Eye on Influenza. o Available Vaccine Products and Indications: See

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1 Archived Dcument Archive Disclaimer: The fllwing Health Care Agency dcument is fr histrical purpses nly. The infrmatin prvided was accurate at the time it was riginally presented. The Health Care Agency des nt review past pstings t determine whether they remain accurate, and infrmatin cntained in such pstings may have been superseded. We accept n respnsibility and specifically disclaim any liability fr readers' use f infrmatin cntained in any archived dcument. By viewing these archived materials, yu acknwledge that yu understand this cautinary statement.

2 September 19, 2011 Vlume 8, Issue 1 Influenza seasn is cming. Prviders are encuraged t begin vaccinating patients as sn as vaccine is available. Annual vaccinatin is recmmended fr all persns 6 mnths f age r lder! Influenza Vaccine Supply: Vaccine cmpanies prject prductin f a recrd number f dses this seasn, between millin. As f 9/9/2011, ~85.9 millin dses had already been distributed Recmmendatins f the Advisry Cmmittee n Immunizatin Practices (ACIP) Highlights: Fr details, see 8/26/11 MMWR available at Vaccine Strains fr U.S. vaccine are identical t thse in the vaccine: A/Califrnia/7/2009 (H1N1)-like, A/Perth/16/2009 (H3N2)-like, and B/Brisbane/60/2008-like. Recmmendatins fr Influenza Vaccinatin Rutine annual vaccinatin is recmmended fr all persns aged 6 mnths. Even thugh vaccine strains are the same as last seasn, annual vaccinatin is recmmended even fr thse wh received the vaccine in the seasn as efficacy may decrease ver time. Vaccinatin f children 6 mnths thrugh 8 years f age: Tw dses (administered a minimum f 4 weeks apart) are recmmended fr children 6 mnths thrugh 8 years f age wh didn t receive the vaccine last year r fr whm vaccinatin status is unknwn. Because vaccine strains have nt changed this year, children aged 6 mnths thrugh 8 years wh received ne dse in the seasn need nly ne mre dse this seasn (instead f the tw dses recmmended in the secnd seasn fr children wh nly received ne dse their first year f vaccinatin). An algrithm fr dsing f children 6 mnths-8 years f age is available n p.1129 (Fig. 1). Vaccinatin f Persns Reprting Allergy t Eggs: Several recent studies have dcumented safe receipt f TIV in persns with egg allergy, and recent revisins f sme TIV package inserts nte that nly a severe allergic reactin (e.g., anaphylaxis) t egg prtein is a cntraindicatin. Vaccine can be administered t certain persns reprting a histry f egg allergy; see the MMWR fr detailed recmmendatins and an algrithm (Fig. 2). Available Vaccine Prducts and Indicatins: See Influenza Vaccinatin Cverage in Healthcare Persnnel and Pregnant Wmen: The cmplete articles can be fund in the 8/19/11 issue f MMWR at Healthcare Persnnel (HCP): In nline surveys f 1,931 HCW, flu vaccine uptake during was 63.5%, similar t 61.9% in In HCP wrking at facilities that required vaccinatin, cverage was ver 98%, cmpared with 58% withut a requirement. Amng HCP withut an emplyer requirement but with n-site vaccinatin, cverage was higher if it was available at n charge r fr mre than ne day. Healthy Peple 2020 target: 90% fr HCP. Pregnant Wmen: Amng 1,457 respndents wh were pregnant between Octber 10 and January 11, vaccine uptake was 49%, similar t during the 2009 pandemic. Amng wmen wh were ffered vaccinatin by a HCP, 71% were vaccinated, cmpared with 14% f thse nt ffered vaccinatin by a HCP. Healthy Peple 2020 target: 80% fr pregnant wmen. Fur Cases f Nvel Swine-Origin Influenza A (H3N2) reprted in children frm Pennsylvania (3) and Indiana (1). The IN child had a caretaker with histry f recent swine expsure. The three PA children had been in the swine area at an agricultural fair. T date, there has nt been any spread in these cmmunities. This nvel virus is different frm the swine-rigin A (H3N2) previusly seen in the US in that it cntains a gene frm the human 2009 H1N1 virus. See Influenza-Assciated Pediatric Deaths reprted in U.S. 9/10-8/11. Of these, 46% were <5 years f age and 49% had n high-risk medical cnditins. Only 23% f thse 6 mnths f age were fully vaccinated. See the 9/16/11 issue f MMWR at If yu have any cmments abut this flyer, cntact Sandra Okub r Michele Cheung, MD at (714)

