A/Prof Nikki Turner Department of GP and Primary Care On behalf of the Primary Care Advisory team:

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1 A/Prf Nikki Turner Department f GP and Primary Care On behalf f the Primary Care Advisry team: Dr Sue Huang, PI SHIVERS, ESR Dr Jhn Camern, Clinical Directr, Prcare Dr Bruce Adlam, ARPHS Barbara McArdle, Prject Manager, Primary Care, UA Ruth Seeds, Prject Manager, SHIVERS, ESR

2 US CDC 5 year funded prject Prject Team multi-centre and multi-disciplinary cllabratin ESR leading rganizatin Sue Huang Principle investigatr (PI) Graham Mackereth Prject manager Ruth Seeds Prject Officer Science teams: Sue Huang/Sally Rberts/Clin McArthur/Camern Grant/Debbie Williamsn/Adrian Trenhlme/Cnry Wng/Susan Taylr/Graham Mackereth/Dn Bandaranayake/Diane Grss/Marc-Alain Widdwsn: bjective 1 Nikki Turner/Heath Kelly/Nevil Pierse/Ange Bissiel/Michael Baker/Dn Bandaranayake/Sue Huang: bjective 2 Vaccine Effectiveness Michael Baker: bjectives 3 & 7 Clin McArthur/Sally Rberts: bjective 4 Sue Huang/Nikki Turner: bjective 5 Primary Care Surveillance Sue Huang/Dn Bandaranayake: bjective 6 Richard Webby: bjective 8 Des O Dea: bjective 9

3 I have flu dctr. Hw d we recgnise flu Hw much is really in the cmmunity In hspital presentatins What are its characteristic presentatins Are we diagnsing it all Wh is mre likely t get flu Wh is mre likely t be severely affected Is there subclinical/asymptmatic? Hw effective are current flu vaccines In subppulatins In different years with shifting strains

4 Overall aims Disease Burden: What prprtin f ppulatin getting influenza? Hspitalizatin GP cnsultatin Infectin Vaccine effectiveness: Hw effective is influenza vaccine? Preventing hspitalizatin Preventing GP cnsultatin Risk factrs: What is the high risk grup fr getting influenza? Immune respnse: Is there any difference in T-cell and B-cell respnse amng individuals : Hspitalizatin GP cnsultatin Infectin

5 Tls: Tw surveillance systems Hspital-based surveillance: enhanced, active, yearrund (5 yrs), ppulatin based surveillance fr hspital SARI (sudden acute respiratry) cases Auckland and Middlemre Hspitals Cmmunity-based surveillance: enhanced, active, (4 yrs), ppulatin based surveillance fr cmmunity ILI (Influenza-like illness) cases caused by influenza Recruitment f sentinel General Practices in greater Auckland (200, ,000 patients)

6 Study ppulatin Ppulatin in ADHB & CMDHB: 837,696 Generally representative f the NZ ppulatin: Age: similar t NZ Ethnicity: higher prprtin fr Mari Pacific, and Asian SES: higher prprtin fr the mst deprived subgrups

7 Objective 5 Cmmunity-based surveillance Specific Aims 5.1 Establish enhanced, active, all-year-rund (4 yrs), ppulatin based sentinel general practice surveillance fr cmmunity ILI cases, caused by influenza and ther respiratry pathgens in ADHB and CMDHB 5.2 Measure incidence, prevalence, demgraphic characteristics (age, sex, ethnicity, SES), clinical spectrum including majr risk factrs fr cmmunity ILI cases 5.3 Identify etilgies f the cmmunity ILI cases attributable t influenza and ther respiratry pathgens 5.4 Determine validity f the data frm the established natinal sentinel GP surveillance by cmparing with this surveillance data 5.5 Describe any pssible risk factr (asthma, pregnancy, high BMI, diabetes etc) fr increasing the risk f influenza related illness 5.6 Prvide samples fr bjective 6, 8 and als prvide data fr bjectives 2, 7 and 9

