Influenza Surveillance to Inform Decision Making

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1 Influenza Surveillance to Inform Decision Making Ms Kate Pennington Epidemiologist Assistant Director, Vaccine Preventable Diseases Surveillance Office of Health Protection Department of Health and Ageing Australia

2 Overview Influenza Surveillance System Context. Objectives of Influenza Surveillance in Decision Making. Vaccination: Strain selection process. Recommendations. Adverse Event Monitoring.

3 Influenza Surveillance System Context

4 Australia

5 Influenza Surveillance Layers FLU Mortality Hospitalisation Severe ED Presentation ILI General Practice Community Mild Geographic Variation

6 Mortality Hospitalisation ED Presentation General Practice Community Community Level ILI NHCCN Health call centre network ILI related calls FluTracking Online survey of community volunteers Self reported ILI, health service use, testing and results.

7 Mortality Hospitalisation ED Presentation General Practice Community General Practice Level ILI ASPREN/VIDRL Sentinel GP ILI related consultations Influenza ASPREN/WASPN Test sub-set of ILI presentations Circulating respiratory viruses Ratio of presentations to positives Rate per 1,000 consultations (ASPREN, NT, VIDRL) 2009 (ASPREN, NT, VIDRL) 2010 (ASPREN, VIDRL) 2011 (ASPREN, VIDRL) Week Weekly rate of ILI reported from GP ILI surveillance systems, Australia, 2008 to 30 October2011 SOURCE: ASPREN and VIDRL GP ILI surveillance systems. NNDSS

8 Mortality Hospitalisation ED Presentation General Practice Community Emergency Department Level ILI Sentinel State EDs Two states EDs (WA & NSW) ILI related presentations & admissions Rate per 1,000 Presentations Week

9 Mortality Hospitalisation ED Presentation General Practice Community Hospitalisation Level Influenza FluCAN Hospital based sentinel surveillance Co-morbidities, pregnancy, Indigenous status ICU admission, treatment & outcome Influenza type and sub-type Vaccine effectiveness APSU Paediatric associated admissions Co-morbidities Influenza type and sub-type State Public Hospitalisation State based public hospitals (QLD-EpiLOG) Linkage between hospital and public lab system NNDSS

10 Mortality Hospitalisation ED Presentation General Practice Mortality Level Community ILI State BDM Sentinel state births, death and marriage register Rate of influenza & pneumonia associated deaths AIHW Mortality National collection of BDM data Not timely, ~2 year delay Influenza NNDSS

11 NNDSS Legislative requirement in all States & Territories Demographics, Indigenous status Type, subtype Testing practices vary Current focus Improving sub-typing data - 40% flu A untyped Improving death, hospitalisation data fields Influenza Notification Surveillance

12 Laboratory Surveillance Sentinel Laboratories and NICs Type, subtype, positivity WHOCCR Type, subtype, strain, antiviral resistance Viruses from all jurisdictions Work to ensure representation of isolates for subtyping PHLN sub typing protocol ACT NSW NT QLD SA TAS VIC WA TOTAL Pandemic A(H1N1) A/California/7/2009-like 2, A/California/7/2009-like (low reactor) A(H3N2) A/Perth/16/2009-like A/Perth/16/2009-like (low reactor) B B/Florida/4/2006-like B/Florida/4/2006-like (low reactor) B/Brisbane/60/2008-like B/Brisbane/60/2008 (low reactor) Total Influenza isolates typed by HI, Australia, 1 January to 27 November 2011 SOURCE: WHO Collaborating Centre 1 Composition of the 2009 Southern Hemisphere influenza vaccine 2 Recommended virus for Pandemic A(H1N1) 2009 vaccines 3 Composition of the 2010 and 2011 Southern Hemisphere influenza vaccine Low Reactor: These viruses show > 8 fold reduction compared to the HI titre obtained with the reference virus and antisera.

