2008-2009 Influenza Season Week 20 ending May 23, 2009 All data are preliminary and may change as more reports are received.
(Due to the response to the novel influenza A (H1N1) investigation, surveillance regions were changed from Census Divisions to Department of Health and Human Services (HHS) Regions.) Synopsis:
During week 20 (May 17 - 23, 2009), influenza activity decreased in the United States, however there are still higher levels of influenza-like illness than is normal for this time of year.
One thousand four hundred fifty (22.4%) specimens tested by U.S. World Health Organization (WHO) and National Respiratory and Enteric Virus Surveillance System (NREVSS) collaborating laboratories and reported to CDC/Influenza Division were positive for influenza.
The proportion of deaths attributed to pneumonia and influenza (P&I) was below the epidemic threshold.
One influenza-associated pediatric death was reported.
The proportion of outpatient visits for influenza-like illness (ILI) was below the national baseline. Two of the 10 surveillance regions reported ILI above their region-specific baseline.
Four states reported geographically widespread influenza activity, 11 states reported regional activity, the District of Columbia and 13 states reported local influenza activity, 21 states reported sporadic influenza activity, and one state reported no influenza activity.
National and Regional Summary of Select Surveillance Components
HHS Surveillance Regions*
Data for current week
Data cumulative for the season
Out-patient ILI†
% positive for flu‡
Number of jurisdictions reporting regional or widespread activity§
A (H1)
A (H3)
Novel A (H1N1)
A (could not be subyped)¥
A(Unsub-typed)
B
Pediatric Deaths
Nation
Normal
22.4 %
15 of 51
7,525
1,919
4,010
519
12,143
10,047
62
Region I
Normal
14.1 %
2 of 6
525
143
422
15
1,088
799
1
Region II
Elevated
15.1 %
2 of 2
270
121
174
13
1,121
710
8
Region III
Normal
18.2 %
3 of 6
1,219
178
286
144
622
1,349
9
Region IV
Normal
10.5 %
3 of 8
805
89
104
32
1,699
1,179
6
Region V
Normal
22.7 %
1 of 6
1,621
170
2,095
101
489
1,282
10
Region VI
Normal
6.0 %
1 of 5
716
95
184
4
3,971
2,434
12
Region VII
Normal
12.7 %
0 of 4
493
54
101
139
453
526
0
Region VIII
Normal
8.8 %
0 of 6
468
201
153
53
1,405
489
5
Region IX
Normal
42.1 %
3 of 4
1,045
600
356
13
954
622
10
Region X
Elevated
30.3 %
0 of 4
363
268
135
5
341
657
1
* HHS regions (Region I: CT, ME, MA, NH, RI, VT; Region II: NJ, NY, Puerto Rico, US Virgin Islands; Region III: DE, DC, MD, PA, VA, WV; Region IV: AL, FL, GA, KY, MS, NC, SC, TN; Region V: IL, IN, MI, MN, OH, WI; Region VI: AR, LA, NM, OK, TX; Region VII: IA, KS, MO, NE; Region VIII: CO, MT, ND, SD, UT, WY; Region IX: AZ, CA, Guam, HI, NV; and Region X: AK, ID, OR, WA)
† Elevated means the % of visits for ILI is at or above the national or region-specific baseline
‡ National data are for current week; regional data are for the most recent three weeks
§ Includes all 50 states and the District of Columbia
¥ The majority of influenza A viruses that cannot be sub-typed as seasonal influenza viruses are novel A (H1N1) influenza viruses upon further testing U.S. Virologic Surveillance:
WHO and NREVSS collaborating laboratories located in all 50 states and Washington D.C. report to CDC the number of respiratory specimens tested for influenza.
During the 2008-09 season, influenza A (H1), A (H3), and B viruses have co-circulated in the United States. On April 15 and 17, 2009, CDC confirmed that two cases of febrile respiratory illness occurring in children who reside in adjacent counties in southern California were caused by infection with a novel influenza A (H1N1) virus. As of May 29, 2009, 8,975 confirmed infections with novel influenza A (H1N1) virus have been identified by CDC and state and local public health departments. Reporting of novel influenza A (H1N1) viruses by U.S. WHO collaborating laboratories began during week 17. The results of tests performed during the current week are summarized in the table below.
