Get documents about "acip slides presentation october 2009, acip
Document Sample
Influenza Epidemiology and
Surveillance
Lyn Finelli, DrPH
Lynnette Brammer, MPH
Krista Kniss, MPH
Lenee Blanton, MPH
Scott Epperson, MPH
Laurie Kamimoto, MD, MPH
Ashley Fowlkes, MPH
Michael Jhung, MD, MPH
Epidemiology/Surveillance
ILI Syndromic Surveillance
Epidemiology/Surveillance
Epidemiology/Surveillance
Epidemiology/Surveillance
Epidemiology/Surveillance
Epidemiology/Surveillance
Epidemiology/Surveillance
Percentage of Visits for Influenza-like Illness (ILI) Reported by
the U.S. Outpatient Influenza-like Illness Surveillance Network (ILINet),
National Summary 2008-09 and Previous Two Seasons
7
6 6.1%
5
% of Visits for ILI
4
3
2
1
0
11 1
10
24
21
21
18
16
30
10 4
13
27
19
11
/3
25
22
7
8
11 5
12 3
12 9
7
7
4
2
5
8
/1
/1
/2
/1
/2
/
/
2/
3/
4/
5/
8/
9/
10
11
10
1/
2/
3/
1/
4/
5/
5/
6/
8/
9/
6/
7/
7/
Week Ending Dates
2006-07† 2007-08† 2008-09 National Baseline
Epidemiology/Surveillance
ILINet - Percent ILI by Month, 2009
7.0
6.0 5.6*
5.0
4.0 3.7
Percent
3.0
3.0
2.1
2.0 1.7 1.6
1.1
1.0
0.0
April May June July August September October
Month
% ILI (Unweighted)
*Preliminary
Epidemiology/Surveillance
Epidemiology/Surveillance
Epidemiology/Surveillance
Epidemiology/Surveillance
Epidemiology/Surveillance
Epidemiology/Surveillance
ACHA ILI Surveillance
7,099 new ILI cases were reported
47,000 cases of ILI among 3.4 M students
78 hospitalizations and no deaths
Courtesy of Jim Turner and Randol Doyle ACHA
Epidemiology/Surveillance
Weekly Influenza Activity Reported by SLTT’s
Epidemiology/Surveillance
Weekly Influenza Activity Reported by SLTT’s
Epidemiology/Surveillance
Severity: H1N1 2009
Seasonal
Severity
Epidemiology/Surveillance
Hospitalization
Epidemiology/Surveillance
Lab-Confirmed Hospitalizations by Age Group through Week 40 (n=4,958)*
Influenza Week 40 – 16 OCT 2009
1400 0-18 = 44.1%
1255
1194 19-64 = 48.3%
1200
65+ = 7.2%
1000 933
Hospitalizations (n)
800 757
600
443
400 356
200
0
0-4 Yrs 5-18 Yrs 19-24 Yrs 25-49 Yrs 50-64 Yrs ≥65 Yrs
Age Group
*Numbers are cumulative from start of MMWR week 35 (August 30, 2009)
Epidemiology/Surveillance
Lab-Confirmed Hospitalization Rates per 100,000 Population by Age Group through Week 40 (n=4,938*)
Influenza Week 40 – 16 OCT 2009
Hospitalizations per 100,000 Population
5
4.44 28 states reporting lab- confirmed
4.5 influenza hospitalization
4
3.5
3
2.5 2.18
2 1.74 1.63
1.37
1.5 1.13
0.92
1
0.5
0
0-4 Yrs 5-18 Yrs 19-24 Yrs 25-49 Yrs 50-64 Yrs ≥65 Yrs All ages
Age Group
*Hospitalizations with unknown ages are not included (n=20).
