1. Influenza Surveillance
Lisa McHugh, MPH
Influenza Surveillance Coordinator
New Jersey Department of Health
and Senior Services

2. Seasonal Influenza 5-20% infected yearly (15-60 million*)
>200,000 U.S. hospitalizations
63% in persons age > 65
Hospitalization rate children <5
With high-risk condition 500/100,000
Without high-risk condition 100/100,000
~36,000 U.S. deaths
Greater than 90% of all deaths in adults > 65 years
Deaths among children uncommon but can occur
Uncomplicated influenza illness is characterized by the abrupt onset of constitutional and respiratory signs and symptoms (e.g., fever, myalgia, headache, malaise, nonproductive cough, sore throat, and rhinitis). Among children, otitis media, nausea, and vomiting are also commonly reported with influenza illness.
The risks for complications, hospitalizations, and deaths from influenza are higher among persons aged > 65 years, young children, and persons of any age with certain underlying health conditions
*Based on population of US Census estimate for 2007

3. Influenza Surveillance
When and where influenza activity is occurring
Determine types of influenza virus circulating
Detect changes in influenza viruses
Track influenza-related illness
Measure influenza’s impact on deaths in the United States

4. Influenza Surveillance in NJ
Disease surveillance
Virologic surveillance
When we look at influenza surveillance it can be broken down into 2 categories
Disease
Virologic

5. Disease Surveillance Influenza-like Illness (ILI)
Impossible to count all cases of influenza
Use ILI to approximate true disease burden
ILI combined with other more reliable information (i.e., laboratory testing) can provide a good estimate of disease burden
Limitation: casts a wide net and will capture other respiratory illness
Looking at Disease Surveillance- we don’t actually count all cases of disease. This would be impossible
Based on 5-20% infected yearly and about 8.5 million NJ residents – this equates to somewhere between 500,000 and 1.7 million NJ residents infected yearly. Instead we use ILI
Above in slide

6. Disease Surveillance Influenza-like illness (ILI) surveillance
Active surveillance- School, ED, LTCF
Sentinel provider surveillance network
Pediatric influenza surveillance
In NJ we use 3 primary types of disease surveillance- ILI, SPSN, and Ped Surv
We use several other secondary types of surveillance to back up these findings – more on this later.

7. Active ILI Surveillance
Weekly reports from ED, LTCF, and Schools
ED and LTCF - # ILI* and total census
Schools - # absent and total census
Currently enrolled in surveillance
LTCF - 132
ED - 87
Schools - 719
Analysis done at state, county and regional level
Data collected using our Communicable Disease Reporting and Investigation system called CDRSS.
* Patients with fever (>100°F, oral or equivalent) AND cough and/or sore throat (in the absence of a known cause).

8. CDRSS ILI Module
Here’s the report from our system. Broken down by county, region and the 3 reporting entities. Also see RSV – more on this later.

9. Sentinel Provider Surveillance Network (SPSN)
A collaborative effort between the public health and medical communities to monitor influenza
State and local health department recruit providers to participate
Providers report weekly the number of patients seen and the number with ILI by 5 age categories
Reporting is from October 1 to mid-May (MMWR week 40 to 20) of each year but year-round reporting is encouraged
The second type of surveillance we use is the SPSN
CDC runs the overall system with recruitment and management at state and local health department level.
Participating providers for the past 2 seasons have received rapid test kits, free testing and free shipping. We will try to continue this program as funding permits.

10. SPSN Goals
Establish the beginning of the influenza season to guide vaccination practices
Monitor the antigenic changes of circulating influenza strains by collecting point of care specimens
Maintain a surveillance system that provides early warning and adequate monitoring capabilities in the event of a pandemic or outbreak
Provide medical entities and other NJ residents with current and accurate information regarding the incidence and severity of disease in NJ

11. SPSN

12. SPSN
This is the season compared to season. See 2 peaks in the data – to a lesser degree in data.
Why do we see this- more on this later.