Week 20
No. of specimens tested
6,469
No. of positive specimens (%)
1,450 (22.4%)
Positive specimens by type/subtype
Influenza A
1,423 (98.1%)
A (H1)
24 (1.7%)
A (H3)
70 (4.9%)
A (unsubtyped)
116 (8.2%)
A (could not be subtyped)
117 (8.2%)
A (novel influenza H1N1)
1,096 (77.0%)
Influenza B
27 (1.9%)
During week 20, seasonal influenza A (H1), A (H3), and B viruses continue to co-circulate with novel influenza A (H1N1). Approximately 84% of all influenza viruses being reported to CDC are novel influenza A (H1N1) viruses.
The increase in the percentage of specimens testing positive for influenza by WHO and NREVSS collaborating laboratories may be due in part to changes in testing practices by healthcare providers, triaging of specimens by public health laboratories, an increase in the number of specimens collected from outbreaks, and other factors.
CDC has antigenically characterized 1,440 seasonal human influenza viruses [877 influenza A (H1), 162 influenza A (H3) and 401 influenza B viruses] collected by U.S. laboratories since October 1, 2008, and 84 novel A (H1N1) viruses.
All 877 influenza seasonal A (H1) viruses are related to the influenza A (H1N1) component of the 2008-09 influenza vaccine (A/Brisbane/59/2007). All 162 influenza A (H3N2) viruses are related to the A (H3N2) vaccine component (A/Brisbane/10/2007).
All 84 novel A (H1N1) viruses are related to the A/California/07/2009 (H1N1) reference virus selected by WHO as a potential candidate for novel influenza A (H1N1) vaccine.
Influenza B viruses currently circulating can be divided into two distinct lineages represented by the B/Yamagata/16/88 and B/Victoria/02/87 viruses. Fifty-eight influenza B viruses tested belong to the B/Yamagata lineage and are related to the vaccine strain (B/Florida/04/2006). The remaining 343 viruses belong to the B/Victoria lineage and are not related to the vaccine strain.
Data on antigenic characterization should be interpreted with caution given that antigenic characterization data is based on hemagglutination inhibition (HI) testing using a panel of reference ferret antisera and results may not correlate with clinical protection against circulating viruses provided by influenza vaccination.
Annual influenza vaccination is expected to provide the best protection against those virus strains that are related to the vaccine strains, but limited to no protection may be expected when the vaccine and circulating virus strains are so different as to be from different lineages, as is seen with the two lineages of influenza B viruses. Antigenic characterization of novel influenza A (H1N1) viruses indicates that these viruses are antigenically and genetically unrelated to seasonal influenza A (H1N1) viruses, suggesting that little to no protection would be expected from vaccination with seasonal influenza vaccine. Antiviral Resistance:
Since October 1, 2008, 904 seasonal influenza A (H1N1), 158 influenza A (H3N2), and 444 influenza B viruses have been tested for resistance to the neuraminidase inhibitors (oseltamivir and zanamivir). Nine hundred fourteen seasonal influenza A (H1N1) and 158 influenza A (H3N2) viruses have been tested for resistance to the adamantanes (amantadine and rimantadine). One hundred thirty-nine novel influenza A (H1N1) viruses have been tested for resistance to the neuraminidase inhibitors (oseltamivir and zanamivir). One hundred nineteen novel influenza A (H1N1) viruses have been tested for resistance to the adamantanes (amantadine and rimantadine). The results of antiviral resistance testing performed on these viruses are summarized in the table below.
Isolates tested (n)
Resistant Viruses,
Number (%)
Isolates tested (n)
Resistant Viruses, Number (%)
Oseltamivir
Zanamivir
Adamantanes
Seasonal Influenza A (H1N1)
904
899 (99.4%)
0 (0)
914
5 (0.5%)
Influenza A (H3N2)
158
0 (0)
0 (0)
158
145 (100%)
Influenza B
444
0 (0)
0 (0)
N/A*
N/A*
Novel Influenza A (H1N1)
139
0 (0)
0 (0)
119
119 (100%)
*The adamantanes (amantadine and rimantadine) are not effective against influenza B viruses.
Antiviral treatment with either oseltamivir or zanamivir is recommended for all patients with confirmed, probable or suspected cases of novel influenza A (H1N1) virus infection who are hospitalized or who are at higher risk for seasonal influenza complications. The novel influenza A (H1N1) virus is susceptible to both neuraminidase inhibitor antiviral medications zanamivir and oseltamivir. It is resistant to the adamantane antiviral medications, amantadine and rimantadine. Additional information on antiviral recommendations for treatment and chemoprophylaxis of novel influenza A (H1N1) infection is available at http://www.cdc.gov/h1n1flu/recommendations.htm
In areas that continue to have seasonal influenza activity, especially those with circulation of oseltamivir-resistant seasonal human influenza A (H1N1) viruses, clinicians might prefer to use either zanamivir or a combination of oseltamivir and either rimantadine or amantadine to provide adequate empiric treatment or chemoprophylaxis for patients who might have seasonal human influenza A (H1N1) virus infection. Pneumonia and Influenza (P&I) Mortality Surveillance
During week 20, 6.7% of all deaths reported through the 122-Cities Mortality Reporting System were due to P&I. This percentage is below to the epidemic threshold of 7.2% for week 20.