Rate / 100,000 by Single Year Age Groups: Denominator source: 2008 Census Estimates, U.S. Census Bureau at:
http://www.census.gov/popest/national/asrh/files/NC-EST2007-ALLDATA-R-File24.csv
Laboratory-Confirmed Influenza
Hospitalization Surveillance, 2009-2010
Pop-Based Hosp Sites (3.5 million)
Emerging Infections Program Sites (22.1 million)
Epidemiology/Surveillance
Cumulative Seasonal Influenza Hospitalization Rates by Age,
Population-Based sites
Hospitalizations Rates
(EIP 2008-09 and Network 2009-10 seasons)
Hospitalization per 100,000 population
40
35.6
Cumulative rates for fall (6 weeks) for
middle age groups are approaching
or exceeding those for last season
30 (6 months)
20.6
20
13.6
9.7
10
6.4 5.9 5.8
4.9 4.9
3.7
0
0-4 years 5-17 years 18-49 years 50-64 years 65+ years
Age Group
08_09 (10/1- 4/14) - H1N1 Predominant 09_10 (9/1 - 10/20) - Network
Epidemiology/Surveillance
Cumulative Seasonal Influenza Hospitalization Rates by Age,
Population-Based sites
Hospitalization per 100,000 population
40 Hospitalizations Rates
(EIP summer 2009 and Network 2009-10 seasons)
30
Rates for fall (6 weeks) are approaching
rates for spring (4 months)
20.6
20
16.3
9.7
10 8.4
5.5 5.9 6.3 5.8 5.1 4.9
0
0-4 years 5-17 years 18-49 years 50-64 years 65+ years
Age Group
09 H1 (4/15 - 8/31) - EIP 09_10 (9/1 - 10/20) - Network
au g
w k 51
au g
w k 49
ju l
w k 47
ju l
w k 45
ju n
w k 43
Cumulative rate of hospitalization/ 100,000 population
ju n
w k 41
m ay
w k 39
m ay
w k 37
ap r
w k 35
Epidemiology/Surveillance
ages 0-4, EIP, 2003-2009
ap r
w k 33
ap r
w k 31
m ar
w k 29
m ar
w k 27
fe b
w k 25
fe b
w k 23
jan
w k 21
jan
w k 19
d ec
w k 17
d ec
w k 15
nov
w k 13
2009 Spr (Novel H1)
nov
w k 11
o ct
wk 9
2003-4 (H3)
2004-5 (H3)
2005-6 (H3)
2006-7 (H1)
2007-8 (H3)
2008-9 (H1)
o ct
wk 7
2009-10
o ct
wk 5
sep
wk 3
sep
wk 1
10
9
8
7
6
5
4
3
2
1
0
au g
w k 51
au g
w k 49
ju l
w k 47
ju l
w k 45
ju n
w k 43
Cumulative rate of hospitalization/ 100,000 population
ju n
w k 41
m ay
w k 39
m ay
w k 37
ap r
w k 35
ages 5-17, EIP, 2003-2009
Epidemiology/Surveillance
ap r
w k 33
ap r
w k 31
m ar
w k 29
m ar
w k 27
fe b
w k 25
fe b
w k 23
jan
w k 21
jan
w k 19
d ec
w k 17
d ec
w k 15
nov
w k 13
2009 Spr (Novel H1)
nov
w k 11
o ct
wk 9
2003-4 (H3)
2004-5 (H3)
2005-6 (H3)
2006-7 (H1)
2007-8 (H3)
2008-9 (H1)
o ct
wk 7
2009-10
o ct
wk 5
sep
wk 3
sep
wk 1
2
1.8
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
au g
w k 51
au g
w k 49
ju l
w k 47
ju l
w k 45
ju n
w k 43
Cumulative rate of hospitalization/ 100,000 population
ju n
w k 41
m ay
w k 39
m ay
w k 37
ap r
w k 35
ages 18-64, EIP, 2005-2009
ap r
Epidemiology/Surveillance
w k 33
ap r
w k 31
m ar
w k 29
m ar
w k 27
fe b
w k 25
fe b
w k 23
jan
w k 21
jan
w k 19
d ec
w k 17
