Lesley BullionInfluenza Surveillance Coordinator

Infectious Disease Control Unit

Swine Novel Pandemic Influenza A (H1N1) in Texas

…OR How I Spent My Summer

Vacation

Not the Same Old Swine Flu

• April 13-17: Two California novel swine influenza H1N1 cases identified– Both cases detected

through seasonal flu surveillance

– One of these patients and his brother traveled to Texas on April 3

• April 21: CDC notifies DSHS of 2 unsubtypeable flu A’s in HSR 8

Novel Flu Surveillance Basics

• Flu is suddenly notifiable • Participation in surveillance

increases• Everyone wants to be tested • Guidance changes frequently• We don’t have time to report

anything else• And…

Flu Reports in the Summer?!

Texas Novel Flu Surveillance• New

– Increased culture/PCR surveillance– Individual case and contact investigations

• Short form(s)• Long form(s)• Addenda

– Weekly Regional and County Aggregate Reports– Airline investigations (DGMQ)– More thorough institutional outbreak investigations– Various studies

• Routine– Culture/PCR Surveillance– NREVSS – ILINet– Reports from Regional Flu Surveillance Coordinators– Investigations of institutional outbreaks (e.g., schools)

ILINet & Novel Flu

• CDC: ‘ILINet was best system for detecting the novel flu’

• 11 additional Texas providers recruited/re-recruited

• Weekly or daily reporting to CDC website or by fax– 13 daily reporters (Texas)

• 143 total Texas ILINet providers as of 7/13/09– Average of 54 reporters each week since week

21

U.S. Outpatient Influenza-Like Illness Surveillance Network (ILINet), Data From Texas Participants, 2008-09

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

50000

2008

40

2008

41

2008

4220

0843

2008

44

2008

45

2008

4620

0847

2008

48

2008

4920

0850

2008

51

2008

5220

0853

2009

01

2009

02

2009

0320

0904

2009

05

2009

0620

0907

2009

08

2009

0920

0910

2009

11

2009

12

2009

1320

0914

2009

15

2009

1620

0917

2009

18

2009

1920

0920

2009

21

2009

22

2009

2320

0924

2009

25

2009

26

October November December January February March April May June July

MMWR Week

Nu

mb

er o

f P

atie

nt

Vis

its

0%

2%

4%

6%

8%

10%

12%

Per

cen

tag

e o

f V

isit

s F

or

ILI

Patients ILI %ILI Regional baseline

NREVSS Texas Flu Positives, 2008-09

0

200

400

600

800

1000

1200

1400

1600

0827

0828

0829

0830

0831

0832

0833

0834

0835

0836

0837

0838

0839

0840

0841

0842

0843

0844

0845

0846

0847

0848

0849

0850

0851

0852

0853

0901

0902

0903

0904

0905

0906

0907

0908

0909

0910

0911

0912

0913

0914

0915

0916

0917

0918

0919

0920

0921

0922

0923

0924

0925

0926

July August September October November December January February March April May June July

MMWR Week

Nu

mb

er

of

Sp

ec

ime

ns

Po

sit

ive

fo

r F

lu

0%

5%

10%

15%

20%

25%

30%

Pe

rce

nta

ge

of

Sp

ec

ime

ns

Po

sit

ive

fo

r F

lu

AH1N1 AH3N2 A/Unk B %pos

Specimens for Influenza Testing Submitted to DSHS Austin Lab Since 4/16/09 (N=9,401*)

HSR Total

1 27

2/3 1141

4/5N 899

6/5S 497

7 3020

8 1000

9/10 117

11 2700

Grand Total 9401

Specimens Received by the DSHS Lab by Date of Collection, and Percentage of Specimens Positive for Influenza Virus

0

200

400

600

800

1000

1200

1400

04/1

6/200

9

04/1

9/200

9

04/2

2/200

9

04/2

5/200

9

04/2

8/200

9

05/0

1/200

9

05/0

4/200

9

05/0

7/200

9

05/1

0/200

9

05/1

3/200

9

05/1

6/200

9

05/1

9/200

9

05/2

2/200

9

05/2

5/200

9

05/2

8/200

9

05/3

1/200

9

06/0

3/200

9

06/0

6/200

9

06/0

9/200

9

06/1

2/200

9

06/1

5/200

9

06/1

8/200

9

06/2

1/200

9

06/2

4/200

9

06/2

7/200

9

06/3

0/200

9

Date of Collection

Nu

mb

er o

f S

pec

imen

s S

ub

mit

ted

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pe

rce

nta

ge

of

Sp

ec

ime

ns

Po

sit

ive

fo

r F

lu

Specimens FluPos%

Specimens Positive for Influenza Since April 16, 2009, DSHS Austin Lab

0

10

20

30

40

50

60

70

80

90

100

04/2

3/200

9

04/2

5/200

9

04/2

7/200

9

04/2

9/200

9

05/0

1/200

9

05/0

3/200

9

05/0

5/200

9

05/0

7/200

9

05/0

9/200

9

05/1

1/200

9

05/1

3/200

9

05/1

5/200

9

05/1

7/200

9

05/1

9/200

9

05/2

1/200

9

05/2

3/200

9

05/2

5/200

9

05/2

7/200

9

05/2

9/200

9

05/3

1/200

9

06/0

2/200

9

06/0

4/200

9

06/0

6/200

9

06/0

8/200

9

06/1

0/200

9

06/1

2/200

9

06/1

4/200

9

06/1

6/200

9

06/1

8/200

9

06/2

0/200

9

06/2

2/200

9

06/2

4/200

9

06/2

6/200

9

06/2

8/200

9

06/3

0/200

9

Date of Collection or Receipt

Nu

mb

er o

f P

CR

Po

siti

ves

Novel Flu A Seasonal Flu A Flu B

Specimens Positive for Influenza since 4/16/09, DSHS Austin Lab

Novel A H1N1, 2023, 92%

Seasonal Flu A, 138, 6%

Flu B, 40, 2%

Influenza-Associated Pediatric Mortality – Novel Flu

• 2 deaths “out of season”• Ages 12 and 13 years

– Both novel flu A H1N1– Only one with significant underlying

medical conditions

• Total of 13 pediatric flu deaths for 08-09 to date

Where are we now?

• Investigations of severe illnesses (ICU) and deaths

• County and Regional Aggregate reports– Reported to CDC via web

• Returning to “regular” surveillance– Weekly flu reports– ILINet– NREVSS– PCR/culture surveillance - limited

• Workgroups: Flu-related topics under discussion

• Lots of questions to answer for fall

Influenza & ILI as Reportable Conditions in Texas, 1920–2009

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

450,00019

2019

2219

2419

2619

2819

3019

3219

3419

3619

3819

4019

4219

4419

4619

4819

5019

5219

5419

5619

5819

6019

6219

6419

6619

6819

7019

7219

7419

7619

7819

8019

8219

8419

8619

8819

9019

9219

9419

9619

9820

0020

0220

0420

0620

08

Year

Nu

mb

er o

f C

ases

Rep

ort

ed

Flu not reportable, 1952–1967

Flu not reportable, 1994–2009*

Putting it in Perspective

Texas Data Seasonal flu, annual estimates*

Novel flu to date

Cases 1.2-4.9 million 4,463

Hospitalizations

16,000+ 183

Deaths 2,880 20

*Based on CDC estimates of national annual flu burden