1 MDH 2010 – 2011 Influenza Season Update for Laboratories Audio-conference MLS Laboratories...

1

MDH2010 – 2011 Influenza Season

Update for Laboratories

Audio-conference MLS LaboratoriesOctober 11, 2010

Aaron DeVriesPaula VagnoneDavid Boxrud

MN Department of Health

2

Objectives

• Prepare the laboratory community for response to the current influenza season

• Update on influenza vaccine.• Describe the variety of surveillance

systems in place at MDH for monitoring influenza in Minnesota

• Apprise laboratorians on the current specimen acceptance criteria for influenza testing

• Describe the current influenza testing algorithm being used by the MDH – Public Health Laboratory

3

Hospitalized Cases of Influenza by Influenza Type, Minnesota, October 1, 2008 – March 27, 2010

2008-2009 influenza season

2009-2010 influenza season2nd H1N1 wave

Summer surveillance1st H1N1 wave

1st H1N1hospitalized

case

0

25

50

75

100

125

150

175

200

225

250

275

300

325

350

375

400

425

450

OCT08

NOV08

DEC08

JAN09

FEB09

MAR09

APR09

MAY09

JUN09

JUL09

AUG09

SEP09

OCT09

NOV09

DEC09

JAN10

FEB10

MAR10

Month/Year of Specimen Collection

Nu

mb

er

of

Ho

sp

ita

liza

tio

ns

A/B (rapid test only)

B (rapid test only)

A (rapid test only)

Seasonal B

Untypeable A

Novel H1N1

Seasonal A

4

Death

Critical Illness

Hospitalization

Moderate Outpatient Illness

Mild Outpatient Illness

Minimal or No Symptoms

1. Deaths with infectious hallmarks

2. Hospitalized patients with ILI

3. Virology Lab Reporting

Influenza Disease Burden

MDH Influenza Surveillance (Case Based)

6. School Absenteeism

5. Longterm Care Facility ILI

4. Sentinel site ILI

5

1. Deaths with infectious hallmarks

2. Hospitalized patients with ILI

3. Virology Lab Reporting

6. School Absenteeism

5. Longterm Care Facility ILI

4. Sentinel site ILI

Influenza Disease Burden

MDH Influenza Surveillance (Non-case Based)Death

Critical Illness

Hospitalization

Moderate Outpatient Illness

Mild Outpatient Illness

Minimal or No Symptoms

No good surveillance for the bulk of influenza disease

6

Hospital Based Influenza Surveillance: 2010-2011

• Specimen submission:– All hospitalized patients with ILI regardless of prior testing

results (includes those with a neg flu rapid test)– Similar to 2009-2010

• Reporting cases:– DIFFERENT THAN SPECIMEN SUBMISSION1. All hospitalized MN residents with laboratory positive

influenza (including rapid testing)2. Any suspected influenza death or critical illness3. Any unusual case incidence or cluster (including LTC)

7

Early Season 2010-11 Laboratory Surveillance

• Establishing early cases is important• Laboratories performing rapid testing

methods – Submit up to two patient specimens that

are positive for influenza (both A and B) each week

8

PHL and Influenza PCR testing

• In 2009, PHL performed clinical testing for the purposes of patient care

– PCR for 2009 H1N1 was not readily available

• In 2010-2011, PHL influenza PCR will be for surveillance purposes

– Cumulative reports– Critical for understanding disease activity and

trends over time

9

Rapid Influenza Testing

• Can be a helpful tool in some circumstances

– Sensitivity is moderate (50-70%)– Specificity is high (90-95%)

• If negative, cannot be reassured that influenza is absent

– Particularly when disease prevalence is high

If positive and hospitalized, should prompt a disease report

http://www.cdc.gov/flu/professionals/diagnosis/rapidlab.htm

10

CDC Infection Control Guidance for Influenza:Adhere to droplet precautions

• Droplet precautions for 7 days after symptom onset or 24 hours after resolution of fever and resp symptoms

