Washington State Department of Health Influenza Surveillance Update Vivian Hawkins, MS PhD Washington State Department of Health Communicable Disease Epidemiology Office

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 Comparisons US and WA Flu Activity

Influenza Laboratory Data, WA (WHO/NREVSS) 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

Courtesy of CDCCourtesy CDC

Influenza Laboratory Data (WHO/NREVSS), WA Season From

Season From Influenza Laboratory Data (WHO/NREVSS), WA

From Season Influenza Laboratory Data (WHO/NREVSS), WA

ILINet From 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) 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) Seasons, through Jan 9, 2016 Early indications that % ILI will be higher for week ending Jan 17 From

Courtesy CDC

WA will be listed as having regional activity for week 2

Lab-Confirmed Influenza Deaths Number and rate of reported laboratory-confirmed influenza-associated deaths by age group, Washington, , 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 Age Group (in years) Number of Deaths Death Rate (per 100,000 population) 0– – – – Total80.12 Season Number of Deaths, All Ages Death Rate (per 100,000 population), All Ages , season to date , total , total , total , total360.53

Antigenic Testing So far this season, the circulating flu viruses CDC has tested have antigenically matched the 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 Issues New Directions in Surveillance

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

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)

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 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 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 The Everett Clinic Evergreen Providence St Peters Tacoma General Olympic Medical Center Tri-Cities 42 2 PAML Pullman Regional Hosp Lab 12 Sacred Heart MC Cumulative 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: Season Courtesy Dr. Ailyn Perez-Osorio, WA DOH PHL Also send a subset of viruses to CDC for antigenic testing

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 General Pending B Genotype Olympic Medical Center55 PAML211 Sacred Heart MC Cumulative 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: Season Also send a subset of viruses to CDC for antigenic testing Courtesy Dr. Ailyn Perez-Osorio, WA DOH PHL

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

Syndromic Surveillance Syndromic Surveillance, Percentage of Hospital Visits for a Chief Complaint of ILI by CDC Week, Western Washington, From

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, From

PHRAID, From 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 – 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:

Highly Pathogenic Avian Influenza (HPAI) H5NX (H5N2, H5N8, H5N1 reassortant) viruses were identified in North American birds in late winter 2014-spring – 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 More info from CDC:

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

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

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

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

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 or