October 21, 2014


Summit Call Recap – October 16, 2014
Information from CDC


Enterovirus D68 (EV-D68) Update – Jane Seward (CDC) and Kris Sheedy (CDC)

Jane provided a brief overview of the outbreak of enterovirus D68 (EV-D68) associated with severe respiratory disease currently occurring throughout the United States. CDC first heard of this in mid-August when reports of severe disease began to be received from children’s hospitals and emergency departments in the Midwest. An Epi-Aid was initiated, and the resulting investigation, Severe Respiratory Illness Associated with Enterovirus D68 – Missouri and Illinois, 2014, was reported in the MMWR on September 12. Jane noted that the respiratory panels used in most laboratories detected only “enterovirus/rhinovirus” without providing information related to strain identification.

After publication of this article, CDC began receiving similar reports from throughout the country. As of October 16, 46 states have reported confirmed cases of EV-D68. In surveillance for additional cases, CDC has prioritized testing of severe respiratory illness in children. Adults are not a priority because they have not exhibited the same levels of severe illness as what has been seen in children.

Last week, CDC coordinated a call with the Council of State and Territorial Epidemiologists (CSTE.)  During this call, state epidemiologists discussed their levels of EV-D68 activity as determined by any data at their disposal, including laboratory tests, physician reports, and hospital emergency department visits of children with similar respiratory illness. EV-D68 infection has a strong bronchospasm component, which frequently, but not exclusively, appears in children with a prior history of asthma or wheezing. CDC has aggregated the information received from state epidemiologists to develop an “intensity map” of Activity of Enterovirus D68-like Illness in States that is now posted on the CDC website. As of October 15, 32 states indicated low or declining levels of activity, while 12 reported increasing or elevated activity. The map will remain available for at least the next few weeks, as CDC continues active investigations.

At a press briefing held earlier this week, CDC announced the availability of a new real-time PCR test which will allow more rapid processing of specimens. Using this test, CDC currently is testing a backlog of >1,000 specimens. It is anticipated this will result in a dramatic increase in the number of confirmed cases. However, it is important to remember that this will reflect an increase in test results rather than an actual increase in disease. Kris Sheedy noted that information about the new laboratory testing was released this week in an effort to prepare the media for the anticipated increase in reported cases. It is hoped that this preemptive approach will decrease the number of headlines causing undue alarm.

CDC continues to conduct a wide variety of activities related to EV-D68. Laboratory protocols covering Specimen Collection, Storage, and Shipment have now been released to state public health laboratories. CDC also is exploring the availability of laboratory testing under an emergency use authorization. However, it remains to be seen if this will occur. CDC also has released resources and related materials for the general public, including a fact sheet for parents and an infographic describing how to keep children from getting/spreading EV-D68.

Jane noted enterovirus infection typically peaks in the summer and declines in the fall. CDC anticipates EV-D68 will follow this pattern, but we will need to continue to watch this situation through the state-by-state map and other surveillance opportunities. EV-D68 infection does appear to be on a decline in the Midwest, where it was first reported.

On a separate note, Jane reported that CDC currently is investigating a neurologic illness of unknown etiology. Through the time of the call, CDC had received reports of 37 confirmed cases in children, with at least a dozen more reports under investigation. These children have exhibited symptoms consistent with enterovirus infection, but this cannot be confirmed. CDC has issued a Health Alert Network (HAN) Advisory related to this illness. Because this is occurring at the same time as the EV-D68 reports, many persons connect these two illnesses. However, CDC has been unable to confirm a connection due to a lack of viral isolation from a sterile site. CDC has been working on a new IgM antibody test for this illness.

Influenza Surveillance Update – Sophie Smith (CDC)

Sophie reported that the published reports for week 40, ending October 4, provide the first reports of the 2014 – 2015 influenza season. Information for weeks 21 – 39 is available on the FluView website. For week 40, all seasonal influenza indicators remain below baseline levels and 3.2% of specimens submitted for testing were positive, with a mixture of both A and B. The ILI-Net national data indicated 1.3% of total patient visits were for ILI, well below the national baseline of 2%. No new pediatric deaths were reported during week 40.

