January 13, 2014

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Summit Call Recap – January 9, 2014

Summit Call Recap – December 19, 2013

Announcements and Headlines

SUMMIT CALL RECAP – JANUARY 9, 2014

Influenza Surveillance Update – Scott Epperson, CDC

Scott acknowledged that influenza activity has greatly increased since the last Summit call held before Christmas. Through Week 52 (December 22-28, 2013), 96% of all positive tests at CDC have been influenza type A, and 99% of these were characterized as 2009 H1N1. In addition, a very small number of tests have been positive for influenza types A (H3N2) and B. Of the 8 positive B specimens, 3 were of the Yamagata lineage, contained in both the trivalent and quadrivalent vaccines, and 5 were of the Victoria lineage, found only in the quadrivalent vaccine.

The proportion of deaths attributed to P&I was below the epidemic threshold. However, outpatient ILI visits were widespread, with 20 states reporting high activity, 8 states and New York City reporting moderate activity, 6 states with low activity, and 16 states with minimal activity. It is possible that we may have reached our peak in Southeastern and Southwestern states, but it is too early to state this definitively. Just over 60% of influenza-associated hospitalizations have been in the 18-64 year age group, compared to last season when only 34% were in this age range, reflecting the impact of 2009 H1N1 this season.

Yesterday Canada reported a human H5N1 infection in a person who had traveled to Beijing. The individual arrived in Canada in December, was admitted to the hospital soon after arrival, and died on January 3. No illness has been reported in any other contacts, and no special precautions have been recommended to date. Scott was unable to provide additional information on this case because the investigation is ongoing in Canada. He suggested that persons check postings on CDC’s influenza website to obtain the most current information available on this case and any other influenza associated topics.

Lisa from Kaiser in Northern California reported that, since the beginning of January, their clinics have experienced a huge increase in requests for influenza vaccine. Anecdotal information indicates they have given as much vaccine this week as they typically give during the entire month of January. L.J speculated that this may have been due to increasing media reports about a general lack of immunity to 2009 H1N1.

National Council on Aging’s Media Tours and NIVW Recap – Yvonne Garcia, CDC

Yvonne provided a presentation summarizing National Influenza Vaccination Week (NIVW), which took place December 8 – 14, 2013. This national observance highlights the continuing need for influenza vaccination and helps bring this message to the forefront during the holiday season. It also provides an opportunity to rally national grassroots partners to share this information through their respective venues.

A wide range of activities, ranging from Twitter chats and other forms of media outreach to local influenza clinics, took place during the week. A complete listing of these activities and a large variety of free seasonal influenza resources are still available.

To kick-off NIVW, CDC hosted a Twitter chat on December 9. This reached 3.7 million accounts, with an estimated over 32 million total impressions. In addition, 785 contributors distributed over 1,400 tweets. On December 12 Drs. Tom Frieden and Anne Schuchat conducted a media teleconference highlighting the current season’s estimated vaccine coverage and a MMWR article discussing the impact of influenza vaccine during the 2012–2013 season. Twenty-eight media outlets covered the teleconference, generating over 400 news articles around the country. A radio media tour held the next day had an estimated reach of over 20 million, with 39 interviews in 101 broadcasts, ninety-one of which were in Top 100 markets.

CDC’s National Influenza Vaccination Disparities Partnership (NIVDP) activities to reach disparate populations received an estimated 139 million media impressions from 132 media placements in TV, radio, and print PSAs. Fifty-three influenza vaccination promotion events occurred in 26 cities. Four additional mayors issued influenza vaccine proclamations, bringing the total for this activity to 92. Other activities included coloring contests and vaccinations delivered at faith-based locations or drive-through clinics.

Upcoming events include a National Council on Aging (NCOA) and CDC-sponsored campaign on January 13. In addition, ABC News will conduct a national health Flu Tweet Chat (#abcDRBchat) with Dr. Richard Besser (ABC) and Dr. Michael Jhung (CDC) on January 14 from 1–2 pm ET. On January 22 at 3 pm ET, Dr. Frieden will conduct a Twitter Chat at #CDCchat.

Yvonne reminded call participants that great influenza campaign resources are still available. L.J noted that all these sites and materials provide terrific information and suggested all Summit partners should take a moment to check these out.

SUMMIT CALL RECAP – DECEMBER 19, 2013

Influenza Surveillance Update – Scott Epperson, CDC

Scott provided an overview of influenza activity through week 49, which ended on December 7. As indicated by both lab testing and ILI surveillance, influenza is continuing to spread. The vast majority of specimens tested to date have been influenza A (H1N1), all of which have been antigenically similar to the strains found in this season’s vaccine. A smaller number of H3N1 positive specimen also were similar to the vaccine component. Only 6 influenza type B specimens have been reported.