• Airborne precautions (fit tested N95 or equivalent) during aerosol generating procedures– Bronchoscopy, sputum induction, intubation

and extubation, autopsies, cardiopulmonary resuscitation, and open suctioning of airways

http://www.cdc.gov/flu/professionals/infectioncontrol/healthcaresettings.htm

11

2010 – 2011 Influenza Vaccine

• Reduces laboratory-confirmed influenza infections• Reduces influenza-associated mortality• Cost effective• Reduces HCW absenteeism• HCW vaccination leads to decreased mortality

among LTC residents

Talbot T, Babcock H, Caplan A, et al. Revised SHEA Position Paper: Influenza Vaccination of Healthcare Personnel. Infect Control Hosp Epidemiol 2010; 31(10):987-995

Bridges CB, Thompson WW, Meltzer MI, et al. Effectiveness and cost-benefit of influenza vaccination of healthy working adults: a randomized controlled trial. JAMA 2000;284(13):1655–1663.

Nichol KL, Lind A, Margolis KL, et al. The effectiveness of vaccination against influenza in healthy, working adults. N Engl J Med 1995;333(14): 889–893.

Hayward AC, Harling R, Wetten S, et al. Effectiveness of an influenza vaccine programme for care home staff to prevent death, morbidity, and health service use among residents: cluster randomised controlled trial. BMJ 2006;333(7581):1241.

Lemaitre M, Meret T, Rothan-Tondeur M, et al. Effect of influenza vaccination of nursing home staff on mortality of residents: a cluster-randomized trial. J Am Geriatr Soc 2009;57(9):1580–1586.

12

• UK• Those who received influenza vaccination had a

lower rate of acute myocardial infarction – Sept – Mid November - Adjusted OR 0.79 (95% CI 0.75–

0.83) – After mid-November - Adjusted OR 0.88 (95% CI 0.79–

0.97)• No reduction in MI with pneumococcal vaccination

– Adjusted OR 0.96, 95% CI 0.91–1.02)

CMAJ 2010. DOI:10.1503/cmaj.091891

13

Preventing Influenza Transmission:Vaccine

• No separate H1N1 vaccine• ACIP recommendation 2010-11

Everyone >6 months age

14

Preventing Influenza Transmission:Vaccine

“Therefore, for the safety of both patients and HCP, SHEA endorses a policy in which annual influenza vaccination is a condition of both initial and continued HCP employment and/or professional privileges.”

15

Current Influenza Activity

June 13-Sept 25• 25,833 respiratory specimens, 326 (1.3%)

tested + for influenza• Pos specimens were from predominantly SE

US– 80% Flu A, (30% H1, 70% H3)

• 97% of H1 were 2009 H1N1 • 96% of H3 were H3N2/A/Perth/16/2009

– 20% Flu B• 88% of B were B/Brisbane/60/2008

MMWR October 8, 2010 / 59(39);1270-1273

16




US– 80% Flu A, (30% H1, 70% H3)



MMWR October 8, 2010 / 59(39);1270-1273

All part of 2010-11 Northern Hemisphere Vaccine

17




US– 80% Flu A, (30% H1, 70% H3)



MMWR October 8, 2010 / 59(39);1270-1273

NOT a part of the 2009-2010 vaccine

18

Current Influenza Activity (cont.)

• IA clusters - early July,– 4 of 13 members of a college sports team; Flu A

(H3)– 9 of 12 children and one parent with ILI in a child

care setting; Flu A (H3)– Neither were associated with recent travel nor

had epidemiologic links• MN

– One nursing home outbreak – Flu A, H3 - Subtype pending

MMWR October 8, 2010 / 59(39);1270-1273

19

Dave Boxrud - Objectives

• Apprise laboratorians on the current specimen acceptance criteria for influenza testing

• Describe the current influenza testing algorithm being used by the MDH – Public Health Laboratory

20

Submission of Specimens

Forms are found on the MDH – PHL website at:

http://www.health.state.mn.us/divs/phl/clin/forms.html



21

Influenza Surveillance Programs that include specimen submission

Project TestingSubmission

form

Hospitalized Flu PCRHospitalized

(project 1492)

Cluster investigation/special circumstances/lab

surveillance

Flu PCR, cultureStandard (project 493)

Sentinel Site Flu PCR, cultureSpecial

(project 1494)

Super sentinel RVP PCRSpecial

(project 1399)

22

• Hospitalized with ILI (fever >100°F and cough or sore throat)