d ec
w k 15
nov
w k 13
2009 Spr (Novel H1)
nov
w k 11
o ct
wk 9
2005-6 (H3)
2006-7 (H1)
2007-8 (H3)
2008-9 (H1)
o ct
2009-10
wk 7
o ct
wk 5
sep
wk 3
sep
wk 1
2
1.8
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
au g
w k 51
au g
w k 49
jul
w k 47
jul
w k 45
jun
w k 43
Cumulative rate of hospitalization/ 100,000 population
jun
w k 41
m ay
w k 39
m ay
w k 37
ap r
w k 35
Epidemiology/Surveillance
ages 65+, EIP, 2005-2009
ap r
w k 33
ap r
w k 31
m ar
w k 29
m ar
w k 27
fe b
w k 25
fe b
w k 23
jan
w k 21
jan
w k 19
d ec
w k 17
d ec
2009 Spr (Novel H1) w k 15
nov
w k 13
nov
w k 11
2005-6 (H3)
2006-7 (H1)
2007-8 (H3)
2008-9 (H1)
o ct
2009-10
wk 9
o ct
wk 7
o ct
wk 5
sep
wk 3
sep
wk 1
10
9
8
7
6
5
4
3
2
1
0
Epidemiology/Surveillance
Mortality
Epidemiology/Surveillance
Pneumonia and Influenza Mortality for 122 U.S. Cities -Week Ending 10 OCT 2009
12
10
% of All Deaths Due to P&I
Epidemic
Threshold
8
6
Seasonal
Baseline
2005 2006 2007 2008 2009
4
41 50 10 20 30 40 50 10 20 30 40 50 10 20 30 40 50 10 20 30 40
Weeks
Epidemiology/Surveillance
Number of Influenza-Associated Pediatric Deaths
by Week of Death:
2005-06 season to present
2009-10
15 2007-08 Number of H1N1
14 2008-09 Deaths
2006-07 Number of Deaths
Reported = 88 Number of Reported=86
13 Number of Deaths
Seasonal Deaths
12 Reported = 78
Reported =69
11
Number of deaths
10
9
8
2005-06
7 Number of Deaths
6 Reported = 46
5
4
3
2
1
0
2005-40
2005-46
2005-52
2006-06
2006-12
2006-18
2006-24
2006-30
2006-36
2006-42
2006-48
2007-02
2007-08
2007-14
2007-20
2007-26
2007-32
2007-38
2007-44
2007-50
2008-04
2008-10
2008-16
2008-22
2008-28
2008-34
2008-40
2008-46
2008-52
2009-05
2009-11
2009-17
2009-23
2009-29
2009-35
Week of Death
Unsubtyped deaths Reported Current Week
Unsubtyped Deaths Reported Previous Weeks 2009 Influenza A (H1N1) Deaths Reported Previous Weeks
Epidemiology/Surveillance
Lab-Confirmed Deaths by Age Group through Week 40 (n=292*)
Influenza Week 40 – 16 OCT 2009
150
0-18 = 16.8%
125 19-64 = 71.6%
65+ = 11.6 %
100 95 94
Deaths (n)
75
50 40
34
25 20
9
0
0-4 Yrs 5-18 Yrs 19-24 Yrs 25-49 Yrs 50-64 Yrs ≥65 Yrs
Age Group
*Numbers are cumulative from start of MMWR week 35 (August 30, 2009)
Epidemiology/Surveillance
Lab-Confirmed Mortality per 100,000 Population by Age Group (n=292*)
Influenza Week 40 – 16 OCT 2009
27 states reporting lab- confirmed
influenza deaths
Deaths per 100,000 Population
0.2
0.17
0.15
0.1 0.09 0.09
0.08
0.07
0.05 0.04
0
0-4 Yrs 5-18 Yrs 19-24 Yrs 25-49 Yrs 50-64 Yrs ≥65 Yrs
Age Group
*Rate / 100,000 by Single Year Age Groups: Denominator source: 2008 Census Estimates, U.S. Census Bureau at:
http://www.census.gov/popest/national/asrh/files/NC-EST2007-ALLDATA-R-File24.csv
Have the risk groups changed?
Who is at risk?
