1. Texas Influenza Surveillance Lesley Bullion Influenza Surveillance Coordinator Infectious Disease Control Unit

2. Flu Surveillance Basics Flu is not a notifiable condition* Participation in surveillance is voluntary “Official” flu season is approximately October to May (MMWR week 40 to MMWR week 20)

3. Texas Flu Surveillance U.S. Outpatient Influenza-Like Illness Surveillance Network (ILINet) Influenza-like illness (ILI) data Culture Surveillance ‘Network’ Specimens from clinics, hospitals, public health labs, health departments Limited specimens from some ILINet providers Research and Hospital Laboratories Flu test results from NREVSS, WHO, TCH, S&W, USAFSAM Regional Flu Surveillance Coordinator Reports ILI, school closures, institutional outbreaks, laboratory results, rapid flu test results, pediatric flu deaths

4. U.S. Outpatient Influenza-Like Illness Surveillance Network (ILINet)

5. ILINet Basics Voluntary nationwide network of healthcare providers sponsored by the Centers for Disease Control and Prevention (CDC) Recruited by each state health department Weekly reports of influenza-like illness (fever ≥100°F AND cough and/or sore throat in the absence of a known cause other than influenza) Some Texas providers also submit specimens to DSHS

6. ILINet Reporting Forms

7. ILINet Data

8. U.S. Outpatient Influenza-Like Illness Surveillance Network (ILINet), Texas Participants (N=143), 2008-09 HSRTotal 19 2/327 4/5N8 6/5S36 79 811 9/1018 1125 Grand Total143 As of 7/13/09

9. Culture Surveillance

10. Culture Surveillance Sites, 1998-1999

11. 2008-09 Influenza Surveillance Specimens Submitted to DSHS Austin Lab (N=1,419*) HSRTotal140 2/3642 4/5N120 6/5S48 7246 8106 9/1044 11173 Grand Total 1419 *through April 15, 2009

12. Additional Laboratory Data

13. Weekly Reports by Individual Labs Texas Children’s Hospital: +cultures Scott & White Hospital Laboratory: +tests (culture, PCR, antigen) by patient county USAFSAM: +cultures/PCR by base LRN laboratories: +PCR

14. NREVSS Laboratory Data NREVSS Flu Reporters in 2008-09 season: Arlington Memorial Hospital Children’s Hospital of Austin Children’s Medical Center of Dallas Cook Children’s Medical Center Covenant Medical Center Driscoll Children’s Hospital Hunt Memorial Hospital District Medical Center of Plano Medical City Dallas Hospital Methodist Children's Hospital Methodist Hospital Mother Frances Hospital Santa Rosa Health Care Scott & White Memorial Hospital South Texas Regional Medical Center Tarrant County Public Health Texas Children’s Hospital Texas Department of State Health Services Tomball Regional Hospital University Hospital/South Texas Medical Center University of Texas Medical Branch – Children’s Hospital University Medical Center NREVSS Flu Reporters in 2008-09 season: Arlington Memorial Hospital Children’s Hospital of Austin Children’s Medical Center of Dallas Cook Children’s Medical Center Covenant Medical Center Driscoll Children’s Hospital Hunt Memorial Hospital District Medical Center of Plano Medical City Dallas Hospital Methodist Children's Hospital Methodist Hospital Mother Frances Hospital Santa Rosa Health Care Scott & White Memorial Hospital South Texas Regional Medical Center Tarrant County Public Health Texas Children’s Hospital Texas Department of State Health Services Tomball Regional Hospital University Hospital/South Texas Medical Center University of Texas Medical Branch – Children’s Hospital University Medical Center

15. Regional Flu Reports

16. Flu Activity Levels No Activity: –Low clinical activity and no lab confirmation Sporadic: –ILI activity not increased –Isolated lab confirmed cases OR an institutional outbreak in a single institution Local: –Increase in ILI plus recent lab confirmation in ONE region of the state OR –Recent lab confirmation AND two or more ILI or lab confirmed outbreaks in ONE region Regional: –Increased ILI OR institutional outbreaks in ≥2 but less than half of the regions –AND recent lab confirmation in affected regions Widespread: –Increased ILI OR institutional outbreaks in at least half of the regions –AND recent lab confirmed influenza in affected regions