3 Nvember 7, 2011 Vlume 8, Issue 2 Influenza has been detected in Orange Cunty! Nw is the time t vaccinate. Influenza vaccine is available thrughut the Cunty. Fr publicly funded vaccine clinics, see Fr retail lcatins, see the Flu Vaccine Finder at Influenza - Orange Cunty: The first cnfirmed case f influenza this seasn was reprted recently. Thus far this seasn, influenza B, parainfluenza, and adenvirus have been identified. Visits t sentinel physicians fr influenza-like illnesses (ILI) remain lw. Hwever, reprts f respiratry illness amng schl children have been nted. Please reprt all utbreaks t and frward specimens n students that are part f respiratry utbreaks t the Orange Cunty Public Health Labratry. Influenza-assciated deaths in persns < 65 years f age reprtable. In additin, we request reprting f severe cases (ICU admissins) f influenza in persns < 65 years f age t OC Epidemilgy (fax ) s we can mnitr the severity f the influenza seasn and identify risk factrs fr illness. Visit ur prvider page fr mre infrmatin n influenza and ther reprtable diseases Free flu materials can be fund at Influenza Califrnia and United States: Based n lw levels f ILI and labratry detectins, verall influenza activity during Week 43 (ending Oct 29) was spradic in Califrnia. Influenza A 2009 H1N1, A H3N2, and B have all been identified this seasn. N states have reprted lcal, reginal r widespread influenza activity. CDC has cnfirmed additinal cases f human infectin with a swine-rigin H3N2 reassrtant in Maine and Indiana. The three latest cases all reprted t expsure t pigs. N nging human-t human transmissin has been identified. Swine influenza A (H3N2) nrmally infects pigs, but rarely can als infect humans, especially when peple are in clse prximity t infected pigs. This nvel virus is different than the swine H3N2 strains usually circulating in the U.S. in that it cntains the M gene frm the human 2009 H1N1 virus. See FDA reminds health care prfessinals that jet injectrs shuld nt be used t administer inactivated influenza vaccines (TIV). TIV labeled fr IM injectin shuld be administered with a sterile needle and syringe. Hwever, based n limited infrmatin frm recent publicatins, FDA and CDC believe that it is NOT necessary t revaccinate peple wh inadvertently were vaccinated with a jet injectr. See Antiviral use in patients hspitalized with influenza increased during the 2009 H1N1 pandemic: New guidelines issued during the 2009 H1N1 pandemic encuraging antiviral treatment fr all hspitalized patients with influenza increased antiviral use in hspitalized patients frm 54% during the fur prepandemic seasns t 82% during the pandemic. Antiviral use in hspitalized pregnant wmen increased frm 22% in prepandemic seasns t 86%. See J Infect Dis Influenza vaccine effectiveness: A recent meta-analysis emphasizes the need fr new, mre effective and crss-prtective influenza vaccines. Hwever, in the meantime, the present vaccines are the best interventin available t prtect against seasnal influenza. Lancet Infect Dis Online First 10/26/11. CDC develps Q&A fr health prfessinals abut vaccine effectiveness and hw it differs frm vaccine efficacy:

4 December 22, 2011 Vlume 8, Issue 3 Influenza activity remains lw in Orange Cunty. It s nt t late t vaccinate! Influenza vaccine is available thrughut the Cunty. Fr publicly funded vaccine clinics, see Fr retail lcatins, see the Flu Vaccine Finder at With the hliday parties and gatherings in full swing, remember t cver yur cugh, wash yur hands, and stay hme when yu are ill! Seasnal Influenza - Orange Cunty: Thus far Orange Cunty has received a few reprts f bth influenza A and B. Parainfluenza and adenvirus have als been identified frm patients with influenza-like illness (ILI). Visits t sentinel prviders fr ILI remain lw. N severe influenza (ICU admissins r deaths) in persns < 65 years f age have been cnfirmed. Seasnal Influenza Califrnia and United States: Influenza activity remains spradic in Califrnia and lw verall in the U.S. ILI visits are at r belw baseline. It is t early in the seasn t tell hw well the vaccine strains will match circulating strains. Thus far this seasn, all islates tested have been susceptible t seltamivir (Tamiflu ) and zanamivir (Relenza ). See fr updates. Additinal human cases f nvel swine-rigin influenza reprted. Circulatin f a nvel swine-rigin triple reassrtant H3N2 influenza (S-OtrH3N2) virus infecting humans has nw been reprted in five states, including Pennsylvania, Indiana, Maine, Iwa and mst recently West Virginia. Since July 2011, a ttal f 11 cases have been identified. This nvel virus is different than the swine H3N2 strains usually circulating in the U.S. in that it cntains the M gene frm the human 2009 H1N1 virus. Almst all cases have ccurred in children, with a median age f three years (range 11 mnths- 58 years). Three had underlying chrnic medical illnesses and were hspitalized; all have recvered. Of the 11 cases, six had either direct r indirect expsure t swine, while investigatin f anther five cases has suggested transmissin by persn-t-persn cntact. T date, these viruses appear t be resistant t amantadine and rimantadine and susceptible t the neuraminidase inhibitr drugs seltamivir and zanamivir. Other nvel swine-rigin influenza strains have als been detected recently in humans. See fr the latest updates. Enhanced surveillance fr S-OtrH3N2 in humans. Orange Cunty Public Health distributed infrmatin t prviders utlining the fllwing enhanced surveillance activities starting last week: Sentinel prviders: Increase submissin f specimens n patients, especially children, meeting the ILI definitin (fever f 100 F r higher accmpanied by a cugh, sre thrat, r bth) fr testing fr influenza; Cntinue t reprt ILI weekly; Reprt t Public Health ( ) immediately with any utbreaks r clusters f ILI r any deaths in patients with ILI. Emergency Departments, Intensive Care Units, Urgent Cares, Outpatient Clinics, Infectin Preventin Departments: Test patients, especially children ( 18 years f age), meeting the ILI definitin fr influenza; Reprt t Public Health immediately with any utbreaks r clusters f ILI, any deaths in patients with ILI, and any critically ill patients (admitted t intensive care) < 65 years f age with suspect influenza. Labratries: Save influenza-psitive specimens fr further characterizatin at the Orange Cunty Public Health Labratry. Fr mre infrmatin, see Natinal Vaccine Advisry Cmmittee (NVAC) seeks public cmments n health care persnnel (HCP) influenza vaccinatin strategies. The Healthy Peple 2020 gal fr HCP influenza vaccinatin is 90%, but accrding t the latest CDC estimates, the current rate is 63%. T review the guidance and submit cmments, g t and search fr Influenza Vaccinatin. CDPH updates Recmmendatins fr the Preventin and Cntrl f Influenza in Califrnia Lng- Term Care Facilities, available at