8 Needs.. Sentinel GP surveillance started 29 April 2013 Apprx : ~ 100,000 registered patients All acute respiratry illnesses presenting t the practice with cugh and fever within 10 days Swab fr flu and ther viruses PMS-based questinnaire (advanced frm) PMS data extractin

9 Participating General Practices Avndale Family Dctr Richmnd Rad Medical Centre Three Kings Family Medical Centre East Tamaki Healthcare ETHC Bairds Rad ETHC Dannemra ETHC Manurewa Blckhuse Bay Medical Centre Epsm Medical Centre Mt Eden Medical Centre Ranfurly Medical Centre Remuera Village Medical Centre Westmere Medical Centre Dr DM de Lacey Surgery EastMed Dctrs Pacifika Hrizn Healthcare Balmral Dctrs Turuki Health Centre Mt Wellingtn Family Health Centre

10 Sentinel practices and DHB ppulatin characteristics Characteristics Ppulatin 1 ADHB&CMDHB Percentage f ttal Practice ADHB&CMDHB Practice Rati 2 Age grup < % 1.3% t % 7.9% t % 23.8% t % 21.1% t % 22.2% t % 14.8% & ver % 8.8% 1.0 Ttal % 100.0% 1.0 Ethnic grup Mari % 9.2% 0.8 Pacific Peples % 27.3% 1.8 Asian % 14.1% 0.7 Eurpean & Other % 49.2% 1.0 Unknwn % 0.1% 0.0 Ttal % 100.0% 1.0 DHB ADHB % 53.3% 1.1 CMDHB % 46.7% 0.9 Ttal % 100.0% 1.0 Sex Female % 52.8% 1.0 Male % 47.2% 1.0 Ttal % 100.0% 1.0

11 Advanced frm in MedTech

12 SHIVERS Prject Lab Frm ESR-Natinal Influenza Centre WHO Natinal influenza Centre Institute f Envirnmental Science and Research (ESR) Natinal Centre fr Bisecurity and Infectius Disease (NCBID)Wallaceville Science Centre - 66 Ward St, Wallaceville, Upper Hutt 5018, New Zealand Telephne: (04) Wallaceville specimen receptin (04) WHO Natinal Influenza Centre Surname : XXXX Dctr : Dr Sam Entwistle First Name : XXX Lab Cde : Reait NZMC N : A Sex / Age : Male / XXy DOB : 01 Feb 19XX Millstne Family Practice NHI : XXXX 17 Yrk Street Address : 76 XXX Street Parnell Newmarket Auckland Date : 25 Feb 2013 Phne Ref N : Services: Influenza virus /ther respiratry virus Sample Type Sample Date 25/4/13 Clinical Details: Signature: _ Dr Sam Entwistle

13 Data frm PMS extractin Influenza vaccinatin recrd: this year and previus years; type and date; batch number Pneumcccal vaccinatin recrd: type f vaccine, date Read cdes: high risk medical cnditins. Read cdes: current, ex r nn-smker Read cdes: last recrded BMI r bdy weight Medicatin list: identify medicatins assciated with chrnic disease (asthma, heart disease, COPD, cancer, immunsuppressin)

14 Subgrup planned fr mre in-depth analysis ILI/ARI practice has tw case definitins (ILI and ARI). If either r bth is met swab is taken ILI/ARI (ne practice): An acute respiratry illness with nset during the last 10 days with histry f fever r measured fever 38 C OR An acute nset f at least ne f the fllwing fur respiratry symptms: cugh, sre thrat, shrtness f breath, cryza; And a clinician s judgment that the illness is due t an infectin

15 ILI cases Weekly ILI and influenza psitive cases since 29 April 2013 t 30 June 2013 ILI cases ILI cases - influenza psitive May Jun Jul Aug Sep Oct Nv Dec Jan Feb Mar Apr Week

16 Number f viruses Prprtin psitive Tempral distributin f the number and prprtin f influenza viruses frm ILI specimens by type and week Week A (Nt subtyped) A(H3) A(H1N1)pdm09 B (Lineage nt determined) B (Yamagata lineage) B (Victria) Prprtin psitive fr influenza