Of these, 4 were B-Victoria, and 2 were B-Yamagata. The proportion of outpatient visits attributed to ILI was 2.1%, just above the 2.0% baseline level. Regions 4 (southeast), 6 (south), and 8 (west) all reported elevated ILI. No additional pediatric deaths were reported during this week, leaving the seasonal total at 3. Information on the pediatric cases will remain limited until after at least 10 cases have been reported.

In response to questions, Scott noted that all type B specimens to date have matched those found in the quadrivalent vaccine. However, because only 6 type B specimens are included, this does not speak to the potential superiority of quadrivalent vaccine. When asked about novel influenza viruses, Scott stated that none have been detected since week 40, when a H3N2v was reported from Iowa.

Discussion of Influenza Vaccine Efficacy (VE) Studies – Mike Osterholm, University of MN

Dr. Osterholm gave a presentation entitled Cochrane Rearranged Reviewed that served as a continuation of the Cochrane Re-arranged discussion on influenza vaccine efficacy provided by Drs. Monto and McElhaney during the last Summit call on December 5. Both presentations provided a review of the original 2010 Cochrane study, “Vaccines for preventing influenza in the elderly.” The 2010 effort examined 75 studies carried out over 40 years of influenza vaccination. The Monto review of the Cochrane paper concluded that, under conditions of virus circulation, the influenza vaccine efficacy (VE) in the elderly was higher than the Cochrane estimate, ranging from 30% against fatal and non-fatal complications to 60% against infection. L.J noted that because the Cochrane Re-arranged review took on the challenge of finding alternative interpretations of the same data used by the Cochrane Group, they were restricted to the same data (published literature) that the Cochrane Group used.

Although supportive of influenza vaccination, Dr. Osterholm’s group challenged these VE estimates by noting that four key issues were not addressed by Cochrane Re-arranged:

1. Some studies used seroconversion to define influenza infection.
As far back as 1955, epidemiologists have noted that serology should not be used as a measurement for outcome, as this likely would overstate VE. This point was restated in a 2011 JID article by Petrie et al. which concluded that “Isolation in cell culture will miss cases, and a serologic end point alone will overestimate inactivated vaccine efficacy.”

In a 2011 study published in The Lancet Infectious Diseases, Osterholm, Kelley, Sommer, and Belongia conducted a systematic review and meta-analysis of the efficacy and effectiveness of influenza vaccines licensed in the U.S. The group examined 31 studies published between 1967 and 2011 that used RT-PCR or culture for confirmation of influenza and which met certain study design characteristics. The TIV studies showed a pooled efficacy of 59% in adults 18–65 years of age, but no trials met the inclusion criteria for children 2–17 years or adults >65 years. LAIV consistently showed highest VE in children 6 months to 6 years.

2. Use of seroprotection to define clinical protection.
Although both the Cochrane and Cochrane Re-arranged studies used pre- and post-vaccination titers to determine infection risk, Osterholm et al. noted that a summary of a 2007 FDA public workshop concluded that “studies to evaluate the effectiveness of influenza vaccines have not identified a specific HI antibody titer associated with protection against culture confirmed influenza illness.” The workshop report published in Vaccine in 2008 stated that “no single end-point can be used as a surrogate of protection.”

3. Did not consider the degree of bias in determining VE against all-cause mortality.
Dr. Osterholm pointed out that the Cochrane Re-arranged review acknowledged a potential bias in that the included studies looked for VE only against influenza fatal and non-fatal complications. One large Kaiser study that adjusted for selection bias found VE to be only 4.6%. Similarly, an analysis conducted by persons from CDC and Canada concluded that influenza vaccination prevented ~4% of influenza-associated hospitalizations and deaths occurring after hospitalizations among older adults in Ontario.

4. Current high quality observational studies using the test-negative design highlight the limited effectiveness of influenza vaccines against >60 years of age.
Dr. Osterholm briefly noted a series of studies that used the test-negative design indicated limited VE. The February 2013 MMWR describing interim adjusted estimates of seasonal influenza VE in the >65 year age group to be 27% overall and 9% for H3N2.

In closing, Dr. Osterholm stated that the conclusions of the Cochrane Re-arranged review “cannot be substantiated and do not provide additional evidence that influenza vaccine is even moderately effective in the elderly.”

Other Items – L.J Tan, IAC

L.J announced that, barring an unforeseen event, the Summit calls will not take place during the next 2 weeks. The next scheduled call will take place on January 9, 2014.

CDC/Influenza Division Weekly Influenza Surveillance Report and CDC Key Points

The CDC weekly influenza surveillance report for week 1 (ending January 4, 2014) and region specific data are now available. For deaths reported through the 122 Cities Mortality Reporting System, 6.9% were due to P&I. This percentage was below the epidemic threshold of 7.1% for week 1.