5 January 24, 2012 Vlume 8, Issue 4 Influenza activity is increasing in Orange Cunty. It s nt t late t vaccinate! Influenza vaccine is available thrughut the Cunty. Fr publicly funded vaccine clinics, see Fr retail lcatins, see the Flu Vaccine Finder at Seasnal Influenza - Orange Cunty: Orange Cunty has received its first reprted case f severe influenza (ICU admissins r deaths) in persns < 65 years f age. The patient is less than 18 years f age and has underlying medical cnditins putting him/her at increased risk fr influenza-related cmplicatins, but has since recvered and was discharged hme. Orange Cunty has received 20 reprts f influenza thus far this seasn (15 A, fur B, and ne A/B unspecified); ver half f these reprts have been received in the previus tw weeks. Of the subtypes identified, seven were seasnal influenza A/H3 and fur were 2009 A/H1. Visits t sentinel prviders fr influenza-like illness (ILI) remain lw at 2.1%. Seasnal Influenza Califrnia and United States: Influenza activity is lcal in Califrnia and lw verall in the U.S. In Week 2, CDPH received the first reprt f a pediatric influenza-assciated fatality this seasn. A ttal f three deaths have been reprted in persns 0-64 years f age. Furteen specimens frm Califrnia residents have been strain-typed this seasn; all but ne matched with cmpnents f the influenza vaccine fr the Nrthern Hemisphere. S far this seasn, all islates tested by the CDC have been susceptible t seltamivir (Tamiflu ) and zanamivir (Relenza ). See fr updates. Statin use may be assciated with reduced mrtality in patients hspitalized with influenza. Data frm the CDC Emerging Infectins Prgram was used t analyze 30-day mrtality in 3,043 patients hspitalized with labratry-cnfirmed influenza in 10 states during the influenza seasn. Statin use prir t r during hspitalizatin was assciated with a 41% reductin in mrtality [dds rati, 0.59 (95% cnfidence interval, )], after adjusting fr ther variables such as age, underlying medical cnditins, antiviral use and influenza vaccinatin. The authrs cncluded that statins may have anti-inflammatry and immunmdulatry effects that culd reduce the risk f mrtality frm influenza. Althugh the study has several limitatins, the findings add t data frm previusly reprted studies n statins suggesting further research in this area may be prmising. See J Infect Dis 2012; 205(1):13-19 available at Investigatrs describe lessns learned frm an influenza utbreak in a residential facility fr children and yung adults with neurlgic and neurdevelpmental cnditins. Amng the 130 residents, 76 had acute nset f respiratry illness, with 13 severely ill f whm 10 were hspitalized and 7 died. Clinicians shuld be aware that patients with severe neurlgic r neurdevelpmental cnditins might have nly subtle deviatins frm their baseline medical status and may be unable t cmmunicate their symptms. Recmmendatins include prmpt testing, early and aggressive antiviral treatment, and chemprphylaxis f all residents f lng-term care facilities regardless f vaccinatin status. See 1/6/2012 issue f MMWR, available at

6 February 24, 2012 Vlume 8, Issue 5 Flu activity is increasing in Orange Cunty and is widespread in Califrnia. It s nt t late t vaccinate! Flu seasn ften cntinues thrugh May. Fr publicly funded vaccine clinics, see Fr retail lcatins, see the Flu Vaccine Finder at Influenza Update - Orange Cunty: Orange Cunty has received a ttal f 110 influenza reprts (101 influenza A, 7 influenza B, and 2 A/Bunspecified). Of the 63 subtyped viruses, 38 (60%) were seasnal influenza A/H3 and 25 (40%) were 2009 A/H1. There have been 3 severe pediatric (ICU) cases reprted s far this seasn. Visits t sentinel prviders fr ILI remain lw at 1.9%. Influenza Update Califrnia and U.S.: During Week 7, tw states reprted widespread flu activity, including CA. Twenty-seven specimens frm Califrnia residents have been strain-typed this seasn; all but fur influenza B strains matched cmpnents f the influenza vaccine fr the Nrthern Hemisphere. Six influenzaassciated deaths in persns less than 65 years f age have been reprted. S far this seasn, all islates tested have been susceptible t seltamivir (Tamiflu ) and zanamivir (Relenza ); hwever, rare spradic cases f seltamivir resistant 2009 H1N1 and H3N2 viruses have been detected wrldwide. Antiviral treatment is recmmended as early as pssible fr patients with cnfirmed r suspected influenza wh are at increased risk fr influenza-related cmplicatins r wh have severe, cmplicated, r prgressive illness and/r require hspitalizatin. Additinal infrmatin n treatment and chemprphylaxis is available at ( The Natinal Vaccine Advisry Cmmittee (NVAC) t the US Department f Health and Human Services apprves recmmendatins designed t increase flu vaccinatin amng healthcare wrkers. The five-part recmmendatin is presented in a tiered apprach and urges healthcare emplyers t strngly cnsider mandatry flu vaccinatin plicies if they fall shrt f the Healthy Peple 2020 gal f 90% immunizatin cverage fr healthcare wrkers. T view the reprt, visit: Autpsy study shws influenza B infectins may be mre severe than riginally thught. The CDC evaluated autpsy tissue samples frm 45 fatal cases f influenza B infectin. Seventeen (38%) had evidence f bacterial pneumnia, 13 with Staphylcccus aureus, f which seven were methicillin resistant. Mycardial injury was seen in 20 (69%) f 29 cases with available cardiac tissue samples. Of the 35 patients with available infrmatin, mst (69%) died within 4 days f illness nset, mre rapidly than ften seen with several ther flu viruses, including 2009 H1N1 and seasnal H3N2. See 1/30/12 editin f the Jurnal f Infectius Diseases available at The Wrld Health Organizatin recmmends changing tw strains fr the seasn influenza vaccine in the Nrthern Hemisphere. Based n circulating strains and their spread, WHO has recmmended that the A/H3N2 and B cmpnents f the vaccine be changed t A/Victria/361/2011 and B/Wiscnsin/1/2010 (B/Yamagata lineage), respectively, but the H1N1 cmpnent (A/Califrnia/7/2009 (H1N1) pdm09) remain the same. This recmmendatin will need FDA apprval befre the final decisin n cmpsitin f the U.S. vaccine. See

