What s happening in NZ with influenza
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- Gertrude Morton
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1 What s happening in NZ with influenza Dr. Sue Huang Principal Investigator, SHIVERS Director, WHO National Influenza Centre Institute of Environmental Science and Research Wellington, New Zealand New Zealand influenza Symposium, 11 November 215, Wellington
2 Outline What happened in 215 winter season Disease burden & epidemiology Vaccine effectiveness Risk factors Aetiology
3 Rate per 1 practice population Consultation rate (per 1,) National sentinel ILI - consultation rates, Seasonal threshold May Sep Week Year (week) Overall ILI activity in 215: Moderate to high Peaked in week 33 (1-16 August) Huang et al, Influenza and other respiratory viruses 28; 2(4):
4 Number of viruses Proportion positive Incidence per 1 residents SHIVERS GP ILI and influenza cases, ILI cases - all others ILI cases - influenza positive 213 ILI cases 214 ILI cases May Jun Jul Aug Sep A (Not subtyped) A(H3N2) A(H1N1)pdm9 B (Lineage not determined) B (Yamagata lineage) B (Victoria) Proportion positive for influenza Week (215) Week (215) Huang et al, a commission review by Influenza and other respiratory viruses 215; 9(4): : highest peak, in wk 35 (24-3 Aug) Most of season, A(H3N2) predominant (till wk 33) More B in late season. B/Victoria > B/Yamagata since wk 36
5 Number of viruses SHIVERS Hospital - SARI & influenza cases, 215 Incidence per 1 residents Proportion positive SARI cases - all others 18 SARI cases - influenza positive /3 SARI cases /4 SARI cases /5 SARI cases May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr A (Not subtyped) A(H3N2) A(H1N1)pdm9 B (Lineage not determined) B (Yamagata lineage) B (Victoria) Proportion positive for influenza Week (215/216) Huang et al: WPSAR 214;5(2): Week (215/216) 215: in the middle seasonal range with two peaks: wk29 (13-19 July) & wk34(17-23 Aug) Most of season, A(H3N2) predominant (till wk 34) B predominant since wk 35 (24-3 Aug)
6 1. Disease burden & epidemiology Flu Death: 2 Flu ICU: 89 Flu Hospitalization: 1,6 Flu consultation: Flu infection (symptomatic/asymptomatic):? New Zealand Population: 4,47,8 212: SARI-Severe influenza 213: ILI-Moderate influenza requiring GP consultation 215: Serosurvey Mild influenza not requiring GP consultation Symptomatic/asymptomatic infection
7 Influenza and RSV circulation by week 8 All ages Year 1 Year 2 Year 3 Year 4 A(H1N1)pdm9 A(H3N2) B RSV
8 SARI-related influenza and RSV incidence (1 ) ILI-related influenza and RSV incidence (1 ) SARI & ILI influenza and RSV Incidence in children Children <15 years < ILI - influenza ILI - RSV ILI related flu and RSV incidence: <1 yr: 5 times more RSV > flu 1 yr and 2-4 yrs: similar RSV & flu 5-14 yrs: more flu > RSV Children <15 years < SARI - influenza SARI - RSV SARI related flu and RSV incidence: SARI-flu & RSV: both declining when age increase <1 yr: 5 times more RSV > flu 1 yr: 4 times more RSV > flu 2-4 yrs: 2 times more RSV > flu 5-14 yrs: 2 times more flu > RSV
9 SARI-related influenza and RSV incidence (1 ) ILI-related influenza and RSV incidence (1 ) ILI & SARI influenza and RSV Incidence in adults Adults 15 years ILI - influenza ILI - RSV Adults 15 years SARI - influenza SARI - RSV ILI related flu and RSV incidence: 4-9 times more flu > RSV ILI-flu: declining when age increasing (>35 yrs) ILI-flu: yrs > yrs. Child-bearing? ILI-RSV: similar incidence yrs. ILI-RSV: incidence for 8+ yrs SARI related flu and RSV incidence: SARI-RSV & flu: both increasing when age increasing yrs: 4-11 times more flu > RSV 65 yrs: 2-3 times more flu > RSV
10 Comparisons of SARI & ILI & ICU related influenza type/subtypes ICU-related influenza type/subtypes (1 ) SARI-related influenza type/subtypes (1 ) ILI-related influenza type/subtypes (1 ) 6 5 * 4 3 * 2 * 1 Overall < ILI - A(H1N1)pdm ILI -A(H3N2) ILI - B * Overa ll * * * * * < SARI - A(H1N1)pdm SARI - A(H3N2) SARI - B * * * Overal l < ICU - A(H1N1)pdm ICU - A(H3N2) ICU - B
11 2. Vaccine effectiveness: A case test negative control design: estimate VE Case: a SARI/ILI patient tested positive for influenza virus Control: a SARI/ILI patient tested negative for influenza virus VE data in from SHIVERS: contributed to WHO/AIVC process for vaccine strain selection for Southern Hemisphere Turner et al: Vaccine. 214; 32(29): Turner et al: Euro Surveill. 214 Aug 28;19(34). Pii:2884 Turner et al: Euro Surveill. 214;19(42). Pii:2934
12 Influenza type & age group VE estimate for ILI & SARI cases, 215 Influenza positive Influenza negative Unadjusted Adjusted * Number vaccinated Total % VE % 95%CI VE % 95%CI Number vaccinated Total % SARI Overall to to 63 6 mo-17 yrs NA NA NA NA yrs to to yrs to to 76 A(H3N2) to to 76 Influenza B to to 74 ILI Overall to to 6 6 mo-17 yrs to to yrs to to yrs to to 95 A(H3N2) to to 53 Clade 3C.2a to to 84 Any influenza B to to 77 B/Victoria to to 86 B/Yamagata to to 89