Risk groups have not changed since the spring wave
• Children and adolescents still remain at the highest risk for
acquisition
• Hospitalizations are highest in young children and decline with age
• Deaths increase with age but only up to 50-64 year old age group
and then decline slightly in 65+ age group
• The majority of those who die and adults who are hospitalized have
underlying conditions, including pregnancy
Emerging Infections Program, Influenza Hospitalization
PEDIATRIC HOSPITALIZATIONS BY UNDERLYING MEDICAL CONDITION* -- I
2009 H1N1 (Apr 15-Aug 31)**
(N=465, 62% had >1 underlying condition)
Medical Conditions* n (% N)***
Asthma 166 (35.7)
Cystic Fibrosis 1 (0.2)
Other Chronic Lung Disease 23 (5.0)
Bronchopulmonary Dysplasia 5 (1.1)
Chronic Cardiovascular Disease 20 (4.3)
Chronic Metabolic Disease 14 (3.0)
Diabetes 6 (1.3)
Renal Disease 12 (2.6)
Neuromuscular Disease 24 (5.2)
Cerebral Palsy 13 (2.8)
*ACIP recognized condition
**excludes nosocomial
***not mutually exclusive; exceeds 100% Data as of 13 October 2009
Emerging Infections Program, Influenza Hospitalization
PEDIATRIC HOSPITALIZATIONS BY UNDERLYING MEDICAL CONDITION* -- II
2009 H1N1 (Apr 15-Aug 31)**
Medical Conditions* -- cont n (% N)***
Hemoglobinopathy 31 (6.7)
Immunosuppressive Condition 21 (4.5)
Seizure Disorder, incl h/o febrile seizures 27 (5.8)
Upper airway abnormality 4 (0.9)
Prematurity 27 (5.8)
Developmental Delay 33 (7.1)
Pregnant 6 (1.3)
*ACIP recognized condition
**excludes nosocomial
***not mutually exclusive; exceeds 100%
Data as of 13 October 2009
Emerging Infections Program, Influenza Hospitalization
ADULT HOSPITALIZATIONS BY UNDERLYING MEDICAL CONDITION* -- I
2009 H1N1 (Apr 15-Aug 31)**
(N=685, 76% had >1 underlying condition)
Medical Conditions* n (% N)***
Asthma 211 (30.8)
Cystic Fibrosis 2 (0.3)
Other Chronic Lung Disease 98 (14.3)
COPD 69 (10.1)
Chronic Cardiovascular Disease 118 (17.2)
Chronic Metabolic Disease 160 (23.4)
Diabetes 136 (19.9)
Renal Disease 57 (8.3)
Neuromuscular Disease 18 (2.6)
*ACIP recognized condition
**excludes nosocomial
***not mutually exclusive; exceeds 100% Data as of 13 October 2009
Emerging Infections Program, Influenza Hospitalization
ADULT HOSPITALIZATIONS BY UNDERLYING MEDICAL CONDITION* -- II
2009 H1N1 (Apr 15-Aug 31)**
Medical Conditions*--cont n (% N)***
Cancer, incl h/o lymphoma, leukemia 24 (3.5)
Immunosuppressive Condition 92 (13.4)
Seizure Disorder 21 (3.1)
Cognitive Dysfunction 15 (2.2)
Pregnant 76 (11.1)
*ACIP recognized condition
**excludes nosocomial
***not mutually exclusive; exceeds 100%
Data as of 13 October 2009
Underlying Conditions
Deaths Case Series April to June 2009
Condition <18 years (%) >18 years (%)
N=48 N= 251
Chronic Lung Disease 38 37
Asthma 17 19
COPD 0 17
Cardiovascular Disease 17 26
Neurologic Disease 52 12
Neurodevelopmental Disorder 38 4
Neuromuscular Disorder 35 5
Seizure Disorder 27 4
Other (non-spec., Alzheimer’s) 13 4
Pregnant 4 6
Diabetes 0 24
Renal Disease 2 15
Cancer 6 16
Immune Suppression 5 24
Hepatic Ds, Hematologic & Metabolic Disorders 2 17
Obesity 7 50
78% persons with ACIP high risk medical conditions
Special Focus on Pregnancy
Updated Information on Pregnant Women with H1N1
(April 15-August 21, 2009)
• 700+ pregnant women with confirmed or probable
2009 H1N1 influenza
• ~ 100 pregnant patients admitted to ICU
• 28 deaths in pregnant women among 484 total H1N1
deaths (6%)
• Pregnant women ~1% of the general population
Clinical Observations Regarding Pregnant Women with
2009 H1N1 Influenza
• Rapid deterioration
• Clinically fragile
• Generally prolonged ICU admissions
• Growing evidence that risk extends a few weeks
postpartum
• Some experienced delays in treatment due to false
negative rapid tests
Additional Clinical Information on Deaths among
Six Pregnant Women
• All patients developed primary viral pneumonia with