7 March 12, 2012 Vlume 8, Issue 6 Flu activity remains widespread in Califrnia. It s nt t late t vaccinate! Fr publicly funded vaccine clinics, see Fr retail lcatins, see the Flu Vaccine Finder at Influenza Update - Orange Cunty: Orange Cunty has received a ttal f 254 influenza reprts (237 influenza A, 14 influenza B, and 3 A/B-unspecified); f the viruses subtyped, 84 (60%) were seasnal influenza A/H3 and 57 (40%) were 2009 A/H1. There have been 8 influenza-assciated ICU admissins reprted s far this seasn, 7 amng children less than 18 years. Visits t sentinel prviders fr influenza-like illness remain lw at 1.9%. Influenza Update Califrnia and U.S.: The percent f specimens testing psitive fr influenza cntinues t increase natinally (see graph at right). During Week 9, nine states reprted widespread flu activity, including Califrnia. Of the 612 specimens strain-typed this seasn by the CDC, 480 (98% H1N1, 78% H3N2, and 46% B) matched with cmpnents f the influenza vaccine fr the Nrthern Hemisphere. S far this seasn, nly ne (ut f 683 specimens tested) has been resistant t seltamivir (Tamiflu ) and all are susceptible t zanamivir (Relenza ). Influenza-assciated hspitalizatins reprted t the Influenza Surveillance Netwrk (FluSurv-NET) have increased 36% in the last week. A ttal f 593 labratry-cnfirmed influenza-assciated hspitalizatins frm ver 80 cunties participating in the prgram have been reprted this seasn. Amng hspitalized cases, 88% were influenza A (75% f which were H3N2),10% were B and 2% were unknwn type. The mst cmmnly reprted underlying medical cnditins amng adults were chrnic lung diseases, besity and metablic disrders. The mst cmmnly reprted underlying medical cnditins in children were chrnic lung diseases, asthma and neurlgic disrders. Half f hspitalized children had n identified underlying medical cnditins. FluSurv-NET is nt natinally representative and mst likely underestimates the actual number f influenza-assciated hspitalizatins. Fr updates, see The US Fd and Drug Administratin (FDA) apprves first quadrivalent influenza vaccine. The vaccine develped by MedImmune is an inhaled live attenuated influenza vaccine (FluMist Quadrivalent) apprved fr use in healthy persns 2 thrugh 49 years f age. MedImmune plans t have the vaccine available fr the flu seasn, see FDA fllws WHO recmmendatins fr Nrthern Hemisphere seasnal influenza vaccine. The A/H3N2 and B cmpnents f the vaccine will be changed t A/Victria/361/2011 and B/Wiscnsin/1/2010 (B/Yamagata lineage), respectively. The H1N1 cmpnent f the vaccine will remain the same, A/Califrnia/7/2009 (H1N1) pdm09. Meta-analysis f rapid influenza diagnstic tests (RIDTs) finds limitatins. The review included 159 studies evaluating 26 RIDTs. The pled sensitivity and specificity were 62% and 98%. Tests were mre accurate in children than adults and were better at detecting influenza A than influenza B. The study was published Feb 27 in the Annals f Internal Medicine:

8 March 23, 2012 Vlume 8, Issue 7 Flu activity cntinues t increase in Orange Cunty. We expect influenza activity t cntinue fr at least the next several weeks. It s still nt t late t vaccinate! Fr publicly funded vaccine clinics, see Fr retail lcatins, see the Flu Vaccine Finder at Influenza Update - Orange Cunty: Influenza reprts cntinue t increase in Orange Cunty. Types/subtypes identified include influenza A (95%) [2009 A/H1 (37%) / H3 (63%)] and influenza B (5%). There have been 9 influenza-assciated ICU admissins reprted s far this seasn, 8 amng children less than 18 years f age. Visits t sentinel prviders fr influenza-like illness remain lw at 1.1%. Hwever, several reprts f increased febrile respiratry illness amng schl children and residential care facilities have been received. Please reprt utbreaks t and frward specimens t OCPHL. Influenza Update Califrnia and U.S.: Percentage f Influenza Types and Subtypes in Respiratry The percentage f specimens reprted by participating labratries as psitive fr influenza in Califrnia cntinued n an upward trend (see graph at right). During Week 11, 20 states reprted widespread flu activity, including Califrnia. Labratry Netwrk and Sentinel Labratries, CA Influenza Testing & Treatment: Testing: A negative rapid influenza diagnstic test (RIDT) des nt rule ut influenza infectin. D nt rely n negative RIDT results fr clinical r infectin cntrl decisins. Antiviral treatment shuld be cnsidered based n clinical signs, symptms, and histry. Plymerase chain reactin (PCR) r viral culture is recmmended t cnfirm RIDT r indirect/direct flurescent antibdy results, distinguish between A r B, and prvide subtype and strain infrmatin. This is especially imprtant in severe cases, in patients wh were vaccinated this influenza seasn, in thse wh had recent clse expsure t pigs, pultry, r ther animals, and in thse patients with histry f recent travel. Treatment: Antiviral treatment with seltamivir (Tamiflu ) r zanamivir (Relenza ) is recmmended as early as pssible fr patients with cnfirmed r suspected influenza wh have severe, cmplicated, r prgressive illness; wh require hspitalizatin; r wh are at greater risk fr influenza-related cmplicatins. Recmmendatins fr treatment and chemprphylaxis fr patients with cnfirmed r suspected influenza virus infectin with antiviral agents are available at ( Annual vaccinatin is recmmended fr everyne 6 mnths f age and lder. See ACIP recmmendatins at Hspitals/labratries Please cntinue t submit psitive influenza specimens t OCPHL. Please reprt severe cases f influenza (deaths/icu admissins) in persns less than 65 years f age t OC Epidemilgy (fax ).