17. Flu activity level Regional reports Lab data Outbreaks SPSN ILI data Link to national report Texas Weekly Flu Report

19. How does Texas surveillance contribute to national surveillance?

20. National Flu Surveillance Centers for Disease Control (CDC) components of influenza surveillance in the U.S. –Viral Laboratory Surveillance –Outpatient Illness Data –Mortality Surveillance –Hospitalization Surveillance –State and Territorial Epidemiologists Reports

21. 2008–2009 Influenza Season in Texas (through April 15, 2009)

23. Texas Flu Summary, 2008–09 First isolate of the season (DSHS Lab) –Flu A/unable to subtype! Specimen collected October 15, 2008 Bell County Swine influenza A (H1N1) –Flu B Specimen collected October 21, 2008 B/Malaysia/2506/2004-like (Victoria lineage) Webb County Predominant type/subtype: A (H1N1)

25. Texas Flu Summary, 2008-09 Early appearance of influenza B and A (H1N1) –Influenza A (H3N2) absent until week 52 Seasonal peak: early February –221 specimens collected, 147 (67%) positive for flu during week 5 (week ending February 7, 2009) –ILINet peak: 7.06% in week 6 –NREVSS-Texas peak: 28.1% in week 5 –“Widespread” designation for 7 weeks Late, small flu B wave (week 8) Mild compared to 2007-08

26. Influenza Types and Subtypes Identified in Positive Specimens, DSHS Austin Laboratory, 2008-2009 Season VirusTotal A H1468 A H337 Unable to subtype1 B/Florida/04/2006-like15 B/Malaysia/2506/2004-like248 Influenza B7 Grand Total776

28. Influenza-Associated Pediatric Mortality Reportable beginning in 2007 in Texas Laboratory-confirmed influenza death in a person under 18 years of age 11 deaths (through week 15) –Age range: 7 months to 17 years –4 Flu A, 7 Flu B –Known MRSA or MSSA co-infection: 2/11 (18%) –Significant underlying medical condition: 8/11 (73%) –Not vaccinated for flu: 4/6 (67%)

29. Review of 2008–09 Vaccine Components (Northern Hemisphere) All 3 were new components! –A/Brisbane/59/2007-like (H1N1) –A/Brisbane/10/2007-like (H3N2) –B/Florida/4/2006-like (B/Yamagata lineage)

30. Antigenic Characterization Testing Performed on limited Texas isolates at CDC laboratory 20 A/H1 (seasonal) isolates: 100% match to vaccine strain 8 A/H3 isolates: 100% match 23 influenza B isolates: –30% match to vaccine strain (Yamagata lineage) –70% Victoria lineage

31. Antiviral Resistance Testing Performed on limited Texas isolates at CDC laboratory 1 swine influenza A/H1 tested (October 2008) –Sensitive to oseltamivir, zanamivir, adamantanes 22 seasonal influenza A/H1’s tested –100% resistant to oseltamivir (sensitive to zanamivir and adamantanes) 7 influenza A/H3’s tested –100% resistant to adamantanes (sensitive to oseltamivir and zanamivir) 22 influenza B’s tested –100% sensitive to oseltamivir and zanamivir

32. 2009-10 Vaccine Composition (Northern Hemisphere) Only the B strain will be changed: –A/Brisbane/59/2007-like (H1N1) –A/Brisbane/10/2007-like (H3N2) –B/Brisbane/60/2008-like (B/Victoria lineage)

33. Texas Flu Surveillance 2009-2010 Season Continue funding all packaging, shipping, and testing related to flu surveillance; however, testing may be limited – how? Increase ILINet participants & culture surveillance sites in selected areas PCR to continue at LRNs VTM ordering process? Limits? To sign up for automatic notification of new flu reports: http://www.dshs.state.tx.us/idcu/disease/influenza/surveillance/2009/