13 3. Risk factors Identify and quantify risk factors for getting influenza: Host: socio-demography (Age, ethnicity, Sex, deprivation), underlying conditions (BMI, Diabetes, Asthma etc) Healthcare: Antivirals/vaccinations, oxygen, ICU, healthcare utilization Environmental factors: housing conditions, crowding Behavioral factors: smoking, contact For socio-demographic risk factors: Population census data with good distribution data on age, sex, ethnicity, deprivation: disentangle the effect of ethnic and socio-economic gradients For specific risk factors (comorbidities, housing conditions): Casecontrol methods Sero-survey participants (a cluster-stratified random sample) as a control group SARI/ILI test negative patients as a control group
14 ILI related influenza incidence (per 1 ) SARI related influenza incidence (1 ) ILI related RSV incidence (per 1 ) SARI-related RSV incidence (per 1 ) ILI related influenza incidence (per 1 SARI related influenza incidence (1 ) ILI related RSV incidence (per 1 ) SARI related RSV incidence (per 1 ) ILI-related influenza incidence (1 ) SARI-related influenza (1,) ILI and SARI related RSV incidence (1 ) SARI-related RSV incidence (1 ) SARI & ILI related influenza & RSV by age, ethnicity, SES, < ILI - influenza SARI - influenza < ILI - RSV SARI - RSV Maori Pacific peoples Asians Europea n & others ILI-Flu SARI-Flu Maori Pacific peoples Asians European & others ILI-RSV SARI-RSV NZDep 1-2 NZDep 3-4 NZDep 5-6 NZDep 7-8 NZDep 9-1 NZDep 1-2 NZDep 3-4 NZDep 5-6 NZDep 7-8 NZDep 9-1 ILI-Flu ILI-RSV SARI-Flu SARI-RSV
15 Influenza associated risk in pregnant woman, Pregnant women (15-45 yrs) Non-pregnant women (15-45 yrs) Pregnancy Flu +ve, No./Total (%) No. of pregnant women Influenza incidence (/1,) Flu +ve, No./Total (%) No. of nonpregnant women Influenza incidence (/1,) RR (95% C.I) p-value Year 1 Year 2 Year 3 Total 9/25 (36.) 5/11 (45.5) 15/28 (53.6) 29/64 (45.3) /15 (22.7) 24/127 (18.9) 67/29 (32.1) 125/486 (25.7) ( ) 4.34 ( ) 4.83 ( ) 4.88 ( )..6..
16 Number of viruses Proportion positive Number of viruses Proportion positive 4. Etiology SARI surveillance RSV parainfluenza 1 parainfluenza 2 parainfluenza 3 rhinovirus adenovirus hmpv Seasonal influenza virus: antigenic drift Monitor non-flu respiratory viruses: under-recognized burden Week ILI surveillance RSV parainfluenza 1 parainfluenza 2 parainfluenza 3 rhinovirus adenovirus hmpv Week Early detection of nonseasonal influenza virus- A(H7N9) & emerging respiratory virus (MERS- CoV) Understand viral-viral, viralbacteria co-detection
17 Percentage of single virus, codetection and no virus detection Single vs codetection vs no virus by age <1 year 1 year 2-4 yrs <1 yr, 1 yr: up to 88-89% of SARI/ILI samples had viral detection <1 yr, 1 yr, 2-4 yrs: 3%, 28% and 13% of virus codetection When age increases, less codetection and more non-virus detection 5-14 yrs yrs yrs 5-64 yrs yrs Codetection Single No virus yrs
18 Conclusion SARI & ILI surveillance combined with NZ healthcare system and well characterised population subgroups: excellent for population-based research SARI & ILI allows studying burden of influenza and noninfluenza viruses in severe & mild respiratory disease, severity, risk factors, impact, VE, clinical spectrum/ outcomes and etiology SARI & ILI platforms can be developed as an integrated respiratory disease surveillance platform for both influenza (incl H7N9), MERS-CoV, and other endemic respiratory pathogen-associated diseases
19 Acknowledgement ESR: Don Bandaranayake, Ruth Seeds, Tim Wood, Ange Bissielo, Graham Mackereth, Thomas Metz, Anne McNicholas, Angela Todd, Namrata Prasad, Laboratory staff, IT staff ADHB: Sally Roberts, Colin McArthur, Debbie Williamson, Kathryn Haven, Research nurses, clinical team staff, laboratory staff, IT staff CMDHB: Adrian Trenholme, Conroy Wong, Susan Taylor, Shirley Lawrence, Research nurses, clinical team staff, laboratory staff, IT staff University of Auckland: Nikki Turner, Cameron Grant, Sarah Redke, Barbara McArdle, Tracey Poole, Anne McLean, Debbie Raroa, Carol Taylor University of Otago: Michael Baker, Nevil Pierse, David Murdoch Primarycare Advisory Group from PHOs (Procare, East Tamaki, Auckland) and ARPHS: John Cameron, Bruce Adlam, Gary Reynolds, Rosemary Gordon, Leane Els, Marion Howie, Gillian Davies ILI sentinel practices WHOCC-St Jude: Richard Webby, Paul Thomas US-CDC: Mark Thompson, Marc-Alain Widdowson, Jazmin Duque, Diane
20 Thank you
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