9 March 30, 2012 Vlume 8, Issue 8 Influenza activity is still elevated in Orange Cunty and is expected t cntinue fr at least the next several weeks. Cnsider influenza in yur patients with fever and/r respiratry symptms. All patients with respiratry infectins shuld be handled using Respiratry Hygiene/Cugh Etiquette ( Influenza Update - Orange Cunty: It s still nt t late t vaccinate! Fr publicly funded vaccine clinics, see Fr retail lcatins, see the Flu Vaccine Finder at This week Orange Cunty has received tw new reprts f severe influenza (resulting in admissin t intensive care) in persns less than 65 years f age; eleven reprts have been received s far this seasn (with nine amng children less than 18 years). Influenza cntinues t circulate at elevated levels; hwever, the number f influenza reprts received decreased in Week 12. Types/subtypes identified include influenza A (95%) [2009 A/H1 (36%) / H3 (65%)] and influenza B (5%). Influenza Update Califrnia and U.S.: During Week 12, sixteen states reprted widespread gegraphic activity (dwn frm 20 in Week 11), including Califrnia; 21 states reprted reginal influenza activity (see map abve). Influenza activity remains relatively lw natinally. Fr CDC updates: Fr mre infrmatin abut influenza diagnstics, antivirals and infectin cntrl in health care facilities, see Fr internatinal influenza activity, visit: // Fr CA flu activity, Infants wh are premature r with underlying medical cnditins appear t be at increased risk fr develping severe influenza 2009 H1N1 infectin: The Califrnia Department f Public Health reviewed medical recrds fr 77 infants hspitalized in the ICU with labratry-cnfirmed 2009 H1N1 between 4/23/09 and 5/1/10. The median age was 109 days (range 1-361) and 73% were less than 6 mnths f age. Sixty percent f the infants had at least ne reprted underlying medical cnditin and 35% had a gestatinal age f 36 weeks r less. Seven (9%) infants died and 35 (45%) required mechanical ventilatin. Five infants acquired infectin during their birth hspitalizatin. The reprt emphasizes the need fr (1) vaccinatin f cntacts f infants less than 6 mnths f age wh are t yung t be immunized and fr whm antivirals are nt FDA-apprved; (2) maintaining a high suspicin fr influenza infectin in infants when influenza is circulating; and (3) implementatin f infectin cntrl measures in hspital settings t reduce nscmial transmissin. See Pediatr Infect Dis 2012;31(3):e52-e55, available at Tw studies cnfirm link between narclepsy in Finnish children and the adjuvanted 2009 H1N1 pandemic vaccine Pandemrix. This vaccine was nt used in the U.S.; n adjuvanted vaccines are licensed in the U.S. Fr details n the studies, see PLS One 3/28/2012 issue at

10 April 6, 2012 Vlume 8, Issue 9 Influenza activity is still elevated in Orange Cunty. Cnsider influenza in yur patients with fever and/r respiratry symptms. All patients with respiratry infectins shuld be handled using Respiratry Hygiene/Cugh Etiquette ( Influenza Update - Orange Cunty: It s still nt t late t vaccinate! Fr publicly funded vaccine clinics, see Fr retail lcatins, see the Flu Vaccine Finder at Orange Cunty received tw new Percentage f Visits t Orange Cunty Sentinel Prviders fr reprts f severe influenza Influenza-like Illness (ILI), Influenza Seasn (resulting in admissin t intensive care) in persns less than 65 years 6 Nte: Data frm ur participating prviders is f age; 13 reprts have been nt ppulatin based and des nt reflect all received s far this seasn (nine ILI activity in the Cunty. amng children less than 18 years). Influenza cntinues t circulate at 4 elevated levels in Orange Cunty. The majrity f reprts are influenza A, predminantly H3, 2 but influenza A H1 and B have als been reprted. The percent f visits t sentinel prviders fr influenzalike illnesses (ILI) has increased 0 fr the secnd week and is Octber Nvember December January February March April May currently at 3.9% (see graph). Disease Week 4/5/12 % f Visits Influenza Update - Califrnia & U.S.: During week 13 (March 25-31), influenza activity was elevated in sme areas f the United States, but declined verall natinally and in mst regins. Califrnia cntinues t reprt widespread influenza activity. Fr CDC updates: Fr CA updates: Studies cntinue t evaluate rle f airbrne particles in transmissin f influenza. A recent study led by the Natinal Institute f Occupatinal Safety and Health used mechanized mannequins t simulate cughing and breathing humans in a patient examinatin rm t lk at transmissin f influenza viruses. Tightly sealed N95 respiratrs prvided the best prtectin, blcking 99.8% f the viruses, while prly fitted respiratrs and lse-fitting masks affrded much less prtectin, blcking 69.9% and 68.9% f viruses, respectively. Accrding t the authrs, unsealed masks had fit factrs similar t thse f masks in real-wrld use. Additinal research frm large cntrlled studies is needed t determine the best prtectin against influenza in healthcare settings. See Clinical Infectius Diseases: Current CDC guidance n the use f masks t prevent seasnal flu transmissin recmmends healthcare persnnel wear a surgical r prcedure mask when in clse cntact (within 3 feet) f a patient wh has symptms f a respiratry infectin: Fr mre infrmatin, see Evaluatin f accuracy f Indirect Flurescent Antibdy (IFA) Assays and Rapid Influenza Diagnstic Tests (RIDT) cmpared t plymerase chain reactin (PCR) testing fr 2009 H1N1 influenza in specimens submitted t the OCPHL: Overall, apprximately 30% f IFA tests and RIDTs submitted fr PCR testing were falsely negative. Sensitivity f RIDTs varied greatly (45-84%) depending n age f patients and severity. A special thanks t sentinel prviders, infectin preventinists and hspital labratry staff fr their cntributins t influenza surveillance in Orange Cunty. T view the article, see:

11 April 13, 2012 Vlume 8, Issue 10 Influenza Update - Orange Cunty: It s still nt t late t vaccinate! Fr publicly funded influenza vaccine clinics, see Fr retail lcatins, see the Flu Vaccine Finder at Orange Cunty has received 14 reprts f severe influenza (resulting in admissin t intensive care) in persns less than 65 years f age s far this seasn (ten amng children less than 18 years). Influenza detectins have decreased frm peak activity in week 11, thugh the virus cntinues t circulate at elevated levels in Orange Cunty (see graph). The majrity f reprts are influenza A, predminantly H3, but influenza A H1 and B have als been reprted. The percent f visits t sentinel prviders fr influenza-like illnesses (ILI) is currently at 3.6%. Influenza Update - Califrnia & U.S.: During week 14 (ending April 7), flu activity declined natinwide. Hwever, the percent f specimens testing psitive fr influenza remains abve 20%. Califrnia cntinues t reprt widespread flu activity. CDC updates: CA updates: New case f nvel H3N2 reprted in Utah: This case invlved a child infected with swine-rigin A H3N2v strain which includes the M (matrix ) gene frm the 2009 H1N1 virus, and is identical t the strain fund in twelve cases frm five states last year. The child had expsure t swine and recvered withut hspitalizatin. All but ne f the 13 A H3N2v infectins have ccurred in children and apprximately half f the cases had a histry f swine expsure. Fr mre infrmatin, visit: A few ther ntes n nvel H3N2: Influenza activity is still elevated in Orange Cunty. Cnsider influenza in yur patients with fever and/r respiratry symptms. All patients with respiratry infectins shuld be cared fr using Respiratry Hygiene/Cugh Etiquette ( **Nte: The number f reprted cases des NOT crrespnd t the ttal number f cases ccurring in OC as nt all hspitals/labs participate, the surveillance prgrams are nt ppulatin based, and testing may be influenced by many factrs such as public interest. Hwever, the trends in influenza activity are likely t be reflected accurately. The latest case f nvel H3N2 was detected during rutine surveillance. Characterizatin f circulating influenza viruses is imprtant t detect nvel strains and mnitr fr changes in epidemilgy and virulence f flu viruses. Please cntinue t submit influenza-psitive specimens t the Orange Cunty Public Health Labratry. Crss-prtectin against the H3N2v influenza A strain evaluated: CDC researchers recently fund that apprximately ne third f persns aged years have crss-reactive antibdies that might prvide sme prtectin frm H3N2v infectin (4/13/2012 MMWR, at There was little r n crss-reactive antibdy t H3N2v fund amng children under 10 years f age, suggesting that they are at increased risk f infectin. Receipt f seasnal flu vaccine bsted levels f H3N2v antibdies amng adults (18 49 years) and lder adults ( 65 years), but less than it raised antibdy levels t vaccine-strain H3N2. Less than 10% f children 6-35 mnths f age generated prtective antibdy levels t H3N2v after flu vaccinatin.

12 April 20, 2012 Vlume 8, Issue 11 Influenza activity has decreased but influenza viruses cntinue t circulate in Orange Cunty. Orange Cunty Influenza Update: Influenza detectins cntinue t decline since peak activity in mid-march. The majrity f reprts are influenza A, predminantly H3, but influenza A, H1 and B have als been reprted. Orange Cunty has received ne new reprt f severe influenza (resulting in admissin t intensive care), fr a ttal f 15 reprts in persns less than 65 years f age (ten amng children less than 18 years) this seasn. N deaths have been reprted in persns less than 65 years f age. Last week the percent f visits t sentinel prviders fr influenza-like illness fell just belw 1%, and is at r belw baseline. Califrnia & U.S. Influenza Update: Influenza activity in Califrnia was dwngraded t reginal during week 15 (ending April 14). Widespread influenza activity was reprted by six states (Alaska, Clrad, Mntana, New Yrk, Oregn, and Vermnt). Influenza indicatrs have remained elevated in sme areas f the United States, but declined in mst areas in the last cuple f weeks. Overall in the U.S., 17.5% f specimens tested last week were psitive fr influenza (graph at right). Fr CA updates: s/influenza(flu).aspx. Fr CDC updates: Internatinal Influenza Update - thrugh 3/31 (map at right): In mst areas f the nrthern hemisphere temperate regins, influenza activity appears t have peaked and is declining. Althugh activity remains elevated acrss several regins in Canada, declining trends are being bserved. Similarly, in Eurpe and nrthern Asia, nearly every cuntry has nw passed its peak f transmissin and activity is declining. See

13 April 30, 2012 Vlume 8, Issue 12 Orange Cunty has received its first reprt this seasn f an influenza-assciated death in a persn less than 65 years f age. Influenza is still circulating in Orange Cunty. Cntinue t cnsider influenza in yur patients with fever and/r respiratry symptms, send apprpriate specimens fr testing, and start treatment as sn as pssible in yur patients at risk fr cmplicatins r with severe disease. Influenza Update: Influenza cntinues t circulate at lw levels in Orange Cunty. The majrity f reprts are influenza A, predminantly H3. Flu A, H1 and B have als been reprted. The first influenza-assciated death this seasn in an Orange Cunty resident was recently reprted. The patient was an adult with underlying medical cnditins that put them at increased risk fr cmplicatins frm influenza. In ttal 16 reprts f severe influenza (resulting in admissin t intensive care r death) in persns less than 65 years f age have been received this seasn. Ten reprts have been amng disease) children less than 18 years. Antiviral treatment with seltamivir (Tamiflu ) r zanamivir (Relenza ) is recmmended as early as pssible fr patients with cnfirmed r suspected disrders) influenza wh have severe, cmplicated, r prgressive illness; wh require hspitalizatin; r wh are at greater risk fr influenza-related cmplicatins (see table). Treatment shuld nt be delayed pending diagnstic testing, and clinical decisins shuld nt rely n results f rapid testing. Fr recmmendatins fr testing, treatment and chemprphylaxis fr influenza, see CDC updates: CA updates: Persns at increased risk fr serius cmplicatins frm influenza fr whm antiviral treatment is recmmended: Adults 65 years and lder Children yunger than 2 years ld Persns with chrnic medical cnditins, such as: Bld disrders (such as sickle cell disease) Chrnic lung disease (such as asthma, chrnic bstructive pulmnary disease [COPD] and cystic fibrsis) Endcrine disrders (such as diabetes mellitus) Heart disease (such as cngenital heart disease, cngestive heart failure and crnary artery Kidney disrders Liver disrders Metablic disrders (such as inherited metablic disrders and mitchndrial Neurlgical and neurdevelpmental cnditins (such as seizure disrder, cerebral palsy, severe develpmental delay) Wmen wh are pregnant r pst-partum (within 2 weeks after delivery) Persns with mrbid besity [BMI 40] Persns with weakened immune systems American Indians and Alaska Natives Residents f nursing hmes and ther chrnic care facilities. Study suggests that antiviral treatment saved many lives in Mexic during the 2009 H1N1 pandemic: Infrmatin n patients wh sught treatment fr influenza-like illness at a clinic r hspital frm April thrugh December 2009 was btained frm Mexic s scial security system, a health system cvering 40% f the Mexican ppulatin. This included data n 117,818 patients, f which 27,437 were lab-cnfirmed H1N1 cases. After adjusting fr age, gender, gegraphic regin, and pandemic wave, investigatrs fund that antiviral treatment reduced the risk f death fr H1N1 patients by 48%. Delayed hspitalizatin was the strngest predictr f death fr thse with cnfirmed H1N1 influenza. See BMC Infect Dis 2012 Apr 20: Pregnant wmen recmmended as the mst imprtant risk grup fr seasnal influenza vaccinatin. Accrding t preliminary recmmendatins released by the Wrld Health Organizatin s Strategic Advisry Grup f Experts (SAGE), alng with pregnant wmen, target ppulatins fr flu vaccinatin include in n particular rder healthcare wrkers, children 6 t 59 mnths, the elderly, and thse with high-risk cnditins. See