Four influenza-associated pediatric deaths were reported to CDC during week 1. Three deaths were associated with a 2009 H1N1 virus and occurred during week 52 (week ending December 28, 2013) and week 1 (week ending January 4, 2014). One was associated with an influenza A virus for which no subtyping was performed and occurred during week 51 (week ending December 21, 2013). A total of 10 influenza-associated pediatric deaths for the 2013-2014 season have been reported. Additional information on influenza-associated pediatric mortality is available on FluView.

Nationwide during week 1, 4.4% 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 above the national baseline of 2.0%. The increase in the percentage of patient visits for ILI in previous weeks may be influenced in part by a reduction in routine healthcare visits during the holidays, as has occurred in previous seasons. ILI is defined as fever (temperature of 100°F [37.8°C] or greater, and cough and/or sore throat. An Influenza Summary Update of the influenza activity reported by state and territorial epidemiologists indicates the geographic spread of influenza viruses, but does not measure the intensity of influenza activity.

During week 1, twenty states experienced high ILI activity (Alabama, Arkansas, Colorado, Idaho, Illinois, Indiana, Kansas, Kentucky, Louisiana, Minnesota, Mississippi, Missouri, Nevada, New Mexico, North Carolina, Oklahoma, Oregon, Tennessee, Texas, and Virginia). Seven states and New York City experienced moderate ILI activity (Alaska, California, New Jersey, Pennsylvania, South Carolina, South Dakota, and Utah). Eleven states experienced low ILI activity (Delaware, Florida, Georgia, Massachusetts, Michigan, Montana, Ohio, Washington, West Virginia, Wisconsin, and Wyoming). Twelve states experienced minimal ILI activity (Arizona, Connecticut, Hawaii, Iowa, Maine, Maryland, Nebraska, New Hampshire, New York, North Dakota, Rhode Island, and Vermont). Data were insufficient to calculate an ILI activity level from the District of Columbia.

Archives of previous FluViews and CDC’s Seasonal Influenza Key Points from January 13, 2014, are now available.

More information from CDC

First Human Avian Influenza A (H5N1) Virus Infection Reported in Americas – Canada has reported the first case of human infection with avian influenza A (H5N1) virus ever detected in the Americas.
Update: Avian Influenza A (H7N9) Virus – Human infections with a new avian influenza A (H7N9) virus continue to be reported in China. The virus has been detected in poultry in China as well. While mild illness in human cases has been seen, most patients have had severe respiratory illness and some people have died. No cases of H7N9 outside of China have been reported.

ANNOUNCEMENTS AND HEADLINES

MedImmune Announces New Learning Opportunites

This winter, MedImmune will host 45-minute, online programs for healthcare professionals interested in learning more about a quadrivalent influenza vaccine. Experts in the field of influenza will discuss the burden of the disease, including the specific contributions of influenza A and B, and the need for protection against both influenza A and B. Audience members will also have the opportunity to participate in a live Q&A session with the experts. Registration information is available online.

From CFR Global Health: Laurie Garrett Provides Update on North American H5N1 Death

As promised, we are trying to stay on top of the H5N1 flu story out of Alberta, Canada. Those of you that use Twitter may want to follow my periodic tweets: @Laurie_Garrett. The case matters because it is the first time either a human or a domestic bird has been confirmed with H5N1 in the American hemisphere – a worrisome event given the very high mortality rate of this virus – roughly 60 percent in people, and 100 percent in domestic poultry.

Though most of the questions I posed in yesterday’s Update remain unanswered, authorities at Health Canada merit some applause. Many people, including social media-using co-passengers that were on the two flights from Beijing and then Vancouver to Edmonton have been less positive in their assessments.

Here is what I think is accurate at this time:

