1. Washington State Department of Health Influenza Surveillance Update Vivian Hawkins, MS PhD Washington State Department of Health Communicable Disease Epidemiology Office 206-418-5500 Vivian.Hawkins@doh.wa.gov

2. 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

3. Rates, Trends and Comparisons US and WA Flu Activity

4. Influenza Laboratory Data, WA (WHO/NREVSS) 2015-2016 Season, through Jan 9, 2016 Number of Positive Specimens 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.pdfhttp://www.doh.wa.gov/Portals/1/Documents/5100/420-100-FluUpdate.pdf

5. Courtesy of CDCCourtesy CDC

6. Influenza Laboratory Data (WHO/NREVSS), WA 2014-2015 Season From http://www.doh.wa.gov/DataandStatisticalReports/DiseasesandChronicConditions/CommunicableDiseaseSurveillanceData/InfluenzaSurveillanceDatahttp://www.doh.wa.gov/DataandStatisticalReports/DiseasesandChronicConditions/CommunicableDiseaseSurveillanceData/InfluenzaSurveillanceData

7. 2013-2014 Season From http://www.doh.wa.gov/DataandStatisticalReports/DiseasesandChronicConditions/CommunicableDiseaseSurveillanceData/InfluenzaSurveillanceDatahttp://www.doh.wa.gov/DataandStatisticalReports/DiseasesandChronicConditions/CommunicableDiseaseSurveillanceData/InfluenzaSurveillanceData Influenza Laboratory Data (WHO/NREVSS), WA

8. From http://www.doh.wa.gov/DataandStatisticalReports/DiseasesandChronicConditions/CommunicableDiseaseSurveillanceData/InfluenzaSurveillanceDatahttp://www.doh.wa.gov/DataandStatisticalReports/DiseasesandChronicConditions/CommunicableDiseaseSurveillanceData/InfluenzaSurveillanceData 2012-2013 Season Influenza Laboratory Data (WHO/NREVSS), WA

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

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

11. Courtesy CDC

13. WA will be listed as having regional activity for week 2

14. Lab-Confirmed Influenza Deaths Number 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 From http://www.doh.wa.gov/Portals/1/Documents/5100/420-100-FluUpdate.pdfhttp://www.doh.wa.gov/Portals/1/Documents/5100/420-100-FluUpdate.pdf Age Group (in years) Number of Deaths Death Rate (per 100,000 population) 0–400.0 5–2400.0 25–4900.0 50–6430.22 65+50.53 Total80.12 Season Number of Deaths, All Ages Death Rate (per 100,000 population), All Ages 2015-2016, season to date80.12 2014-2015, total1572.28 2012-2013, total540.80 2011-2012, total180.27 2010-2011, total360.53

15. 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

16. Surveillance Methodology and Issues New Directions in Surveillance

17. What is Reportable in WA Lab-confirmed influenza deaths ILI outbreaks in long-term care facilities

18. Additional Data Streams This 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)

19. 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

20. Influenza Sentinel Collaborating Labs Courtesy Dr. Ailyn Perez-Osorio, WA DOH PHL

21. Influenza RT-PCR Subtyping Results Sentinel Laboratory Site Total 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 3530 4 1 The Everett Clinic 5037 8 5 Evergreen 65352420 4 Providence St Peters 2724 2 1 Tacoma General 100681311 17 Olympic Medical Center 4337 6 Tri-Cities 42 2 PAML 44421 1 Pullman Regional Hosp Lab 12 Sacred Heart MC 4631 113 1 Cumulative 4303184867429 Influenza A (2009 pdmH1N1) Antiviral Pyrosequencing Results None performed, 4 sent to CDC. Influenza A (H3) Antiviral Pyrosequencing Results This 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 Courtesy Dr. Ailyn Perez-Osorio, WA DOH PHL Also send a subset of viruses to CDC for antigenic testing

22. Influenza RT-PCR Subtyping Results Sentinel Laboratory Site Total Number of specimens tested Subtyping - Genotyping results (Cumulative) Comments InfA (H3N2) InfA (2009 pdmH1N1) InfB - Victoria Lineage InfB - Yamagata Lineage Indeterminate Negative at WA PHL* Peace Health Laboratories531 1 Pending B Genotype Evergreen44 Tacoma General1541 6 4 Pending B Genotype Olympic Medical Center55 PAML211 Sacred Heart MC54 1 1 Cumulative36213 7 Influenza A (2009 pdmH1N1) Antiviral Pyrosequencing Results None performed, 3 sent to CDC. Influenza A (H3) Antiviral Pyrosequencing Results None performed, 21 sent to CDC. WA State Sentinel Laboratory Network: 2015-2016 Season Also send a subset of viruses to CDC for antigenic testing Courtesy Dr. Ailyn Perez-Osorio, WA DOH PHL

23. Sentinel Laboratories Aware of a lab that may want to participate? Please let me know!

24. Syndromic Surveillance Syndromic Surveillance, Percentage of Hospital Visits for a Chief Complaint of ILI by CDC Week, Western Washington, 2013-2016 From http://www.doh.wa.gov/Portals/1/Documents/5100/420-100-FluUpdate.pdfhttp://www.doh.wa.gov/Portals/1/Documents/5100/420-100-FluUpdate.pdf

25. Thinking beyond flu What else is circulating in the community that could result in ILI symptoms?

26. 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?)

27. WHO/NREVSS labs Courtesy CDC

28. 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

29. 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

30. PHRAID, 2015-2016 From http://www.doh.wa.gov/Portals/1/Documents/5100/420-100-FluUpdate.pdfhttp://www.doh.wa.gov/Portals/1/Documents/5100/420-100-FluUpdate.pdf

31. PHRAID, 2015-2016 From http://www.doh.wa.gov/Portals/1/Documents/5100/420-100-FluUpdate.pdfhttp://www.doh.wa.gov/Portals/1/Documents/5100/420-100-FluUpdate.pdf No subtyping data! Some labs DO have subtype, and can enter that in NREVSS.

32. Flu Prediction When does the flu season start and stop? How severe will the season be?

33. 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!

34. Avian Influenza Update

35. 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.htmhttp://www.cdc.gov/flu/avianflu/h5/index.htm

36. 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.htmhttp://www.cdc.gov/flu/avianflu/h5/index.htm

37. 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

38. 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

39. Courtesy USDA

40. Minnesota National Guard Image courtesy Wikipedia

41. 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

42. CDC/USDA Joint Planning 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

43. CDC/USDA Joint Planning 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

44. CDC/USDA Joint Planning 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 working closely with local, state and federal agencies on avian flu planning

45. Courtesy Seattle Times

46. 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

47. Discussion Ideas for how to improve flu surveillance in WA? Please contact me at 206-418-5500 or Vivian.Hawkins@doh.wa.gov Vivian.Hawkins@doh.wa.gov