September Public Health Practice Committee Meeting

When: Monday, September 28th 2009; 12:30-1:30 pm EDT

Agenda:

1. Welcome

2. ISDS Updates: Rachel Viola, ISDS Project Manager and Julia E. Gunn, RN, MPH (ISDS Board Representative)

3. Michael Jhung MD, MPH, of the CDC Influenza Division: Surveillance & Response Team will provide information on the syndromic surveillance component of the state's weekly influenza report to the CDC in a presentation entitled: “New Aggregate National Influenza Surveillance. For the 2009-2010 Influenza Season” (see PDF of his slides)

4. ISDS Funding & DiSTRIBuTE Project Updates: Don Olson, ISDS Research Director

Next Meeting: Monday, October 26th at 12:30 pm EDT.

Data Visualization for Health Surveillance: Webinar Recording and Slides Now Available

The recording and presentation slides from the Research Committee's webinar on "Data Visualization for Health Surveillance: Current Concepts and New Horizons" are now available on the ISDS wiki.

Thanks to all who attended and have continued to make the Research Committee's webinars a success. If you would like to get involved in future activities of the Research Committee, please contact: rviola-at-syndromic.org.

School Based Surveillance Research Opportunities

As a follow-up from the Research Committee's July webinar on school based surveillance research, Dr. Francisco Averhoff of the CDC has invited ISDS members to participate in research studies related to this topic.

Study areas include:

1. Why some schools K-12/Universities have outbreaks and not others (risk factors)
2. Use of school absenteeism data
3. Occupational risk for ILI in school personnel
4. Lessons learned about control of ILI in schools/universities

If you are interested in participating, please contact:
fma0-at-cdc.gov
syw9-at-cdc.gov
dic6-at-cdc.gov

Research Committee September Topical Meeting

For its upcoming topical meeting, the Research Committee will be hosting a webinar panel discussion entitled “Data Visualization for Health Surveillance: Current Concepts and New Horizons.” Participating panelists include:

-Wayne Loschen, Johns Hopkins University Applied Physics Laboratory
-Karl Soetebier, Georgia Division of Public Health
-Paul Picciano, Aptima, Inc.
-Frank Hardisty, Penn State University

The panelists include veteran developers with long public health relationships as well as visualization experts newer to health surveillance but with substantial experience in other fields.

Each panelist will present for 10-15 minutes followed by an open discussion.

This webinar will be taking place on Wednesday, September 23rd from 10:00-11:30 am, US Eastern Time. Register here

September Article Listing for Literature Review

The following list contains the most recent articles collected by the Research Committee's automated search. These articles will be reviewed on the next Literature Review call, taking place on Thursday, October 29th, 2009 at 10:00 am EST.

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van Hal SJ, Foo H, Blyth CC, McPhie K, Armstrong P, Sintchenko V, Dwyer DE.
Influenza outbreak during Sydney World Youth Day 2008: the utility of laboratory testing and case definitions on mass gathering outbreak containment.
PLoS One. 2009 Sep 3;4(9):e6620.

Elbert Y, Burkom HS.
Development and evaluation of a data-adaptive alerting algorithm for univariate temporal biosurveillance data.
Stat Med. 2009 Sep 1

Caudle JM, van Dijk A, Rolland E, Moore KM.
Telehealth Ontario detection of gastrointestinal illness outbreaks.
Can J Public Health. 2009 Jul-Aug;100(4):253-7.

Bayesian Information Fusion Networks for Biosurveillance Applications.
J Am Med Inform Assoc. 2009 Aug 28

Elliot AJ, Powers C, Thornton A, Obi C, Hill C, Simms I, Waight P, Maguire H, Foord D, Povey E, Wreghitt T, Goddard N, Ellis J, Bermingham A, Sebastianpillai P, Lackenby A, Zambon M, Brown D, Smith GE, Gill ON.
Monitoring the emergence of community transmission of influenza A/H1N1 2009 in England: a cross sectional opportunistic survey of self sampled telephone callers to NHS Direct.
BMJ. 2009 Aug 27;339:b3403.

Uscher-Pines L, Farrell CL, Cattani J, Hsieh YH, Moskal MD, Babin SM, Gaydos CA, Rothman RE.
A survey of usage protocols of syndromic surveillance systems by state public health departments in the United States.
J Public Health Manag Pract. 2009 Sep-Oct;15(5):432-8.

