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