subsequent ARDS requiring mechanical ventilation
• Pregnancy outcomes:
– 5 with cesarean delivery (27-36 weeks gestation –
3 in ICU or ED),
– 1 fetal loss at 11 weeks
• Length of time from symptom onset to receipt of
antiviral medication was 6-15 days (median 9 days)
• Length of time from presentation for medical care
until receipt of antiviral treatment was 2-14 days
(median 4 days)
Jamieson DJ et al., Lancet 374:451-8, 2009
EpidemiologySurveillance
Race - Ethnicity
H1N1 Case Report Data
Race/Ethnicity by Date of Illness Onset
April 19 - May 3, n=647
Race/Ethnicity n (%)
White, NH 282 (44)
This slides shows the decline in the Black, NH 35 (5.4)
proportion of Hispanics from the Hispanic 210 (32)
beginning to middle of the outbreak Native HI/Oth. Pac. Islander 2 (0.3)
Asian 13 (2)
American Indian/AK Native 20 (3)
Multiracial 4 (0.4)
Unknown 81 (13)
May 4 - May 18, n=249 May 19 - June 16, n=26
Race/Ethnicity n (%) Race/Ethnicity n (%)
White, NH 125 (50) White, NH 13 (50)
Black, NH 17 (6.8) Black, NH 0
Hispanic 58 (23) Hispanic 5 (19)
Native HI/Oth. Pac. Islander 4 (1.6) Native HI/Oth. Pac. Islander 0
Asian 7 (2.8) Asian 1 (3.8)
American Indian/AK Native 11 (4.4) American Indian/AK Native 1 (3.8)
Multiracial 0 Multiracial 0
Unknown 27 (11) Unknown 6 (23)
Race/ethnicity of adult respondents with influenza-like illness (ILI) in the U.S.,
Behavioral Risk Factor Surveillance System (BRFSS),
Sept 1- Sep 30, 2009
ILI Total Weighted % Weighted
ILI (95% CI)
Race/ethnicity
White, non-Hispanic 1026 22254 5.48 (4.87–6.10)
Black, non-Hispanic 121 2135 5.40 (3.68–7.13)
Hispanic 109 1934 3.83 (2.28–5.39)
Other race only, Non- 74 1074 6.41 (3.77–9.05)
Hispanic
Multiracial, Non- 43 435 13.2 (6.34–20.07)
Hispanic
Not asked or missing 18 310 4.12 (1.46–6.78)
This slide shows that all race-ethnicities have approximately equal
incidence of ILI during the month of September
Health care seeking behavior of adults respondents with ILI in the
U.S., by race/ethnicity, BRFSS,
Sept 1- Sep 30
Sought medical Total Weighted Weighted
care for ILI %Yes (95% CI)
White, 454 1026 41.4 (35.7–47.1)
non-Hispanic
Black, 63 120 49.5 (33.3–65.7)
non-Hispanic
Hispanic 51 109 39.5 (20.6–58.4)
Other race 35 74 40.0 (18.3–61.7)
only, non-
Hispanic
Multiracial, 24 43 48.5 (19.2–77.8)
non-Hispanic
This slide shows that all race-ethnicities have approximately equal
incidence of seeking care for ILI during the month of September
Influenza Associated Pediatric Mortality
Distribution of laboratory-confirmed pediatric 2009 H1N1 and seasonal influenza
deaths by race/ethnicity, 2009
H1N1 deaths 4/14- H1N1 deaths 9/1- Seasonal
8/31/2009 present Deaths
Hispanic – any race (15%) 17 (35%) 6 (21%) 18 (25%)
White (67%) 19 (40%) 7 (25%) 30 (42%)
Black (12%) 6 (13%) 9 (32%) 13 (18%)
Asian (4%) 2 (4%) 1 (4%) 5 (7%)
Alaska Native or American
Indian (1%) 0 1 (4%) 1 (1%)
Native Hawaiian or Pacific
Islander (0.14%) 0 0 2 (3%)
Unknown race or
race/ethnicity 4 (8%) 4 (14%) 2 (3%)
Totals 48 28 71
Conclusions
• H1N1 is now widespread over most of the US
• ILI Net rates are currently higher in October than they have been at the peak of
the last 5 influenza seasons
• Hospitalizations are highest in the youngest children and decline with age,
excess hospitalizations are highest in the 5-17 year old age group
• Deaths are lowest in the youngest children and increase with age but only up
to 50-64 year old age group -- deaths decline slightly in 65+ age group
• The majority of those hospitalized and dying from flu have underlying
conditions
– Asthma is common among those hospitalized
– Neuromuscular disorder is common among children dying from influenza
• Pregnant women are disproportionately affected by severe outcome
• Racial ethnic disparities in severe outcomes exist and warrant investigation
Related docs