Blair PJ, Wierzba TF, Touch S, Vonthanak S, Xu X, Garten RJ, Okomo-Adhiambo MA, Klimov AI, Kasper MR, Putnam SD.
Influenza epidemiology and characterization of influenza viruses in patients seeking treatment for acute fever in Cambodia.
Epidemiol Infect. 2009 Aug 24;:1-11.

Babin SM.
Using syndromic surveillance systems to detect pneumonic plague.
Epidemiol Infect. 2009 Aug 24;:1-8.

20Aug2009
Osnas EE, Heisey DM, Rolley RE, Samuel MD.
Spatial and temporal patterns of chronic wasting disease: fine-scale mapping of a wildlife epidemic in Wisconsin.
Ecol Appl. 2009 Jul;19(5):1311-22.

Wang X, Zeng D, Seale H, Li S, Cheng H, Luan R, He X, Pang X, Dou X, Wang Q.
Comparing Early Outbreak Detection Algorithms Based on Their Optimized Parameter Values.
J Biomed Inform. 2009 Aug 12.

Uphoff H, Geis S, Grüber A, Hauri A.
What will the next influenza season bring about: seasonal influenza or the new A(H1N1)v? An analysis of German influenza surveillance data.
Euro Surveill. 2009 Aug 13;14(32.

Links to International Novel A (H1N1) Influenza Picture

The following list of links was compiled for the Global Outreach Committee's blog series on the Novel A (H1N1) influenza virus.

Centers for Disease Control (US): International Map

BBC - United Kingdom (Source: WHO): Swine Flu by Country

HealthMap - Harvard Medical School, US
(Diseases last 30 days - select none then Swine flu)

H1N1: A Veterinary Perspective

The following article was written by Victor Del Rio Vilas, DVM, MBA, MSc, PhD, for the Global Outreach Committee's blog series on the Novel A (H1N1) influenza virus.

To date, four incidents of pandemic H1N1 2009 virus in domestic species have been reported worldwide (OIE). The first incident was reported in Canada and affected pigs. Pigs were also reported from Argentina and Australia. The fourth incident, in Chile, affected two commercial breeding turkey farms. This last incident in turkeys is the first report of birds being infected with the pandemic H1N1 2009 virus. This finding is at odds with previous evidence that showed that poultry (chickens) were refractory to infection (Lange et al., 2009). In all four cases there was some evidence that personnel working or visiting the premises showed some flu-like illness. In the Australian incident, pandemic H1N1 2009 virus was isolated from staff.

UK’s Government position, referring to disease in pigs, is one of collaboration with the industry. To date, UK’s animal authorities consider novel influenza in pigs an industry’s problem and so the industry should lead. UK’s authorities have supported the industry and provided advice in the production of a code of practice against influenza viruses (not only pandemic H1N1 2009). Other approaches have been developed elsewhere (e.g. the development of contingency plans for novel influenza in swine herds in the Netherlands). With regard to poultry, the British Veterinary Association (2009) has issued warnings to poultry keepers to prevent staff with flu-like illness from working with poultry.

There appears to be a consensus that infection in swine herds would not constitute a significant source of infection to humans, compared to human to human transmission, in a situation of widespread infection of the human population. However, there is uncertainty as to what it would be the impact of pandemic H1N1 2009 incidents in animal populations once the peak of the epidemic in humans has passed. At the tail of the epidemic in humans, if H1N1 does not become a recurrent event as it is the case of regular flu, the relevance of animal transmission to humans, and the surveillance value of reverse zoonosis incidents might increase. This would resemble the situation at the start of the epidemic when the first case reported in Canada in pigs had some value in the detection of human infection hidden to the regular Public Health surveillance systems.

The importance of pandemic H1N1 2009, from a veterinary perspective, goes beyond its Public Health impact. Following UK’s four reasons for Government intervention (welfare impact, Public Health impact, wider society impact and trade impact), novel influenza in any domestic species could result, as it has happened already, in trade restrictions. So far, infection in animals has shown mild disease presentations, in swine and birds, with rapid recovery. On this basis, the impact on the welfare appears to be reduced. Finally, the impact on the wider society, at the peak of the epidemic in humans, is likely to be, in comparison to the potential disruption caused by the human form, insignificant. This assessment may or course change in the future if the epidemic in humans recedes.

Surveillance of potential pandemic H1N1 2009 incidents in Great Britain relies on submissions of suspect cases by farmers. The number of submissions in 2009 remains steady. This is a positive result that challenges initial fears of a drop in the number of submissions by farmers due to potential retail pressures.