• Please submit specimen even if positive for influenza in your facility by culture or PCR

• Please submit hospitalized with ILI specimens regardless of rapid results

• MDH performs flu PCR

Hospitalized Surveillance

24

Cluster investigation/special circumstances/lab surveillance

• Cluster investigation/unusual circumstances (consult with MDH epi 651-201-5414)

• Laboratory surveillance (2 positive flu/wk early in season)

• Include testing results, methods used (DFA, rapid EIA, PCR, etc.) and name of test kit(s) in the comment section at the bottom of the form

• Send positive influenza viral culture• MDH performs flu PCR and culture

(serotyping on culture pos for vaccine compatibility)

25Insert rapid/PCR results here

26

• FDA cleared real-time PCR from CDC• Screen for influenza A, B and RNP• If type A PCR +

– Then type for H1, H3 and 2009 H1

• Influenza RT-PCR takes ~5 hrs• TAT ~1 week (surveillance vs Dx)

MDH-PHL Influenza PCR Testing

27

Influenza Surveillance Programs that include specimen submission

Project TestingSubmission

form

Hospitalized Flu PCRHospitalized

(project 1492)

Cluster investigation/special circumstances/lab

surveillance

Flu PCR, cultureStandard (project 493)

Sentinel Site Flu PCR, cultureSpecial

(project 1494)

Super sentinel RVP PCRSpecial

(project 1399)

28

Sentinel Provider Network

• 26 participating out-patient clinics in Minnesota

• Part of a CDC national program • Weekly reporting – ILI visits/total

patient visits• 2 specimens/week submitted for

confirmatory testing at MDH PHL

29

– Critical Access Hospital– Emergency Medicine– Family Practice– Hospital– Infectious Disease– Internal Medicine– Pediatrics– Student Health– Urgent Care

Influenza Surveillance – Sentinel surveillance sites

30

Influenza Sentinel Site Locations

31

Sentinel Surveillance Sites

ACMC Wilmar

Adams Clinic - Mayo Health System

Alexandria Clinic

Allina Medical Clinic Shoreview

Altru Clinic

Bois Forte Medical Clinic

Boynton Health Service

Brainerd Medical Center

Edina Family Physicians

Fairview Lakes Pediatric Clinic

Glenwood Medical Center (Glacial Ridge)

Infectious Diseases - Minneapolis LTD

Innovis-Park Rapids

Johnson Memorial Health Services

Kittson Memorial Health Center

Mankato Clinic, LTD

Merit Care Clinic - Mahnomen

Minnesota State University

Open Cities Health Center

Park Nicollet Clinic - Creekside

Rainy Lake Medical Center and Hospital

Regina Medical Group

Saint Mary's University of MN

Sawtooth Mountain Clinic

St. Mary's Innovis Health Clinic - Detroit Lakes

Student Health (Marshall)

32

“Super” Sentinel Sites Influenza Incidence Project

• CDC led program • Project runs 8/1/10-7/31/11• 4 providers submit to MDH

– Up to 10 specimens with ILI – Up to 10 specimens with ARI (2 of the

following-rhinorrhea or nasal congestion, sore throat, cough or fever)

• Collect illness data (symptoms)

33


• Participants – ACMC (Willmar)– Boynton (U of MN, Minneapolis)– Open Cities Health Care (St Paul)– Fairview Lakes Pediatric

34


• Real-time PCR for:– Influenza A and B (results reported)– RSV– Adenovirus– MPV– Rhinovirus– Coronavirus (229E, OC43, NL63, HKU1)– Parainfluenza virus (PIV) 1-4

• PCR TAT 1-2 weeks• Cumulative weekly results posted to website

35

“Super” Sentinel Sites-Preliminary Results

Dates # Tested # Rhino + Other +

8/16-8/22 17 3 0

8/23-8/29 3 2 1 adeno

8/30-9/5 6 2 0

9/6-9/12 19 6 1 para 4

9/13-9/19 33 15 1 para 2

9/20-9/26

44 16

1 adeno

5 coro OC43

1 para 3

36

Other Testing at MDH

• Pyrosequencing to detect anti-viral (oseltamivir) resistance in 2009 H1 (H275Y)