One influenza-associated pediatric death was reported to CDC during week 20 (Ohio); and was due to an influenza A virus. The death reported this week occurred during week 5 (the week ending February 7, 2009). Since September 28, 2008, CDC has received 62 reports of influenza-associated pediatric deaths that occurred during the current influenza season.
Of the 31 children who had specimens collected for bacterial culture from normally sterile sites, 13 (41.9%) were positive; Staphylococcus aureus was identified in eight (61.5%) of the 13 children. Three of the S. aureus isolates were sensitive to methicillin and five were methicillin resistant. Twelve of the 13 children with bacterial coinfections were five years of age or older and 10 (76.9%) of the 13 children were 12 years of age or older. An increase in the number of influenza-associated pediatric deaths with bacterial coinfections was first recognized during the 2006-07 influenza season. In January 2008, interim testing and reporting recommendations were released regarding influenza and bacterial coinfections in children and are available at (http://www2a.cdc.gov/HAN/ArchiveSys/ViewMsgV.asp?AlertNum=00268).
Laboratory-confirmed influenza-associated hospitalizations are monitored in two population-based surveillance networks: the New Vaccine Surveillance Network (NVSN) and the Emerging Infections Program (EIP).
During October 12, 2008 to May 16, 2009, the preliminary laboratory-confirmed influenza-associated hospitalization rate for children 0-4 years old in the NVSN was 3.85 per 10,000. Because of case identification methods utilized in this study, there is a delay from the date of hospitalization to the date of report.
During October 1, 2008 – May 16, 2009, preliminary laboratory-confirmed influenza-associated hospitalization rates reported by the EIP for children aged 0-4 years and 5-17 years were 3.7 per 10,000 and 0.7 per 10,000, respectively. For adults aged 18-49 years, 50-64 years, and = 65 years, the rates were 0.4 per 10,000, 0.5 per 10,000, and 1.5 per 10,000, respectively.
Nationwide during week 20, 2.0% of patient visits reported through the U.S. Outpatient Influenza-like Illness Surveillance Network (ILINet) were due to influenza-like illness (ILI). This percentage is below the national baseline of 2.4%.
On a regional level, the percentage of outpatient visits for ILI ranged from 0.4% to 5.3%. Two of the 10 surveillance regions reported an ILI percentage above their region specific baseline (Regions II and X). ILI increased during week 20 in six of 10 regions compared to week 19. Geographic Spread of Influenza as Assessed by State and Territorial Epidemiologists:
The influenza activity reported by state and territorial epidemiologists indicates geographic spread of both seasonal influenza and novel influenza A (H1N1) viruses and does not measure the severity of influenza activity.
During week 20, the following influenza activity was reported:
Widespread influenza activity was reported by four states (Arizona, California, New Jersey, and Virginia).
Regional influenza activity was reported by 11 states (Alabama, Connecticut, Hawaii, Illinois, Maryland, Massachusetts, New York, Pennsylvania, South Carolina, Tennessee, and Texas).
Local influenza activity was reported by the District of Columbia and 13 states (Alaska, Georgia, Kansas, Louisiana, Maine, Michigan, Nevada, New Mexico, North Carolina, Oklahoma, Oregon, Rhode Island, and Washington).
Sporadic activity was reported by 21 states (Arkansas, Colorado, Delaware, Florida, Idaho, Indiana, Iowa, Kentucky, Minnesota, Mississippi, Missouri, Montana, Nebraska, New Hampshire, North Dakota, Ohio, South Dakota, Utah, Vermont, Wisconsin, and Wyoming).
No influenza activity was reported by one state (West Virginia).
--------------------------------------------------------------------------------
A description of surveillance methods is available at: http://www.cdc.gov/flu/weekly/fluactivity.htm
Recombinomics Commentary 13:29 June 1, 2009 Commentary
(snip)
Although various government agencies had offered optimistic reassurances that the swine flu levels would decline during the summer "off season", the latest data case serious doubt on that projection. The swine H1N1 has an avian PB2, which has an E at position 627. Consequently, the replication rate for the virus is optimal at 41 C, the body temperature of a bird. This is in marked contrast to seasonal flu, which had E627K, which optimizes replication rates to 33 C. Consequently, the swine H1N1 has increased activity as the weather warms in the northern hemisphere, and seasonal flu has declined as summer months approach.