17 Number f viruses Prprtin psitive Tempral distributin f the number and prprtin f nninfluenza viruses frm ILI specimens by type and week RSV parainfluenza 1 parainfluenza 2 parainfluenza 3 rhinvirus adenvirus hmpv Week

18 SARI cases Hspital surveillance: Weekly SARI and influenza psitive cases since 29 April 2013 and previus seasn (2012/3) SARI cases SARI cases* Influenza psitive 2012/3 SARI cases May Jun Jul Aug Sep Oct Nv Dec Jan Feb Mar Apr Week

19 Influenza viruses amng ILI and SARI cases 2013 since 29 April 2013 Influenza viruses ILI SARI Cases Cases ICU Deaths N. f specimens tested N. f psitive specimens (%) 32 (7.9) 17 (5.4) 3 (16.7) - Influenza A A (nt subtyped) A (H1N1)pdm A (H3N2) Influenza B B (lineage nt determined) B (Yamagata) B (Victria) Influenza and nn-influenza c-detectin (% +ve) 5 (15.6) 1 (5.9) - -

20 Nn-influenza respiratry viruses amng ILI and SARI cases, since 29 April 2013 Nn-influenza respiratry viruses ILI Cases Cases ICU Deaths N. f specimens tested N. f psitive specimens (%) (48.7) 47 (43.1) SARI Respiratry syncytial virus (RSV) Parainfluenza 1 (PIV1) Parainfluenza 2 (PIV2) Parainfluenza 3 (PIV3) Rhinvirus (RV) Adenvirus (AdV) Human metapneumvirus (hmpv) Single virus detectin (% f psitives) 159 (86.9) 36 (76.6) - - Multiple virus detectin (% f psitives) 24 (13.1) 11 (23.4) - -

21 Challenges Research needs versus wrking general practice needs Hw t keep csts dwn fr research grup Culd nly d MedTech practices, excludes practices Hw t manage within the wrking general practice Hard t make cntact directly with GPs nce they are n bard Hard t get t the whle practice team 1. What is in this fr general practice? Feedback n flu psitive r anther virus t help clinical infrmatin Regular reprting gives lcal knwledge f burden f flu and ther respiratry illnesses Funding t PHOs fr gdwill, staff time, advisry grup 2. Data extractin key apprach Wrking via the PHOs N extra up frnt effrt fr the practices Funding t the PHOs and their allied IT cmpanies fr data extractin tl develpment ( a big thanks t all the fantastic wrk frm KARO) 3. Taking swabs fr ILI?Part f quality general practice apprach? Tw swabs needed fr Grup A Strep Using a duel swab Subgrup (ARI) that als needs a questinnaire per patient: extra csts Pay per patient

22 Strengths A mdel fr research/data cllectin within functining general practice Fantastic champins GPs, PNs and PHO staff Strng supprt and enthusiasm frm PHOs Data extractin tls well develped and lts f ptential fr mre The rle f Kar has been vital! Keeping csts dwn via minimal extra activities fr frnt line staff Gd feedback and cmmunicatin t practices

23 Key principles Need champins within general practice Wrk clsely with PHOs and data management partners Need gd understanding f hw a general practice flws Utilise existing general practice, dn t expect frnt line staff t change behaviur fr research gains Must be sme psitive gain fr the practices/clinical team Must be f interest t the practice If extra effrt required frnt line staff need t be recgnised and remunerated

24 Primary Care Advisry Grup

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26 AIM: Cmprehensive investigatin f influenza epidemilgy, aetilgy, immunlgy and vaccine effectiveness Nine bjectives 1. Understand severe respiratry diseases caused by influenza & ther pathgens 2. Assess influenza vaccine effectiveness 3. Investigate interactin between influenza & ther pathgens 4. Understand causes f respiratry mrtality 5. Understand nn-severe respiratry diseases caused by influenza & ther pathgens 6. Estimate influenza infectin by cnducting sersurvey 7. Identify & quantify risk factrs (age, ethnicity, SES etc) fr getting influenza 8. Assess immune respnse amng individuals with varying disease spectrum 9. Estimate healthcare, scietal ecnmic burden caused by influenza and vaccine cst-effectiveness