As shown in CDC’s weekly influenza summary map, the geographic spread for influenza for week 40 indicates activity levels that are:

  • Widespread – Guam
  • Regional – Puerto Rico
  • Local – 3 states
  • Sporadic – 28 states, District of Columbia, and the Virgin Islands
  • No activity – 18 states
  • No report – 1 state

Carolyn Bridges pointed out that the antigenic characterization of viruses seen throughout the summer was included in an October 3 MMWR article, Update: Influenza Activity – United States and Worldwide, May 18-September 20, 2014.

Vaccine Supply Discussion – Litjen Tan (IAC) and Carolyn Bridges (CDC)

L.J and Carolyn facilitated a short discussion to obtain feedback on Summit members’ current experience with the supply of influenza vaccine. This is especially pertinent given announcements from at least 2 manufacturers about short shipment delays. In particular, the only manufacturer of vaccine for children age 6 months – 2 years is reporting delays, so the pediatric supply is clearly affected.

Lisa Brill with Kaiser Permanente in northern California reported that they have been conducting mass clinics since late September. They are experiencing high demand, similar to the level seen in the previous year. The high dose vaccine is proving to be extremely popular, and Kaiser is likely to use their entire supply of this formulation. FluMist use also is going well. There has only been a small demand for the intradermal vaccine.

Cori Ofstead in Minnesota reported that her staff experienced difficulty in obtaining quadrivalent vaccine from the local Walgreens and CVS pharmacies. She also noted that Walgreens was not carrying the intradermal vaccine because, during the prior season, recipients reported they did not like the “unpleasant sensation” they experienced when receiving the vaccine.

Summit callers who wish to provide additional comments on the vaccine supply through a more private venue are encouraged to email L.J Tan, Carolyn Bridges, or LaDora Woods.


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

The CDC weekly influenza surveillance report for week 41 (ending October 11, 2014) and region specific data are now available. During week 41, 5.4% of all deaths reported through the 122 Cities Mortality Reporting System were due to pneumonia and influenza (P&I.) This percentage was below the epidemic threshold of 6.0% for week 41.

For the 2014–2015 influenza season, CDC/Influenza Division and the National Center for Health Statistics (NCHS) are collaborating on a pilot project to use NCHS mortality surveillance data for the rapid assessment of P&I mortality.

No influenza-associated pediatric deaths were reported to CDC during week 41. A total of 108 influenza-associated pediatric deaths have been reported during the 2013–2014 season.

Nationwide during week 41, 1.3% 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 2.0%. 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, which indicates geographic spread of influenza viruses but does not measure the intensity of influenza activity, is available. This currently reflects data from October 11, 2014.

The FluView report for week 41 and archives of previous FluViews are available from CDC. CDC also has released seasonal influenza key points for October 17, 2014.

More information from CDC
  • Resources on Unexplained Neurologic Illness

CDC has released up-to-date (October 15, 2014) key points about the investigation of neurologic illness with limb weakness of unknown cause in children, including the weekly update of CDC-verified neurologic illness cases reported by states that meet the case definition. Note: These key points are separate from the EV-D68 key points (see below) that CDC updates and distributes daily.

  • Resources for Communicating about EV-D68 Infections and Disease

The United States has been experiencing a nationwide outbreak of enterovirus D68 (EV-D68) associated with severe respiratory illness. The most recent version of CDC’s key points on EV-D68 (October 21, 2014) is available. CDC will be updating these daily until the disease incidence has declined.

On October 14, 2014 CDC issued a press release sharing news about a new lab test developed by CDC for EV-D68 which will allow more rapid testing of specimens. Because of this new test, confirmed cases of EV-D68 will appear to rise rapidly over the next 7 – 10 days as specimen testing accelerates; however, changes in case counts won’t represent a real-time influx of new cases.

Almost all of the CDC-confirmed cases of EV-D68 infection this year have been among children, many of whom had asthma or a history of wheezing. Many parents continue to be worried about the outbreak and want information about what they can do to prevent illness and protect themselves and their families. CDC has developed information and resources for parents about EV-D68.  Please help CDC address parents’ questions and concerns and make them aware that these resources are available.

