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NBSB Pandemic Influenza Working Group Detailed Report who come to a health care provider with symptoms and the diagnosis is not necessarily laboratory-confirmed. BioSense collects information electronically from emergency departments (EDs), pharmacies, and laboratories. It provides a good sense of patient visits to EDs, use of antivirals, and use of commercial testing. The Behavioral Risk Factor Surveillance System (BRFSS) helps identify what’s going on in a community. It gathers State-level data based on telephone surveys in which participants are asked about ILI in the past few weeks or months. ILINet data can show patterns of disease over time. It can illustrate regional patterns, such as the spike in H1N1 underway in the New Jersey/New York region. CAPT Fiore believes that spike will plateau this week, and some spikes in other parts of the country have resolved. BRFSS is useful for getting a community-level picture of the spread of illness. It captures people who may not seek health care, which is important information in determining the severity of disease. In some cases, illness is confirmed neither clinically nor by a laboratory test, but it tracks well with past experience and can be used as a model to identify novel H1N1. Surveillance data on severe disease comes from death certificates, pediatric mortality reporting, and reports of severe infections among hospitalized patients, for example. The goals of surveillance and epidemiologic study from June through September 2009 are as follows: Identify continued circulation of novel H1N1 and cocirculation with seasonal influenza (both of which are now confirmed). Monitor: o genetic and antigenic variability o antiviral sensitivity o severity of illness o transmission characteristics. Estimate effects of interventions. International surveillance comes from well-established platforms at established sites, such as the Global Disease Detection Program (GDD) and the International Emerging Infections Program. These programs operate with CDC staff and funding in partnership with the Global Aids Program for additional laboratory support. For the past five years, in an effort to bolster pandemic preparedness, CDC has established influenza programs in 32 countries to conduct surveillance of severe acute respiratory illness (SARI) surveillance, improve laboratory capacity, and provide reagents. The Southern Hemisphere Initiative is coordinated by CDC and the U.S. Agency for International Development and partners with the Pan American Health Organization to enhance surveillance through Department of Defense (DoD) Laboratories. In addition, the GDD coordinates with WHO offices for surveillance, and the Global Influenza Surveillance 8
NBSB Pandemic Influenza Working Group Detailed Report Network provides additional virus surveillance. CAPT Fiore described additional morbidity surveillance efforts through these programs to identify ILI and SARI with laboratory confirmation. Population-based surveillance and community surveys provide still more information. The WHO Global Surveillance Global Influenza Surveillance Network is likely to be a key source of information in the next few months, said CAPT Fiore. It involves four WHO Collaborating Centres and the CDC in surveillance that includes Australia and Japan. The Centers collect specimens, isolate and characterize the virus, then ship the samples to other laboratories for more sensitive testing. CAPT Fiore said relatively few participating countries (25 of 126) are located in the Southern Hemisphere, but he expects to see both seasonal and H1N1 virus circulation in the tropical areas of the Northern Hemisphere. A fair amount of CDC staff is stationed in areas in which H1N1 circulation is anticipated. Information is coming in from the Southern Hemisphere. In Australia, 1,400 cases of influenza have been tested, of which about one third represent novel H1N1. The rest are seasonal influenza, mostly H3N2. Surveillance in Central and South America have been reinvigorated with funding and staff, said CAPT Fiore. Peru has established outpatient surveillance similar to ILINet but on a smaller scale, with a focus on severe disease in Lima. Field staff in South America can provide weekly or biweekly information that points to unusual clusters of disease. CAPT Fiore summarized what we know so far in those areas where H1N1 is circulating: Will the pandemic virus continue to circulate? Yes. Will it cocirculate with other influenza viruses? Preliminarily, yes. Is the virus changing? Viral surveillance plans are in place to evaluate this question. Are epidemiologic parameters changing (e.g., attack rate, incubation period)? It will be difficult to obtain representative data in most countries, but ongoing outbreaks in the United States will also provide data. Are clinical manifestations changing (e.g., severity, secondary infections)? It will be difficult to determine given different health care parameters, but getting viruses from unusual or severe cases is feasible. Are community mitigation interventions working? It may be possible to assess this question in several countries (e.g., from Chile’s school closings), but it is unlikely that laboratory-confirmed outcomes data will be available. CDC is working to increase funding for reporting and field staff. It faces challenges in obtaining representative samples of the virus from other countries. In countries with less surveillance in place, CDC faces challenges in interpreting the data it receives. 9
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