever > 100 ºC; and Cough or sore throat or shortness of breath without another identified cause. New admissions for pneumonia or influenza. New deaths from pandemic influenza

26. 26 Infectious Disease Epidemiology Program For more information… IDEP: http://www.wvidep.org/AZIndexofInfectiousDiseas es/Influenza/tabid/1518/Default.aspx IDEP: http://www.wvidep.org/AZIndexofInfectiousDiseas es/Influenza/tabid/1518/Default.aspx http://www.wvidep.org/AZIndexofInfectiousDiseas es/Influenza/tabid/1518/Default.aspx http://www.wvidep.org/AZIndexofInfectiousDiseas es/Influenza/tabid/1518/Default.aspx Protocols – please review / comment Protocols – please review / comment Surveillance data Surveillance data Information sheets Information sheets Avian and pandemic guidance Avian and pandemic guidance CDC: http://www.cdc.gov/flu/ CDC: http://www.cdc.gov/flu/http://www.cdc.gov/flu/ WHO: http://www.who.int/topics/influenza/en/ WHO: http://www.who.int/topics/influenza/en/http://www.who.int/topics/influenza/en/

27. 27 Infectious Disease Epidemiology Program Acknowledgement Flu Study team members, 2008 - 2009 West Virginia Bureau for Public Health West Virginia Bureau for Public Health Kay Shamblin, RN, BSN Kay Shamblin, RN, BSN Caroline Williams, MD Caroline Williams, MD Carolyn Winkler, RN Carolyn Winkler, RN Mary Myers, RN Mary Myers, RN Allie Clay, RN Allie Clay, RN Thein Shwe, MPH, MS, MBBS Thein Shwe, MPH, MS, MBBS Charleston Area Medical Center Charleston Area Medical Center Deana Samms, BS, MA, CIC Deana Samms, BS, MA, CIC