Below are CDC resources about EV-D68 developed for parents:

 Here are just a few ideas of how you can use and share these resources:

  • Link to the URLs above on your parent-facing webpages.
  • Share the infographic or Web Feature with parents over social media.  Below are some sample tweets, or create your own:
    • Parents, CDC addresses your questions & concerns w/ new educational materials about EV-D68. http://1.usa.gov/1o92Sdx
    • Concerned about #enterovirus? Here’s what you need to know about EV-D68 & respiratory illness. http://1.usa.gov/1sC9Jfc
    • Parents, follow these steps to protect kids, esp those w/ asthma, from EV-D68 & other viruses that cause respiratory illness http://go.usa.gov/VyzA
  • Syndicate content from the CDC website. CDC encourages organizations to mirror CDC’s web text through content syndication rather than copy text onto their websites. Benefits include immediate and automatic updates whenever changes are made on the CDC site and ensures all content is consistent and current across the Internet.  If you’d like to include EV-D68 Web content without having to monitor and copy updates, visit Content Syndication for free one-time setup instructions. Enterovirus 68 is listed under “Syndication Topics.”
  • Place the text of the matte article on your website, or in e-newsletters and other publications you have that reach parents.
  • Run the matte article in regional or community newspapers.
  • Download, print, and distribute the fact sheet to parents through schools, child care facilities, doctor’s offices, clinics, faith communities, other community settings.
  • Work with your state and local child care licensing and/or accreditation organizations to share CDC information with parents.  For example, they could:
    • Ask child care centers to place the drop-in article in parent newsletters
    • Ask child care centers to print and post the fact sheet and/or infographic
  • Work with your state department of education and school districts to share CDC information with parents.  For example, they could:
    • Print and send copies of the fact sheet and/or infographic home with children
    • Email parents links to information on the CDC website
    • Post links to CDC information on schools’ social media accounts

Remember, as enterovirus season is expected to taper off, flu activity usually begins to increase in October. While there is not a vaccine to prevent illness from enteroviruses, the single best way to protect against the flu is to get vaccinated each year.  Many resources for parents and others can be found on the CDC Seasonal Influenza (Flu) Free Resources website. CDC recommends that ALL children 6 months and older get a flu vaccine.

  •   CDC Perspective on 2009 H1N1 and Pregnant Women Published in NEJM

On October 9, 2014, a perspective piece by CDC experts Sonja Rasmussen, MD, MS and Denise J. Jamieson, MD, MPH was published in the New England Journal of Medicine. The perspective, entitled 2009 H1N1 Influenza and Pregnancy — 5 Years Later, explores what experts have learned about how the influenza virus affects pregnant women and their unborn babies since the 2009 H1N1 influenza pandemic. An interview with Dr. Rasmussen and Dr. Jamieson was also posted as a Medscape Expert Commentary. (log-in may be required).

  • CDC and Professional Medical Organizations Publish Joint Letter on Flu Vaccination and Pregnant Women

CDC and a host of professional medical organizations and public health partners have jointly published a letter to health care professionals encouraging flu vaccination in pregnant women to protect them and their unborn babies.


CDC Issues New Guidance for Infection Control in Healthcare Workers for Ebola

CDC’s latest recommendations and guidelines for the 2014 CDC Response to Ebola in the United States and West Africa are shown below. Share your comments or ask CDC a question by sending an email to coca@cdc.gov.

CDC Response to Ebola Update

CDC’s latest recommendations and guidelines for the 2014 CDC Response to Ebola in the United States and West Africa are shown below. Share your comments or ask CDC a question by sending an email to coca@cdc.gov.

> CDC Tightened Guidance for U.S. Health Care Workers on Personal Protective Equipment for Ebola

CDC is tightening previous infection control guidance for health care workers caring for patients with Ebola, to ensure there is no ambiguity. The guidance focuses on specific personal protective equipment (PPE) health care workers should use and offers detailed step by step instructions for how to put the equipment on and take it off safely.

Recent experience from safely treating patients with Ebola at Emory University Hospital, Nebraska Medical Center and National Institutes of Health Clinical Center are reflected in the guidance.

The enhanced guidance is centered on three principles:

  • All healthcare workers undergo rigorous training and are practiced and competent with PPE, including putting it on and taking it off in a systemic manner
  • No skin exposure when PPE is worn
  • All workers are supervised by a trained monitor who watches each worker putting PPE on and taking it off.