A young woman, said to be in her late twenties, traveled from Canada to Beijing. Though it is not certain, it appears the purpose of her trip was business, and the World Health Organization insists there is absolutely no evidence that she visited any bird markets or had contact with either wild or domestic live birds. (In response to yesterday’s Update, a question was raised regarding the authenticity of this no-contact-with-birds information. The WHO and Health Canada have been emphatic about this, and the victim was thoroughly interviewed. Having spent a fair amount of time in Beijing myself, I think it would be difficult for a foreign traveler to even find live animal markets. I have sought them out, but they are not located in areas frequented by business travelers and foreign tourists.)
Canadian health officials have announced the woman’s flight schedule, which was Beijing to Vancouver on Air Canada flight 030 on December 27, then went on to Edmonton, Alberta aboard Air Canada flight 244 (via South China Morning Post).
Though she apparently took ill during her travels, the woman reportedly never presented with classic flu symptoms, such as coughing, sneezing, nausea. And her initial clinical visit was equivocal – again, she did not have typical flu symptoms, and was sent home. (One news account below states that the doctors sent her home because she seemed to have “routine H1N1 flu,” but our sources contradict that. We look forward to further details from Health Canada.) It appears she suffered encephalitis, a rare but very dangerous form of influenza infection. This means the virus infected her central nervous system, prompting symptoms such as headaches, fever, blurred vision, disorientation, malaise, and eventual neurological dysfunctions of more profound natures. Though some critics have declaimed Health Canada’s failure to immediately diagnose the case, we are stunned that they even had the insight to think of H5N1 and order a test for the virus. I very much doubt that average physicians in the United States would consider H5N1 in a routine workup on a patient in her twenties presenting with disorientation, headache, and fever.
The woman died on January 3, 2014.
How the woman acquired the infection in Beijing remains mysterious. Though H5N1 is circulating in the country, this particular flu strain has never been seen in the capital. Moreover, most Chinese H5N1 cases have been rural, involving farmers and poultry brokers/sellers, or their families.
The young woman apparently had no other disease history or underlying chronic ailment. At least, none reported publicly at this time. She would, therefore, have been in prime health. That makes both her infection and clinical presentation all the more mysterious. (At the risk of raising the 1918 bogeyman specter, that influenza afflicted young adults more severely than any other age group, and cases of sudden, profound encephalitis were recorded. John Barry’s masterpiece The Great Influenza describes young individuals that boarded a subway in Coney Island in fine apparent health, passed out at some point in the train, and were found dead by the time the subway reached midtown Manhattan.)

As I indicated yesterday, I do not think this case warrants any rash actions, such as changes in personal or corporate travel plans, prophylactic medication, or avoidance of any type of products (including foods) from any particular country. The same personal precautions I indicated yesterday for travelers and residents in Beijing would apply today.

There is no indication whatsoever at this time that the H5N1 infection of this young traveler has spread to anybody else in Canada. Health authorities are now interviewing fellow passengers.

Some further reading options (though there are minor inaccuracies that are understandable as information is still unfolding):

From CTV News: Alberta woman who died from bird flu was in her late 20s: WHO
From CDC: First Human Avian Influenza A (H5N1) Virus Infection Reported in Americas
From WHO: Human infection with avian influenza A(H5N1) virus – update
From the BBC: First N. America H5N1 bird flu death confirmed in Canada

From the Center for Vaccine Ethics and Policy: Vaccines and Global Health: The Week in Review

Vaccines and Global Health: The Week in Review is a digest — summarizing news, events, announcements, peer-reviewed articles and research in the global vaccine ethics and policy space. Content is aggregated from key governmental, NGO, international organization and industry sources, key peer-reviewed journals, and other media channels. The summary proceeds from the broad base of themes and issues monitored by the Center for Vaccine Ethics & Policy in its work: it is not intended to be exhaustive in its coverage. The January 2014 editions of their weekly digests are now available.

SAVE THE DATE! 2014 Summit Face-to-Face Meeting Information

The 2014 face-to-face annual meeting of the National Adult and Influenza Immunization Summit will be held in Atlanta, Georgia, at the Hyatt Regency hotel on May 13-15, 2014. As details are finalized, we will continue to inform the Summit partners on the agenda, rooming block, etc. Thank you all for your continued support and participation!

Update: China Confirms 11 More H7N9 Cases, 1 Fatal

Lab tests in China have confirmed 11 moreH7N9 influenza infections over the past 3 days, including a fatal case, and Hong Kong has confirmed an H7N9 death in a previously reported case.

National Conference on Immunization and Health Coalitions – Seattle, WA, May 21–23, 2014

Partnering for Prevention from Sea to Summit is the theme of the 11th National Conference on Immunization and Health Coalitions (NCIHC) which will take place in Seattle, WA from May 21-23, 2014. NCIHC is the only conference solely dedicated to collaboration and partnership as a way to improve the health status of communities. Keynote speakers will include Dr. David Williams, Dr. William Foege, Dr. Wendy Sue Swanson (Seattle Mama Doc), and Sara Rosenbaum, JD.

The call for abstracts for the conference was closed as of December 13, 2013. However, the website notes that individuals who feel strongly that their presentation would be of interest to conference attendees may contact Sara Jaye Sanford.

Additional information is available on the conference website.

Summit Website Offers Wonderful Resources on Influenza Vaccination!

Remember to visit the Summit website for the latest on influenza immunization resources. You also can find archival copies of these newsletters there.

Reminder: Please email L.J or LaDora if you have any updates on activities to provide to the Summit.