13. Pediatric Influenza Surveillance
In the influenza season, an increase in pediatric deaths observed nationally
CDC implemented pediatric mortality reporting
Subsequent years severe pediatric illness and mortality data collected in NJ

14. Pediatric Influenza Surveillance
Case Definition
Pediatric patients (i.e., less than 18 years of age) with laboratory confirmed influenza*
AND
Influenza-related deaths (in which there is no period of complete recovery between illness and death); OR
Influenza encephalopathy (defined as altered mental status, or personality changes in patients lasting more than 24 hours and occurring within 5 days of the onset of an acute febrile respiratory illness);
Severe illness defined as admission to an intensive care unit for influenza-related illness (in previously health children)

15. Pediatric Influenza Surveillance
Online entry form – used primarily by hospital Infection Control Professionals.
Changed every year to adopt new epidemiologic questions.
Questions added – daycare, travel, treatment, co-infection with bacterial agents.

16. Pediatric Influenza Surveillance
Findings
Season *
No. Reports 62
100 45
No. Meet Case Def. 25 17 19
Deaths 1
Vaccinated 4 3
Not Vaccinated 11 16
Unknown Vaccination 5
Following is brief overview of past 3 seasons.
We know we are not capturing all cases of severe and fatal pediatric illness but can use collected data as a representative sample.
We do have a report on the pediatric data on our website – see bottom of slide.
Plans to collate the 3 years of data and complete report.
* As of March 11, 2008
New Jersey Pediatric Influenza Summary Report: Influenza Season can be found at:

17. Other Surveillance Activities
122 City Mortality Report
ED Volume/Admission Data
Real-time Outbreak and Disease Surveillance (RODS)
Health Monitoring System
BioSense (Influenza Module)
QuadraMed
I mentioned earlier that we have 3 primary surveillance systems that we use – but also some secondary comparison and here they are. This helps to validate the data we collect for ILI.
122 City- tracks deaths due to pneumonia and influenza (P&I) from 6 NJ cities
ED volume – track increase in visits and admission from NJ hospitals – not specific syndromes
RODS – over the counter data to track pruchase of cold/flu medications
HMS- chief complaint data from hospitals in UASI region (area surrounding NYC)
BioSense – Influenza module – evaluated SPSN data by using EARS flu analysis – compare provider to themselves and flag at threshold
QuadraMed – Currently exploring – Hospital billing data – lag time but ICD-9 coded.

18. Virologic Surveillance
Goals
Identify and characterize circulating strains for vaccine development
Identify and characterize strains with pandemic potential
Monitor trends and compare season differences
Participants
Any laboratory conducting influenza tests
NREVSS
That conclude disease surveillance – now lets look at virologic surveillance

19. Types of Influenza Testing
Influenza Diagnostic Table
Procedure
Influenza
Types
Detected
Acceptable Specimens
Time for
Results
Rapid
result
available
Viral culture
(GOLD STANDARD)
A and B
NP swab, throat swab, nasal wash,
bronchial wash, nasal aspirate,
sputum
3-10 days No
Immunofluorescence
DFA Antibody
Staining
NP swab, nasal wash, bronchial
wash, nasal aspirate, sputum
2-4 hours
RT-PCR
1-2 days
Serology
paired acute and convalescent
serum samples6
>2 weeks
Enzyme Immuno
Assay (EIA)
bronchial wash
15-30
minutes
Yes
In order to discuss virologic surveillance – need to understand a little bit about lab testing and what we use in virologic surveillance.
Our primary focus is Culture, PCR and rapid testing methodologies.
Where each conducted?
Rapid –
Range of sensitivities and specificities depending on product and prevalence of influenza in community
When to use
To guide patient management
To determine the cause of an outbreak
To support public health surveillance efforts

20. NREVSS/WHO National Respiratory and Enteric Virus Surveillance System
24 participating laboratories in NJ
Report directly to CDC on 16 respiratory and enteric viruses
NJ receives and analyzes data weekly
How do we collect virologic data -