OIE (2009)
Lange E., Kalthoff D., Blohm U., Teifke J.P., Breithaupt A., Maresch C., Starick E., Fereidouni S., Hoffmann B., Mettnleiter T.C., Beer C., Vahlenkamp T.W. (2009). Pathogenesis and transmission of the novel swine-origin influenza virus A/H1N1 after experimental infection of pigs. Journal of General Virology 90, 2119-2123.

About the Author:
Victor J Del Rio Vilas, DVM, MBA, MSc, PhD
UK
*The views expressed above are solely those of the author.

Novel A (H1N1) Influenza Virus Medical and Clinical Issues for Epidemiologists

The following list of recommendations and resources was compiled by Larissa May, MD, MSPH, for the Global Outreach Committee's blog series on the Novel A (H1N1) influenza virus.

***All recommendations are based on CDC and WHO guidelines and are based on the current relatively mild disease noted in patients in the developed world. These recommendations are subject to ongoing review and change. In the event of increased virulence of the novel A (H1N1) strain, or changes in morbidity and mortality, or regional variations in pattern of disease, recommendations are likely to change.***

Clinical Features:
Novel Influenza A (H1N1) presents in a similar fashion to seasonal influenza. Symptoms include fever, cough, sore throat, nasal congestion, myalgias, headache, chills, and fatigue/malaise. 25% of persons, including adults, may have GI-related symptoms, including vomiting and diarrhea (CDC, 2009) (Dawood F et al, 2009).

Diagnosis:
Clinicians should consider testing persons with ILI who are severely ill or at risk of influenza-related complications. In the event of a pandemic, the diagnosis of influenza will typically be made clinically by the treating provider, and most information on viral strains will be available through laboratory-based surveillance mechanisms. CDC is no longer recommending testing of all persons with suspected influenza infection.

Vaccination:

Seasonal Influenza:
This year, the CDC’s Advisory Committee on Immunization Practices (ACIP) has extended the recommendations for annual seasonal influenza vaccination to include those individuals 6 months to 18 years of age, in addition to the traditional target groups:
• Healthcare workers
• Individuals greater than 65 years of age
• Individuals with comorbidities such as asthma, cardiopulmonary disease, chronic neurological issues, and immune suppression.
(CDC ACIP, 2009)

Novel A (H1N1) Influenza:
While a novel Influenza A (H1N1) vaccine is currently undergoing clinical trials, the expected dates for distribution are unknown due to uncertainty in clinical trial completion dates and time required for manufacture. In the event of a pandemic due to the novel Influenza A (H1N1) strain, in the United States it is likely the vaccine will be distributed via public health authorities through special allocation. Requirements for vaccine administration are yet to be finalized regarding the possibility of concurrent administration of seasonal and H1N1 vaccines and number of doses required. The ACIP is expected to revise their recommendations before the 2009-2010 influenza season. Currently, in terms of prioritization, the focus is on schools grades K-12, pregnant women, children 6 months to age 4, household contacts of infants less than 6 months, those under 65 at risk for severe influenza, and health care workers and first responders (CDC, 2009).

Treatment Recommendations:
Persons at risk are:
• Children younger than 5
• Persons aged 65 or older
• Children and young adults under 18 on long term aspirin therapy
• Pregnant women, adults and children with asthma
• Chronic pulmonary, cardiovascular, hepatic, hematologic, neurologic/neuromusuclar or metabolic disorders including diabetes)
• Adults and children with immunosuppression (includes HIV and immune suppressive medications)
• Residents of nursing homes or other long term care facilities.

Antiviral Medications:
According to the CDC, antiviral medications with activity against influenza are useful adjuncts in the prevention and early treatment of influenza (CDC ACIP, 2009).

Four antiviral agents are currently FDA licensed: amantadine, rimantadine, zanamivir, and olsetamivir. During the 2007-2008 and 2008-2009 influenza seasons, influenza A (H1N1) viruses with a mutation conferring resistance to olsetamavir commonplace in United States (99% resistance rate) and other countries (Lackenby et al, 2008; Meijia et al, 2009; WHO, 2009, CDC, 2008). However, the novel A (H1N1) strain has shown susceptibility to olsetamivir (Dharan et al, 2009).

During the novel A (H1N1) outbreak in May 2009, CDC published interim guidelines for treatment and prophylaxis of influenza in patients diagnosed with the novel H1N1 virus (CDC H1N1 Recommentations).

