Influenza, a vaccine preventable disease Carina Blackmore, DVM, PhD, - - PowerPoint PPT Presentation

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Influenza, a vaccine preventable disease Carina Blackmore, DVM, PhD, Dipl.ACVPM State Epidemiologist Florida Department of Health a HEALTH Objectives The viruses The vaccines The surveillance methods a HEALTH Division of Disease

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HEALTH

Influenza, a vaccine preventable disease

Carina Blackmore, DVM, PhD, Dipl.ACVPM State Epidemiologist Florida Department of Health

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HEALTH

Objectives

 The viruses  The vaccines  The surveillance methods

Division of Disease Control & Health Protection 2

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Hemagglutinin Neuraminidase Nucleic Acid

Influenza virus

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Influenza A: a promiscuous virus!

 Orthomyxovirus

  • Envelope
  • Surface spikes

 Hemagglutinin protein (HA) (18 types)  Neuraminidase protein (NA) (9 types)

  • SS(-) RNA
  • 8 segmented genes

HA NA 1 2 3 4 5 6 7 8

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HEALTH

Why are we concerned?

 The only infectious disease on the top 10 list of leading

causes of death in the United States (# 8, 2016)

  • 57,000 flu and pneumonia deaths in 2016

 High risk groups

  • Children under 5 years (2 years)
  • Adults 65 years and older
  • Pregnant women
  • American Indians and Alaska Natives
  • People with underlying medical conditions (lung, heart, etc)

Division of Disease Control & Health Protection 6

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Cycles of the Asian H5N1Virus in Animals and Humans

Waterfowl Humans Domestic birds Mammals Waterfowl (primarily swine)

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SLIDE 9

Interactions On the Farm and the Market

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HEALTH

Potential for Influenza Pandemics

 All influenza viruses can mutate  Avian flu can cause illness in humans  Little to no herd immunity to avian strains

among humans

 If avian viruses acquire human genes

  • Facilitate efficient person-to-person transmission
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SLIDE 11

Federation

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  • Areas reporting occurence in poultry
  • Areas reporting occurence only in wild birds

1,200 2,400 Kilometers

Division of Disease Control & Health Protection 11

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SLIDE 12

2003 2009* 2010 2014- 2015 2016 2017 2018

Total cases deaths cases deaths cases deaths cases deaths cases deaths cases deaths cases deaths Azerbai ijan 8 5 8 5 Bangladesh 1

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6 1 1 8 1 Cambodia 9 7 47 30 56 37 Canada

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1 Thailand 25 171 25 17 Turkey 12 4 12 4 Viet I Nam 112 57 15 7 127 64 Total

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Cumulative number of confirmed human cases for avian influenza A(H5N1) reported to WHO, 2003-2018

468 282 233 125 145 42 10 3 4 2 860 454

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Nine days in April, 2009

 April 17, Swine influenza H1N1 confirmed in 2

CA children

  • Strain not seen in U.S. swine
  • No swine-human contact

 April 22, T

wo TX adolescents +

 April 23, Respiratory outbreak in Mexico

confirmed as novel H1N1

 April 28, Cases reported in 5 states, 4

countries

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Swine influenza

Common respiratory

illness in swine

Usually mild 1-2 human cases/ year Swine infected by

human influenza viruses

Swine flu vaccines

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1918

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1930

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HEALTH

How do we know this was a pandemic?

 Spread fast around the globe  Affecting younger individuals (healthy adults)  Mortality seen in healthy adults (pregnant

women)

 Although morbidity and mortality not higher

than seasonal flu, could change…

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SLIDE 19

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Data Source

GD OC and lnilue;nz.a Divisjori I ~ em8' ·a nal Te ' NO IE.: Case• counts appesa1r as i;e,parted by W O un less a erw;ise ·ndicated.

International Map

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  • Week

Influenza isolates by subtype, FL 2008-2009

600 500 400 300 200 100

Week

A (H1N1) Novel A (H3) Seasonal A (H1) Seasonal A (Unspecified) B 40 42 44 46 48 50 52 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43

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2009 H1N1 influenza in swine (and other critters)

May 2, commercial swine herd,Alberta July, show pig, Minnesota August, turkey farm, Chile October, ferret Oregon November, commercial swine herd, Indiana, 

cat, Iowa, cat, Oregon, dogs, China,

turkey farm, Virginia

December, cheetah, California

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HEALTH

Influenza A H3N2v

 12 human cases from 5 states in 2011  309 cases from 12 states in 2012 

16 hospitalizations

1 death

80-90% in swine exhibitors+families

 Swine management practices changed  25 cases in 2013-15  79 cases in 2016-17

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State and County Fairs Exposures