13 International Surveillance WHO, including WPRO and IHR ProMed, CIDRAP International Ministries of Health websites Media

14 Summary of Surveillance Systems Virology Mortality Hospitalisation ED ILI NSW BDM AIHW Mortality Sentinel State EDs (NSW & WA) Sentinel State EDs (NSW & WA) Influenza WHOCCR NICs and other PH laboratories NNDSS FluCAN APSU State Public Hospitalisation (Qld) NNDSS GP ASPREN/VIDRL ASPREN/WASPN NNDSS Community NHCCN FluTracking

15 Objectives of Influenza Surveillance in Decision Making

16 Monitor seasonal activity: Location and timing Size & intensity Morbidity and mortality trends Health care system burden Significance of trends Influenza Surveillance System Objectives Monitor circulating viruses: Define the types and subtypes of circulating influenza viruses Detect antigenic changes in circulating viruses Identify risk factors for severe disease Provide comparable data for influenza activity between seasons and during a pandemic. Provide baseline systems that can be enhanced during a pandemic response. Provide reliable data to inform decision making.

17 Role of Influenza Surveillance in Decision Making Provide early alert: Time public health messages. Implement preventative measures eg. vaccination. Detect & respond to outbreaks. Characterise epidemiology of the season: Inform clinical, laboratory, PH and health care response. Target interventions to high-risk populations. Evaluate impact of measures: Effective use of interventions and measures. Long term planning. Vaccine effectiveness.

18 Role of Influenza Surveillance in Decision Making Characterise circulating viruses: Information on antigenic drift and novel viruses. Antiviral effectiveness. Inform vaccine strain selection for future season. Assess disease burden: Capacity to meet demands. Health system planning. Inform longer term policy development. Estimate impact (health, services, economic and social). Accurate and timely information: Informed responses and planning decisions. Appropriate interventions. Public needs.

19 Stakeholders Whole of Government (National & State) Communicable Diseases Network Australia Australian Technical Advisory Group on Immunisation Pharmaceutical Benefits Advisory Committee Australian Influenza Vaccination Committee Strategic decision making. Operational Planning. Technical & Health Professionals Health care providers Public health units Delivery of appropriate responses Public Knowledge of issues Awareness to inform personal decision making

20 Vaccination Recommendations, Decision Making and Surveillance

21 Vaccination Recommendations and Decision Making Vaccination recommendations: Three key elements: Vaccine component selection Vaccination recommendations Monitoring adverse events

22 Vaccine - Component Selection Decision Maker: Australian Influenza Vaccine Committee Annually recommend the influenza vaccine components for next Southern Hemisphere. Consider WHO recommendations. Surveillance Source: WHO CC: Circulating strains in Australia, the region and globally. NNDSS, NICs and Public Health Laboratory: types and sub-types. representativeness of WHO CC data.

23 Vaccine - Recommendations Primary focus: administration to populations at-risk severe of disease. Secondary focus: any person wishing to reduce likelihood of becoming ill with influenza. Populations where vaccine promoted: Increased risk of severe disease; Contacts of people at increased risk of severe disease; Commercial poultry workers; Essential service workers; Travellers.

24 Vaccine - Recommendations National Immunisation Program: Vaccine free to identified populations. Legislation requires cost-effectiveness. Influenza Immunisation Program eligibility: >65 years of age. Indigenous people > 15 years of age. Pregnant women. Medical conditions predisposing to severe influenza > 6 months of age.

25 Vaccine - Recommendations To include a vaccine on the NIP: Decision Maker: Australian Technical Advisory Group on Immunisation Pharmaceutical Benefits Advisory Committee Surveillance Source: All sources, including, NNDSS, FluTracking, ASPREN, FluCAN, APSU, Mortality data: Risk factors for severe disease. Burden of disease. Clinical features.

26 Summary

27 Acknowledgments State and Territory Health Departments Providers of additional surveillance data: WHO CC NICs Sentinel Laboratories FluTracking ASPREN VIDRL FluCAN APSU NHCCN. ISSWG members Rhonda Owen, DOHA

28 Resources Australian Influenza Surveillance Report Immunise Australia The flu and you u-broch-1 Influenza Guidelines Influenza Infection A6CA E0AC7/$File/Influenza-SoNG-july11.pdf Influenza Outbreaks - Residential Care Facilities A1ACA2572F F0/$File/fluguide.pdf

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