All patients treated at Emory University Hospital, Nebraska Medical Center and the National Institutes of Health Clinical Center have followed the three principles. None of the workers at these facilities have contracted the illness.

For more information visit:

> Additional Clinician Resources

  • Put CDC Ebola content on your website that will update automatically. Add a CDC Ebola Microsite to your web page. The embed code for this microsite is available in CDC’s new syndication site, the Public Health Media Library. Ebola HTML content, images, and other media are being added and also are available for syndication from this site. Please contact IMTech@cdc.gov for technical support.

> External (Non-CDC) Resources on Personal Protective Equipment

ACOG Updates

The American College of Obstetricians and Gynecologists (ACOG) recently updated its Committee Opinion on Influenza Vaccination During Pregnancy to reflect new safety data. As this is a major concern for pregnant women, this may help others promote and encourage vaccination for pregnant women.

Visit the NEJM’s Ebola Outbreak Page

Visit the Ebola Outbreak page on NEJM.org for a collection of articles and other resources, including powerful, personal essays with first-hand reporting from caregivers in the field, an interactive graphic with information on past and present Ebola outbreaks, and an audio interview with NIAID Director Dr. Anthony Fauci about the current epidemic and the promise of candidate vaccines and therapies. The page also offers clinical reports and management guidelines, and will be updated as more information on this world health crisis becomes available.

Families Fighting Flu (FFF) Teams up with Novartis Consumer Health to Help You Get Flu-Ready

FFF has partnered with Novartis Consumer Health, Inc., the makers of Theraflu, who’s working with performer and father of two young children, Nick Cannon, to launch the Fluprint program. For every Like on the Theraflu Facebook page, Novartis Consumer Health, Inc. will donate $1 up to $100,000 to support FFF in its efforts to help families and those in need get flu-ready. Program details can be found on the Facebook page.

What is Fluprint?

The Fluprint program is a five-step action plan to help you and others get flu-ready:

  • LEARN: learn about the cold and flu, including prevention tips
  • VACCINATE: find out where to get a flu shot near you
  • PREPARE: get ready before symptoms hit; steer clear of sick friends and family to help prevent the cold and flu and have Theraflu products on-hand
  • TREAT: find relief if you get sick and explore over-the-counter cold and flu medications
  • SHARE: spread the word about the program and rally others to the cause

Check back on the Theraflu website or visit FFF on Twitter and Facebook to learn more.

Remember – the flu is a serious illness. It kills more Americans each year than all other vaccine-preventable diseases combined. Each year, between 10 and 20 percent of the U.S. population is infected with the flu virus. Also, the flu causes an average of 20,000 children under the age of five to be hospitalized every year.

The flu can be harmful, so make sure you protect yourself and your family today!

FFF and Healthy Schools “Teach Flu a Lesson”

FFF and Healthy Schools LLC have developed a new partnership to raise awareness about the importance of annual flu vaccination and to increase the vaccination rates of children in Florida. This new education and action-oriented program, Teach Flu a Lesson, brings school-located flu vaccination clinics to more than 200,000 elementary through high school students as well as valuable resources for schools to educate parents about the critical need for annual flu vaccination.

Through Teach Flu a Lesson, children attending participating schools will have the opportunity to receive a flu vaccine at no cost, whether or not they have medical insurance. Recent studies have shown that school-located flu vaccination clinics are valuable offerings to children, parents, school administrators, and the community at large. Infection rates among children are typically higher than other populations, and they tend to spread the flu virus more easily. By vaccinating a larger number of children, flu transmission rates drop, vulnerable populations within the community are better protected, and it decreases the risk for further complications, such as hospitalizations or even death. For parents and children, this is a convenient, quick and simple way to get vaccinated while also reducing potential absenteeism from both school and work.

Every Child By Two (ECBT) Compiles Media Information on Its Website

On a daily basis, ECBT assembles significant news media coverage on immunizations in their “Daily Clips.” Summit partners may find this effort useful.

Summit Website Offers Wonderful Resources on Influenza Vaccination!

Remember to visit the Summit website for the latest on influenza immunization resources. You can also find archived copies of The Summit Buzz there.


Summit calls are scheduled every Thursday at 3 pm ET, unless cancelled. Please email L.J Tan or LaDora Woods if you have any updates on activities to provide to the Summit.


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