Trock 2012

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HEALTH

Highly Pathogenic Influenza A (HPAI) in birds

 HPAI Eurasian (EA) H5N8  H5 gene derived from EA clade 2.3.4.4 H5N1  EA H5N8 in Washington State in Dec 2014  HPAI North American (NA) H5N2, Dec 2014  HPAI NA H5N1, Jan 2015

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Influenza A H7N9, China

 1567 human cases (39% case fatality rate) since March

2013

 About 50% of cases occurred in 2016-2017  Poultry contact  14 clusters of limited human to human transmission

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Cases Deaths Count 2013 2014 2015 2016 2017 2018 Week and Year

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Division of Disease Control & Health Protection

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Canine flu

 It started with 6 dead greyhounds…

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Cat flu

Division of Disease Control & Health Protection 31

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Animal-human interface

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HEALTH

Influenza Surveillance Goals

  • 1. Identify and characterize flu viruses; pandemic potential
  • 2. Situational awareness: onset, peak, and duration of flu season
  • 3. Track geographic spread and detect outbreaks
  • 4. Monitor severity of season: track visits to emergency

departments and deaths

  • 5. Describe clinical infection and those at risk
  • 6. Guide decisions for interventions and prevention
  • 1. high-risk populations (children, adults aged 65 and older, and pregnant women)

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252 of 259 Emergency

Departments

participate Submit data daily

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  • Emergency Department & Urgent Care

Center Visits (n=322 facilities)

Percent of Visits 12 10 8 6 4 2 40 42 44 46 48 50 52 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 Week

35

2014-15 2015-16 2016-17 2017-18 Peak activity this season occurred in early-February

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  • Emergency Department and Urgent Care

Center Visits Among PregnantWomen

Number of Visits 120 100 80 60 40 20

Week

2014 -15 2015- 16 2016-17 2017-18

Activity has returned to normal levels for this time of the season

40 44 48 52 3 7 11 15 19 23 27 31 35 39

36

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Emergency Department & Urgent Care Center Visits by Age Group

Percent of ED Visits

20

0 to 4 years old

18 16 14 12 10 8 6 4 2

5 to 24 years old 25 to 64 years old ≥65 years old

40 41 42 43 44 45 46 47 48 49 50 51 52 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Week

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National Data Florida Data

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Expected Percent Raw Data Percent

Percent of Deahts Due to P&I Week

Upper Bounds Percent

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  • Influenza-Associated Pediatric Deaths

Number of Deaths 15 10 5 2013-14 2014-15 2015-16 2016-17 2017-18 Vaccination status unknown Vaccinated Unvaccinated

  • Influenza vaccination can reduce a child’s risk of dying from

influenza by 50-60%

(https://www.cdc.gov/media/releases/2017/p0403-flu-vaccine.html)

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Influenza-Positive Specimens T ested by Bureau of Public Health Laboratories by Subtype, 2017-2018

Total Number of Positive Tests 225 200 175 150 125 100 75 50 25 A (H3) A 2009 (H1N1) A (not yet subtyped) B Victoria B Yamagata B (not yet subtyped)

40 42 44 46 48 50 52 2 4 6 8 10 12 14

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Influenza Activity by County-week16

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493 total outbreaks to date 28 counties (41%) with five or more

  • utbreaks reported

Outbreaks of Influenza and ILI

  • 42
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  • Outbreaks of Influenza and ILI by Facility

Number of Outbreaks

90 80 70 60 50 40 30 20 10

Week Schools/camps Child daycares Adult daycares Nursing facilities Assisted living facilities Other long-term care facilities Correctional facilities and juvenile detention centers Hospitals Shelters

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  • Outbreaks in Settings Serving the Elderly

 240 outbreaks of influenza and influenza-like illness (ILI)

reported in facilities serving the elderly:

59 (25%) in assisted living facilities 82 (34%) in skilled nursing facilities 99 (41%) in long-term care facilities (LTCFs), not otherwise specified

Assisted living facilities Skilled nursing facilities

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HEALTH

Outbreaks in Facilities Serving the Elderly: Vaccination of Residents 2017-2018 Flu Season

Skilled Nursing Facilities Assisted Living Facilities Other Long- T erm Care Facilities 61%* 59%** 67%***

* 45

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HEALTH

Outbreaks in Facilities Serving the Elderly: Vaccination of Staff 2017-18 flu season

*

Skilled Nursing Facilities Assisted Living Facilities Other Long- T erm Care Facilities 37%* 43%** 47%***

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HEALTH

InfluenzaVaccine

 Advisory Committee on Immunization Practices (ACIP)

recommends everyone 6 months and older should get a flu vaccine every season

 People at High Risk:

  • Children < 5, but especially children < 2 years old
  • Adults 65 years of age and older
  • Pregnant women (and women up to two weeks postpartum)
  • Residents of nursing homes and other long-term care facilities
  • American Indians and Alaska Natives
  • Chronic medical conditions (e.g., heart, lung, neurological and

metabolic disorders)

  • Initial vaccination of children < 9, 2 doses, 4 weeks apart

Division of Disease Control & Health Protection 47

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HEALTH

Vaccine determination process

 ACIP  Grow in eggs or cells per FDA regulations  6 months to produce large quantities

Division of Disease Control & Health Protection 48

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HEALTH

Vaccine safety and efficacy

 Mild side effects possible

  • Rare severe allergic reactions (including Guillain Barre)

 Live attenuated vaccines only for 2-45 year olds who are

not pregnant

 Efficacy varies by year and population group

  • Lower in immunocompromised individuals (elderly)

Division of Disease Control & Health Protection 49

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2018-2019 Vaccine Composition

  • A/Michigan
  • A/Singapore
  • B/Colorado – replaces B/Victoria from 2016-2017 formulation
  • B/Phuket

Division of Disease Control & Health Protection 50

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HEALTH

Vaccine types

 Quadrivalent inactivated

  • Standard dose
  • Standard dose, cell culture based
  • Intra-dermal

 Trivalent, inactivated

  • Standard dose
  • Adjuvant
  • High dose

 Recombinant

  • Quadrivalent
  • Trivalent

 Live attenuated

Division of Disease Control & Health Protection 51

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HEALTH

InfluenzaVaccine Ordering

 Pre-Book – In July, for the 2018 – 2019 influenza season. Providers should

pre-book the number of doses that they expect to administer.

 “Push” Mode – The

VFC Program receives influenza vaccine allocations from CDC in increments; vaccine shipments begin as allocations are received. The VFC office will ship a percentage of pre-booked vaccine to each provider, to ensure an equitable distribution of vaccine.

 “Pull” Mode – As the supply of vaccine exceeds the demand, providers are

able to order up to 100% of their pre-booked flu order.

 If providers exhaust their pre-booked influenza vaccine, contact theVFC

helpdesk, FloridaVFC@FLHealth.gov to order additional vaccine.

 Return all unused influenza vaccine to McKesson once the vaccine has

expired.

Division of Disease Control & Health Protection 52

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HEALTH

Vaccines for Children (VFC) Program

  • Provides free vaccines to enrolled

providers for eligible children 0-18 years

  • f age
  • In 2017, 4.8 million doses of vaccine

valued at $268 million was shipped to 1,800+ public and private health care providers

  • Medicaid
  • Uninsured
  • American Indian/Alaskan Native
  • Underinsured – OnlyVFC eligible at a

Federally Qualified Health Center

Division of Disease Control & Health Protection

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Influenza Vaccine Funding

CHILDREN 0 – 18 YEARS OLD

County Health Departments (CHDs)

  • Any child who presents at a CHD should be offered an influenza

vaccination

  • VFC influenza vaccine for all

VFC eligible patients

  • The Immunization Section provides every CHD with state purchased

influenza vaccine to immunize “privately insured” and “underinsured children” Private Providers

  • Private Insurance
  • VFC Eligible

School Located Influenza Clinics

  • VFC eligible
  • Privately insured

Division of Disease Control & Health Protection 54

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HEALTH

Influenza Vaccine Funding

ADULTS  Pharmacies  Private Providers  Federally Qualified Health Centers (FQHC)  County Health Departments

317 Funded Vaccine – Provided through CDC and can be administered to uninsured and underinsured patients. 317 funding is available to CHDs and FQHCs for qualified patients.

Division of Disease Control & Health Protection 55

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HEALTH

Florida SHOTS

  • Statewide immunization registry
  • Almost 4.5 million children 0-18 years
  • f age participate in the registry
  • 17,000+ public and private providers

including pharmacies currently enrolled in the registry

Division of Disease Control & Health Protection

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HEALTH

Summary

 Influenza causes significant morbidity and mortality  It is preventable

Division of Disease Control & Health Protection 57

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For More Information

 Our website: www.flufreeflorida.com  Florida’s weekly surveillance report, the

Florida Flu Review: www.floridahealth.gov/floridaflu

 Local county health department contacts

www.floridahealth.gov/chdepicontact

 Bureau of Epidemiology 24/7/365:

(850) 245-4401

58

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HEALTH

 Carina Blackmore, DVM, PhD,ACVPM  Florida Department of Health  850-245-4732

Division of Disease Control & Health Protection 59