• Mutations that may indicate increased virulence (D222G)

• 1 H275Y mutation and 1 D222G mutation (same specimen)

37

FDA Cleared PCR Assays for 2009 H1 Influenza

• CDC developed • Prodesse ProFast+• Focus Simplexa

38

MDH Guidance for Lab - Developed Influenza Assays

• Labs should validate tests according to their SOPs

• MDH requires submission of clinical samples and result reporting for surveillance activities

39

How MDH-PHL Can Help for Lab - Developed H1N1 Tests

• MDH-PHL can help validate tests as resources permit– Sharing of confirmed positive or negative

samples– Confirmatory testing on positive and

negative samples – Provide cultured virus

• MDH cannot make recommendations regarding specific regulatory requirements for individual laboratories

40

One more Surveillance Program – Paula Vagnone

• MLS Weekly Influenza/RSV Laboratory Surveillance

41

MLS Weekly Influenza & RSVLaboratory Surveillance

What is it?• 115 hospital- and clinic-based labs (8

viral culture labs)• Weekly data submission• Influenza and RSV• Rapid tests, PCR and culture data• Voluntary!

42

Southwest Southwest RegionRegion

Wash-ing-ton

Lake

Cook

Le Sueur Rice Goodhue

NoblesRock Jackson Martin Faribault Freeborn Mower Fillmore Houston

WinonaOlmstedDodgeSteeleWaseca

Blue EarthWatonwanCottonwoodMurrayPipestone

Nicollet Wabasha

DakotaScott

Chisago

Isanti

Brown

Sibley

Carver

Hennepin

WrightMeeker

Kandiyohi

Renville

Redwood

Sherburne

LyonLincoln

Yellow Medicine

Lac Qui Parle

Swift

Big Stone

PopeStevensTraverse

Chippewa

StearnsBenton

Carlton

Pine

KanabecMilleLacs

Aitkin

Crow Wing

Morrison

CassHubbard

Wadena

Todd

DouglasGrant

OttertailWilkin

BeckerClay

ClearWater

MahnomenNorman

Red Lake

PenningtonPolk Beltrami

Marshall

Itasca

Koochiching

Lakeof theWoods

RoseauKittson

St. Louis

McLeod

71Anoka

HennepinRam-sey

MLS Influenza/RSV Lab Surveillance

West Central West Central RegionRegion

Northeast Region

Central Region

Metro Region

Southeast RegionSouth Central RegionSouth Central Region

Northwest Region

43

Weekly Data Submission• # of tests performed• # of positives• Based on influenza week (Sat – Sun)• No MDH-PHL testing associated with this

surveillance

http://www.health.state.mn.us/divs/idepc/diseases/flu/stats/index.html


44

Why is this data Important?• Assists healthcare providers with

patient diagnosis of ILI• Provides an indicator as to the

progression of the influenza season

• Indicator of prevalence of disease in

the community


45

0

250

500

750

1000

1250

1500

35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Week of Specimen Collection

Nu

mb

er

of

Po

sit

ive

Ra

pid

Te

sts

0

10

20

30

40

50

60

70

80

90

100

% o

f P

os

itiv

e R

ap

id T

es

ts

Flu B+

Flu A/B+

Flu A+

2007-2008 % +

2008-2009 % +

2009-2010 % +

Number and Percentage of Positive Influenza Rapid Test Results, MN Laboratory System Rapid Testing Sites, Sept. 2007 – April 2010

46


47


48


49

QUESTIONS?

50

• Dave Boxrud, MS Molecular Epidemiology/Virology SupervisorPhone: 651-201-5257 Email: [email protected]

• Aaron DeVries, MD, MPHMedical Epidemiologist, Infectious Disease Epi. Prevention & ControlPhone: 651-201-5080Email: [email protected]

51

• Paula M. Vagnone, MT (ASCP) MN Laboratory System Program Advisor, Emergency Prep. & Response

Phone: 651-201-5581Email: [email protected]

1 MDH 2010 – 2011 Influenza Season Update for Laboratories Audio-conference MLS Laboratories...

Documents

Transcript of 1 MDH 2010 – 2011 Influenza Season Update for Laboratories Audio-conference MLS Laboratories...