14 May 18, 2012 Vlume 8, Issue 13 Influenza activity is lw at this time and this is the final week f the regular influenza surveillance seasn. This will be the last rutine Eye n Influenza issue this seasn. Any updates t the seasn summary will be psted n ur website. Orange Cunty Influenza Seasn Summary: Influenza detectins started t increase in January, peaked in mid-march, and tapered ff in May (see graph). Peak influenza activity ccurred later than in recent flu seasns, which were in February. The majrity f reprts were influenza A (92%), [H3 (67%), H1 (33%)] and B (8%) was als reprted. Adenviruses, RSV and parainfluenza als circulated during the seasn. Severe influenza cases (resulting in admissin t intensive care r death) in persns <65 years f age: There have been 18 severe cases, including ne death, reprted during the seasn. Fifteen (83%) f the severe cases were amng males. Eleven cases (61%) were amng children. All severe pediatric ICU cases were under 10 years f age, with the majrity (70%) f cases ccurring in thse under 5 years. Influenza A was detected in specimens cllected frm the majrity (89%) f severe cases. Of the 12 flu viruses that were subtyped, 11 were A/H3 and 1 was 2009 H1N1. Tw PICU patients tested psitive fr flu B viruses and ne adult patient tested psitive fr bth A and B. Califrnia & U.S. Influenza Update: Number f Reprts Reprted Influenza Detectins Orange Cunty, CA Influenza Seasn Influenza A (11-12) Influenza B (11-12) Influenza A/B, unspec (11-12) * Data fr Week 20 is incmplete Oct Nv Dec Jan Feb Mar Apr May Specimen Disease Week & Apprximate Mnth As f May 18, 2012 **Nte: The number f reprted cases des NOT crrespnd t the ttal number f cases ccurring in OC as nt all hspitals/labs participate, the surveillance prgrams are nt ppulatin based, and testing may be influenced by many factrs such as public interest. Hwever, the trends in influenza activity are likely t be reflected accurately. Fr CDC updates: During week 19, flu activity was lw natinally, hwever, the percent f specimens testing psitive fr influenza remained abve 10 percent, indicating that flu activity is nging. Tested viruses this seasn remain susceptible t the antiviral drugs seltamivir and zanamivir with the exceptin f H1N1 viruses that were seltamivir-resistant. Eleven f the 16 seltamivir-resistant viruses detected were frm Texas. Fr CA updates: Other Influenza News: Study finds neurlgic cmplicatins frm 2009 H1N1 infectins are mre cmmn in children and Asian/Pacific Islanders. Researchers frm the Califrnia Department f Public Health and the CDC lked at 2,069 severe r fatal cases f 2009 H1N1 reprted in Califrnia frm April thrugh December Of these cases, 77 (3.7%) were classified as either having encephalpathy/encephalitis (n=29), seizures (n=44), meningitis (n=3), r ther (n=1; Guillain- Barré syndrme). Mst cases were in pediatric patients and Asian/Pacific Islanders appear t be ver-represented cmpared with the Califrnia ppulatin. Fr details, see May 9 Clin Infect Dis: A special thanks t ur influenza surveillance partners fr yur cntributins during the influenza seasn. Year-rund surveillance is imprtant t detect nvel viruses and utbreaks. Hspital/labratries: Please cntinue t submit psitive influenza specimens thrughut the summer. ILI sentinel prviders: Please cntinue t reprt weekly n ILI thrughut the summer. *