21. Virologic Surveillance
Rapid antigen test kit project
Season
64 sentinel laboratories (8 facilities returned kits)
35 sentinel providers
NJDHSS asked that all positive tests be forwarded to NJPHEL for PCR and culture
678 samples received from 29 (45%) facilities
How does lab surveillance work.
In the past we received around 130 samples for influenza. Sample submission was sporadic and did little to help track influenza (types and geographic spread).
NJDHSS implemented Rapid test kit project in influenza season.
In the season- project continued but reduced # of facilities to 16 with 2-3 samples per week. (reduced funding)

22. Virologic Surveillance
Test Results
CDC/WHO
(n=135,973)
Positive=17,997 NJ
(n=139)
Positive=75
(n=172,735*)
Positive=23,181
(n=810)
Positive =611 A
13,857 (81%)
8,209 (59%)
73 (97%) H1
13 (18%)
18,392 (80%)
12,290
(67%)
428 (70%)
49 (11%)
420
(3%)
3,872 (21%)
144 (34%) H3
5,228 (38%)
60 (82%)
2,230
(12%)
235 (55%) B
3,642 (18%)
2 (3%)
4,789 (20%)
183 (30%)
Other Virus 2 9
NVI/QNS 62
190
This is a table showing the and influenza season with regards to number of samples received and the type of influenza identified.
See 7 fold increase in 06-07
Reverse of national picture more H3 than H1 – and lots of B
*Data as of MMWR week 20

23. 06-07 type breakdown
Lots of H3
Not much difference in PCR and culture – EXCEPT in NVI where PCR excels at detecting virus in Old samples.

24. Very few samples in 65+
Many in 1-18
Not sure if that’s testing is ordered more or if really and increase in disease. SPSN – show similar trend – Could be overwhelming # of peds participating in SPSN program.
Of note – few LTCF outbreaks.

25. National data for 06-07 season
Peak in week 6- more H1 than H3

26. INFLUENZA ISOLATES FROM THE MID-ATLANTIC REGION Reported By WHO/NREVSS Collaborating Laboratories Season

27. NJ for 06-07 our peak was week 12
Later than national and later than previous seasons.

28. 2007-2008 Influenza Culture Results by Subtype
Rapid test kit project
15 labs and 20 sentinel providers
Asked to submit 2-3 specimens per week to PHEL
387 received as of MMWR week 9
Currently – looks like peak was week 5 but still looking at lab data and still seeing widespread flu around the state.

29. RSV Surveillance
Minimum of one hospital per county reports the number of RSV tests and the number positive
Surveillance is important because RSV infection can often be confused with influenza
Assists providers with administration of
RSV-IGIV and palivizumab
Spoke earlier about how using ILI for surveillance casts a wide net and we pick up other respiratory disease – one of those is RSV.
So we collect it – helps to extract data which is not ILI

30. RSV Surveillance 2007-2008 Influenza Season 2007-2008 data
Peak week 52- usually earlier than influenza season – end of RSV is beginning of influenza so can miss the start of flu season.

31. RSV
RSV
Heres an example of how we can use disease and virologic data together.
Sent pro – lots of noise- but overlay with lab data and you begin to see trends.
FLU
FLU

32. Influenza Vaccine 2007-2008 A/Solomon Islands/3/2006 (H1N1)-like
A/Wisconsin/67/2005 (H3N2)-like (or A/Hiroshima/52/2005 virus)
B/Malaysia/2506/2004-like antigens (or B/Ohio/1/2005 virus)
Collect all this data – why
Well see when flu is cicculating but also help with vaccine develop – Explain the process
I am sure you have heard of the vaccine mis-match this year – so let’s discuss