Does anyone know whether the avian PB2 phenomenon will affect spread in the Southern Hemisphere as the temperatures there become colder?
Does anyone know whether the avian PB2 phenomenon will affect spread in the Southern Hemisphere as the temperatures there become colder?
I suspect the swine H1N1 in the southern hemisphere will pick up E627K, either by acquiring a human PB2 via reassortment, or simply through recombination with seasonal flu.
Thus, there will be a summer version with avian PB2, and a winter version, with E627K.
The latest surveillance report (week 20) from the CDC, clearly indicates that swine H1N1 activity is on the rise in the United States, as seasonal flu levels continue to decline. Consequently the ratio of swine H1N1 to seasonal flu (H1N1, H3N2, influenza B, combined) is greater than 10 to 1. Thus, the vast majority of influenza infections in the United States are now swine flu, which is clear from the latest figures, even though reporting agencies in the United States are limiting testing (see updated maps). The latest figures show 1213 (1096+117) swine H1N1 cases compared to a total of 121 for seasonal flu (24+70+27). More importantly however, is the steady increase in the percentage of samples which are positive, (now at 22.41%), which is a frequent characteristic of seasonal flu at the height of flu season.
Although various government agencies had offered optimistic reassurances that the swine flu levels would decline during the summer "off season", the latest data case serious doubt on that projection. The swine H1N1 has an avian PB2, which has an E at position 627. Consequently, the replication rate for the virus is optimal at 41 C, the body temperature of a bird. This is in marked contrast to seasonal flu, which had E627K, which optimizes replication rates to 33 C. Consequently, the swine H1N1 has increased activity as the weather warms in the northern hemisphere, and seasonal flu has declined as summer months approach.
This increase in H1N1 swine flu has been masked to varying degrees by reporting protocols. In Mexico, the national reports are limited to confirmed cases, and there is a large backlog in confirming probable cases. Thus, the reported numbers in Mexico grossly underestimates cases that have been lab confirmed (considered probable because they are influenza A positive, but not sub-typable with human flu reagents).
In the Unites States, the confirmatory tests have been shifted from the CDC to the 44 states that are certified to run the confirmatory tests. However, the number of confirmatory test kits is limited, so many states have focused on hospitalized patients and have stopped testing mild cases. Similarly, testing of school clusters is also limited to initial cases. The vast majority of infected students and teachers are also not tested. However, in spite of these limitations, the frequency of H1N1 swine positives has risen steadily.
These increases in the United States have begun to affected surveillance programs by countries outside of North America. An increasing number of cases link back to the United States. However, the programs in these other countries also grossly underestimates the number of cases, because the case definition includes travel from an H1N1 infected region, so local cases are not tested unless they link back to imported cases. However, this airport surveillance program misses the vast majority of imported cases because cases infected within a few days of travel are not symptomatic, and a high percentage of cases do not develop a high fever. Moreover, the rapid test used to confirm cases has a low sensitivity. Consequently, most imported cases are not detected, and local infected patients are also not tested because they do not meet the case definition.
This lack of testing is the used to claim that there has been no "evidence" of sustained community transmission, because the local cases are not tested until. However, this limited testing still identifies community cases which happen to be linked to a transmission chain under investigation. Similarly, the local cases lead to school outbreaks, which are not easily ignored, especially in countries in the northern hemisphere, because seasonal flu season has ended, so outbreaks involving students with flu-like symptoms leads to limited swine flu testing.
However, the large number of cases being reported daily, is leading to additional testing and additional examples of community transmission, which will clearly demonstrate that the pandemic is at Phase 6. Redefining phase 6 to include severity of disease will just delay the inevitable, because the swine H1N1 will continue to adapt to its new host, which will likely lead to an increase in fatal cases, which involves the same age group (25-44), which was reported in for the initial cases in Mexico.
.
__________________
"The next major advancement in the health of American people will be determined by what the individual is willing to do for himself"-- John Knowles, Former President of the Rockefeller Foundation
Once again, Dr. Niman's Commentary is an excellent and sharp-eyed analysis of the situation.
And thank you, Alaska Denise for posting it !
I'd like to propose, that Dr.Niman's commentaries should be posted in a separate thread. I think, some people could have missed them, while the headlines refer to other items (e.g. "CDC week 20")
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CDC Week 20
Linear Mode