15 August 9, 2012 Vlume 8, Issue 14 New cases f swine-rigin H3N2v influenza have been reprted in the U.S., leading t the interim recmmendatins fr the public and fr health care prviders frm the CDC and CDPH. In additin, seasnal influenza activity is widespread in parts f the Suthern Hemisphere. Variant H3N2 Update: New human cases f variant influenza A H3N2 (H3N2v) have been reprted in the U.S. Between 7/12 and 8/3/2012, 16 cases frm three states (Hawaii, Indiana, and Ohi) were reprted. Each f these 16 cases had cntact with swine prir t their illness, with the majrity f cases attending r exhibiting swine at agriculture fairs. As f 8/8/2012, 113 cases have been reprted frm Indiana and 30 frm Ohi. Signs and symptms f H3N2v infectin are similar t that f seasnal influenza. This virus was first identified in July 2011 and cntains the matrix (M) gene frm the influenza A (H1N1)pdm09 virus which may cnfer increased transmissibility t and amng humans, cmpared t ther variant influenza strains. Thus far nly limited human-t-human transmissin has ccurred. N H3N2v cases have been identified t date in Califrnia. Nte: Flu viruses are nt spread by eating prperly handled r prepared prk r prk prducts. Health care prviders shuld: Cnsider influenza in patients with influenzalike illness (ILI) even in the summer mnths, especially in severely ill r fatal cases. Cnsider influenza A H3N2v in patients with ILI and recent swine expsure r cntact with cnfirmed human cases and reprt suspect cases t OC Epidemilgy at Reprt any respiratry utbreaks immediately t OC Epidemilgy. Submit specimens fr plymerase chain reactin (PCR) testing thrugh Orange Cunty Public Health n suspect H3N2v cases; testing is available n a case-by-case basis thrugh OC Epidemilgy. Rapid influenza diagnstic tests (RIDTs) may nt detect H3N2v virus in respiratry specimens. A negative RIDT des nt rule ut influenza infectin and a psitive test fr influenza A cannt differentiate between human and variant strains. Cnsider antiviral treatment with seltamivir (Tamiflu ) r zanamivir (Relenza ) in patients with suspect r cnfirmed H3N2v infectin. Treatment is mst effective when started as sn as pssible after illness nset. Members f the public shuld: Take precautins when visiting cunty fairs, including washing hands befre and after expsure t animals and aviding eating r drinking in animal areas. Cnsider aviding expsure t pigs and swine barns if yu are at high risk fr influenza cmplicatins (e.g., children yunger than 5 years, peple 65 years and lder, pregnant wmen, and peple with certain chrnic medical cnditins). Fr mre infrmatin, see chealthinf.cm/epi. Seasnal Influenza Glbal Update: Influenza activity is increasing in the suthern hemisphere where it is widespread in Australia and abve baseline in New Zealand. Activity varies by cuntry; fr mre infrmatin, see int/influenza/surveillance_mnit ring/updates/en/. Year-rund surveillance is imprtant t detect nvel viruses and utbreaks. Hspital/labratries: Cntinue t submit psitive influenza specimens thrughut the summer. ILI sentinel prviders: Cntinue t reprt weekly n ILI thrughut the summer and submit specimens.

16 August 21, 2012 Vlume 8, Issue 15 Variant H3N2 Update Human Case Surveillance: Mre states have reprted cases f H3N2v. Frm July 12 thrugh August 16, 2012, a ttal f 224 cases have been reprted in eight states (HI, IL, IN, MI, OH, PA, WV, and WI). S far during the current utbreaks, eight cnfirmed cases have been hspitalized; n deaths have been reprted. All recently cnfirmed cases have reprted direct r indirect expsure t pigs, primarily at agricultural fairs. Hwever, limited human-t-human transmissin f H3N2v was nted in 2011 and may reccur. Updated Interim Recmmendatins fr Health Care Prviders: Clinicians evaluating patients with ILI and an epidemilgical link t recent swine expsure shuld : Obtain respiratry specimens and cntact OC Epidemilgy t arrange fr testing. Clinicians shuld nt rely n rapid influenza diagnstic tests (RIDTs) t rule ut H3N2v infectin due t their variable sensitivity in recent evaluatins ( Variant H3N2 influenza has spread t mre states. Cnsider H3N2v infectin in patients with influenza-like illness (ILI) and recent swine expsure r cntact t ill persns with swine expsure. Ntify OC Epidemilgy immediately f any suspect cases r respiratry utbreaks. Cnsider antiviral treatment as sn as pssible, withut waiting fr labratry results, especially in patients wh are hspitalized, have severe illness, r are at increased risk fr cmplicatins f influenza. H3N2v viruses tested t date are susceptible t the antiviral drugs seltamivir (Tamiflu ) and zanamivir (Relenza ). Antiviral recmmendatins fr H3N2v infectin are based upn thse fr seasnal influenza: See the full reprt fr mre infrmatin: Interim Infrmatin fr Clinicians abut Human Infectins with H3N2v Virus: Interim Guidance fr Schls: Ask students with ILI abut expsure t pigs, r cntact with ill persns wh had expsure t pigs. Ntify OC Epidemilgy immediately f any suspect cases r respiratry utbreaks. Refer students with flu-like illness at high risk fr cmplicatins frm flu t their health care prvider, regardless f whether they have recently been near pigs. Encurage sick students and staff t stay hme. Recmmendatins fr Organizers f Fairs r Other Public Settings with Animals: See Serlgic study suggests that children and middle-aged adults are mst vulnerable t H3N2v. Canadian researchers lked fr crss-reactive antibdies t H3N2v, using 1,116 serum samples that had been cllected in 2010 frm peple acrss the age spectrum. Additinally, they tested sera cllected befre and after receipt f seasnal flu vaccine. Children and middle-aged adults have little r n immunity t H3N2v, while abut half f thse 14 t 40 years f age have sme degree f immunity. Seasnal flu vaccines used during the past tw seasns did nt imprve participants ability t munt an immune respnse t H3N2v. The full reprt can be fund in the Jurnal f Infectius Diseases: Please reprt patients with ILI and recent swine expsure r cntact t ill persns with swine expsure t Epidemilgy. All reprted cases are fully investigated t limit further expsure f humans t any infected animals that are identified and t mnitr fr sustained human-t-human transmissin f the virus. Seasnal Influenza Update FDA cmpletes apprval f flu vaccines fr the seasn. The strains t be included are A/Califrnia/7/2009 (H1N1); A/Victria/361/2011 (H3N2); and B/Wiscnsin/1/2010. Six manufacturers are licensed in the U.S. and 149 millin dses are expected. CDC Advisry Cmmittee fr Immunizatin Practices updates recmmendatins fr preventin and cntrl f influenza, See August 17, 2012 editin f MMWR at