33. 2007-2008 Circulating Strains A- H1N1 (191 specimens)
147 (77%) A/Solomon Islands/3/2006-like
19 (10%) Reduced titers to A/Solomon Islands/3/2006-like
25 (13%) A/Brisbane/59/2007-like
A- H3N2 (86 specimens)
12 (14%) A/Wisconsin/67/2005-like
67 (78%) A/Brisbane/10/2007-like
7 (8%) Reduced titers to A/Wisconsin/67/2005-like
In green – current vaccine
In yellow- future vaccine
CDC data as of MMWR week 9

34. 2007-2008 Circulating Strains B (89 tested) Victoria lineage (6)
4 (67%) B/Ohio/01/2005-like
2 (33%) Reduced titers to B/Ohio/01/2005-like
Yamagata lineage (83)
82 (99%) B/Florida/04/2006-like
1 (1%) Reduced titers to B/Florida/04/2006-like
CDC data as of MMWR week 9

35. Influenza Vaccine
FDA recommends all three vaccine components to be changed for the influenza season
A/Brisbane/59/2007-like (H1N1)
A/Brisbane/10/2007- like (H3N2)
B/Florida/4/2006-like

36. Proposed New Influenza Vaccine Rule
The NJDHSS is proposing a new rule at N.J.A.C.8:57-19 to establish that all children six through 59 months of age entering or attending a licensed child care center or preschool facility on or after September 1, 2008 shall annually receive at least one dose of influenza vaccine between September 1 and December 31 of each year.

37. Antiviral Resistance Neuraminidase inhibitors Adamantanes*
45 (8.7%)of 519 H1N1 viruses tested were resistant to Oseltamivir
Adamantanes*
111 (21.7%) of 511 influenza A viruses were resistant
98.9% of H3N2
4.3% H1N1
Four approved for influenza treatment
Two adamantane derivatives
Amantadine (Symmetrel®), rimantadine (Flumadine®)
Older drugs approved 1966 and 1993 respectively
Interferes with function of protein channels
Two neurominidase inhibitors
Oseltamivir (Tamiflu®), zanamivir (Relenza®)
Both approved in 1999
Neurominidase inhibitors
*CDC and ACIP recommend that neither amantadine nor rimantadine be used for the treatment or chemoprophylaxis of influenza A in the United States

38. Weekly Influenza Report
All surveillance data is analyzed on a weekly basis (MMWR weeks)
Influenza activity level is evaluated for both the state and 5 public health regions

39. Activity Levels
No Activity- At least 2 of 3 parameters at or below state baseline AND no lab confirmed cases
Sporadic – At least 2 of 3 parameters above state baseline AND confirmed laboratory cases anywhere in the state OR at least one laboratory confirmed outbreak in an institution anywhere in the state
Local – At least 2 or 3 parameters above state baseline in a single county AND confirmed laboratory cases from that same county within the previous 3 weeks (other counties may be above baseline without lab confirmed cases) OR confirmed outbreaks in 2 or more institutions in a single county

40. Activity Levels
Regional – At least 2 of 3 parameters above state baseline in > 2 but < 10 counties AND laboratory confirmed cases from these same counties in past 3 weeks OR confirmed outbreaks institutions in more than 2 but less than or equal to 10 counties
Widespread – At least 2 of 3 parameters above state baseline in more than 10 counties OR institutional outbreaks in more than 10 counties AND lab confirmed influenza cases in previous 3 weeks.

41. NE Region (Bergen, Essex, Hudson)
CE Region (Middlesex, Monmouth, Ocean, Union)
NW Region (Morris, Passaic, Sussex, Warren)
CW Region (Hunterdon, Mercer, Somerset)
South Region (Atlantic, Burlington, Camden, Cape May, Cumberland, Gloucester, Salem)

42. Weekly Influenza Report

43. Weekly Influenza Activity New Jersey
0=No report/activity 1=Sporadic 2=Local 3= Regional 4=Widespread

44. Weekly Influenza Activity United States

45. Questions? Lisa McHugh, MPH Infectious & Zoonotic Disease Program
Influenza Surveillance Program
New Jersey Department of
Health & Senior Services