These guidelines recommend that all hospitalized patients with confirmed, probable or suspected H1N1 and persons at high risk for complications be treated with antiviral agents. Clinical judgment should be reserved for others on a case by case basis. Either olsetamivir or zanamivir may be used for treatment or prophylaxis. Chemoprophylaxis is recommended for close contacts of influenza cases who are at high risk, including healthcare workers, first responders and public health workers. Post exposure prophylaxis should be continued for ten days beyond the date of last exposure. Pre-exposure prophylaxis can be considered for persons at high risk who cannot avoid contact with an individual with influenza, i.e. caregivers of persons with influenza who are in high-risk categories. For ongoing occupational risk, temporary reassignment for persons at risk is recommended, or the use of personal protective equipment where exposure cannot be avoided. Consultation with local public health and medical experts is recommended (CDC, 2009).

Infection Control in Healthcare Settings:
CDC guidelines for contact and droplet precautions should be followed. Routine cleaning and disinfection protocols should be followed. In the event that a high risk procedure is undertaken (i.e. elective intubation, aerosol generating procedures such as the administration of nebulized medications, etc), airborne isolation in a negative pressure room with 6 to 12 air changes per hour should be instituted. If patients must be transported outside the room, a surgical mask should be placed on the patient. Although there is little evidence that use of an N95 respirator provides improved protection over a surgical mask, CDC is recommending all healthcare workers entering the room of a patient with influenza wear an N95 or equivalent respirator and be fit tested. Isolation precautions should be continued for 7 days or until symptoms resolve, whichever is longer. Healthcare workers in high risk categories should consider temporary reassignment, or if this is not possible, the use of a respirator. If a healthcare worker shows signs and symptoms of ILI, they should self-isolate at home and not return to work for 7 days or until symptoms resolve, whichever is longer (CDC Infection Control Guidelines).

Self-Isolation of Ill Persons with ILI:
Persons with ILI suspected of having influenza should self-isolate at home. They should separate themselves from other members of the household, particularly those at risk of developing complications of influenza, such as: infants under 6 months of age, the elderly, and those with comorbidities such as cardiopulmonary disease, diabetes, or immunosuppression. They should not return to work or school until 24 hours after resolution of fever or symptoms, whichever is longer. This is a change from the initial recommendation to stay away from others for 7 days (CDC Home Care Guidance) (CDC Exclusion Guidelines).

Use of Masks in the Non-Healthcare Setting:
For persons ill with confirmed, probable or suspected novel A (H1N1) (in the event of a pandemic, anyone with ILI), self isolation at home is recommended. Ill persons should stay at least 6 feet away from healthy individuals. Where this is not possible and in common areas of the home, the person should wear a facemask if tolerable, or tissue to cover their cough and sneeze. Persons at increased risk of severe illness due to influenza should avoid being the caregiver to a person with ILI. If unavoidable, they should consider the use of a facemask or respirator. Otherwise, routine use of masks by household contacts is not recommended.

For non-healthcare occupational settings, facemasks and respirators are not generally recommended, although they can be considered in those at risk of severe influenza where temporary reassignment is not possible (CDC Mask Recommendations).

Preparedness for H1N1:
United States: pandemicflu.gov
International: WHO Pandemic Preparedness

Resources:
• Updates:
CDC International Situation Update
CDC Situation Update
• Guidance: CDC H1N1 Guidance

References:
H1N1 General Information

CDC Interim Guidance on Antiviral Recommendations for Patients with Novel Influenza A (H1N1) Virus Infection and Their Close Contacts

Dawood FS, Jain S, Finelli L, et al. Emergence of a Novel Swine-Origin Influenza A (H1N1) Virus in Humans. NEJM 2009; 361:1-10.

Fiore AE. Shay DK. Broder K, et al. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices. MMWR 2009: (58 Early Release): 1-52.

Dharan NJ, Gubavera LV, Meyer JJ, et al. Olsetamivir Working Group. Infections with Olsetamivir-Resistant Influenza A (H1N1) Virus in the United States. JAMA 2009; 301 (10): 1034-41.


About the Author:
Larissa May, M.D., M.S.P.H.
Associate Director of Clinical Research
Assistant Professor, Emergency Medicine,Microbiology, and Epidemiology
Co-director, MS in Public Health Microbiology and Emerging Infectious Diseases
The George Washington University
Washington, D.C.