Influenza (FLU) Update for Week Ending 2-16-19

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Influenza (FLU) Update for Week Ending 2-16-19

For week #07 (ending 2-16-19) the CDC reported that Influenza (Flu) activity, which includes diagnosed flu as well as ILI (Influenza-Like-Illness), continued to increase during week #7.  The percentage of respiratory specimens testing positive for flu increased to 26.7% from 24.6% last week, all 10 Regions reported flu levels above baseline, and the number of hospitalizations from flu continued to increase, setting a new high for this flu season.  The CDC expects flu and ILI activity to stay at elevated levels for at least a few more weeks, however, none of the numbers approach last season’s (2017/18) flu severity.

Influenza A viruses were the most common found in the samples tested, with Influenza A(H1N1)pdm09 the most dominant, except in Region 4 (the Southeast), which for 4 weeks now, and Regions 6 (South Central) & 7 (Central Plains) started just this week, had Influenza A(H3) viruses dominate. Region 2 (NY, NJ, PI, & US VI) had an about equal amount of A (H1N1)pdm09 and (A) H3 strains circulating.  Overall, Influenzas A (H1N1), A (H3N2) and Influenza B viruses were co-circulating.

The majority of the flu viruses were genetically similar to the 2018/19 Flu Vaccine.

The CDC has published its 2018/19 Flu Season Preliminary Burden Estimates, and from October 1, 2018 through February 16, 2019, there have been an estimated with 17.7 – 20.4 million flu illnesses, 8.2 – 9.6 million medical visits for flu, and 214,000 – 256,000 flu-related hospitalizations, and 13,600 – 22,300 flu deaths.

As part of the CDC’s Epidemic Prediction Initiative (EPI), their forecast as of 2/5/19, is that flu activity is most likely to increase for the next few weeks and there is about a 60% chance that this year’s flu season has not peaked yet and that February will have the highest level.  This link provides information on the EPI prediction:  https://www.cdc.gov/flu/weekly/flusight/index.html

FirstWatch RIN (Regional Influenza Network):  Alerts doubled in number compared to the previous week.

For the most recently reported week, ending February 16, 2019, the CDC reported:
Influenza-like illness (ILI) visits to clinics & other non-hospital facilities increased to 5.1% (l. w. 4.8%) & remained above the national baseline of 2.2%, and the highest percentage yet during this flu season.  All 10 regions reported ILI at or above their region-specific baselines, with a range of 2.5% to 10.1%.  New York City and 30 states reported high ILI activity.

Flu cases, documented by positive flu tests on respiratory specimens, were reported as Widespread in Puerto Rico and 48 states again.  Clinical lab testing for influenza was positive for 26.7% of specimens, compared to 24.6% last week, with a range of 12.9% (Region 9) to 32.5% (Region 6).  All regions were in the double digits, with seven (7) at > 20% and two (2) at > 30%.

Influenza A remained the dominant flu for 97.3% of the flu tests reported (97.8% last week), with 53.1% (64.5% last week) as A (H1N1)pdm09 viruses and the H3N2 subtype at 49.67% (35.5% last week).  The rest of the tests showed 2.7% (2.2% l. w.) tested as Influenza B viruses, with 30% the Yamagata lineage and 70% as the Victoria lineage.
This shows similar percentages of Influenza A and B viruses, as in previous weeks, although B viruses increased a little and H3N2 are increased more than 10%.  Typically, Influenza B viruses cause less severe illness and occur more towards the Spring.

More than 99% of the flu viruses tested were found to be sensitive to the antivirals oseltamivir, zanamivir (100%), and peramivir (Tamiflu, Relenza, and Rapivab, respectively.  Baloxavir marboxil, under the brand name Xofluza, is a new influenza antiviral drug approved in October 2018, as a new alternative.  It also works on Influenza B viruses and controls the virus in a different way.
The CDC recommends treatment with antivirals, as early as possible, for those with confirmed or suspected flu with severe, complicated, or progressive disease, those who are hospitalized, or at high risk for complications of flu.  See this link for a list of those at risk for complications from flu:
https://www.cdc.gov/flu/about/disease/high_risk.htm

The CDC provides an interactive U.S. map that will link to each state’s public health authorities.  ILI and Flu information and processes, as well as other diseases and public health topics.   This site includes a tremendous amount of information at the State and even Local level.  Find it at this site:  https://www.cdc.gov/flu/weekly/usmap.htm

For Influenza-Like Illness:

High ILI Activity:  (New York City & 30 states):  Alabama, Alaska, Arkansas, Colorado, Georgia, Indiana, Kansas, Kentucky, Louisiana, Maine, Massachusetts, Mississippi, Missouri, Nebraska, New Jersey, New Mexico, New York, North Carolina, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, and Wyoming
Moderate ILI Activity:  (Washington D.C., & 11 states):  Arizona, California, Connecticut, Delaware, Hawaii, Idaho, Illinois, Iowa, Maryland, Montana, and Oregon
Low Activity:  (6 states):  Florida, Michigan, Nevada, North Dakota, South Dakota, and Wisconsin
Minimal Activity:  (U.S. Virgin Islands & 3 states):  Minnesota, New Hampshire, and Ohio
Insufficient Data:  Puerto Rico`

For Flu (positive flu tests): 

Widespread Activity:  (Puerto Rico & 48 states):  Alabama, Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, Wisconsin, and Wyoming
Regional Activity (1 state):  West Virginia
Local Activity (Washington D.C.):  
Sporadic Activity:  (the U.S. Virgin Islands & 1 state)  Hawaii
Guam did not report

Other Data:

The Hospitalization rate from Flu was 27.4 per 100,000 (last week 23.8/100,000).  Older adults (age > 65 years) had the highest hospitalization rate at 75.6 per 100,000 (l.w. 64.1/ ); children (ages 0-4) had 40.2 per 100,000 (last week 36.8/ ), and adults (age 50-64 years) were at 37.7 per 100,000 (l.w. 32.5/ ).  Most, 94.8% (l.w. 94.4%), were caused by Influenza A viruses; 4.3% (l.w. 4.6%) were from Influenza B viruses; 0.4% (l.w. 0.5%) showed co-infection with both Influenza A and B viruses; and 0.5% (same as last week) were not typed for a specific flu virus.

As of 2/21/19, the death rate for pneumonia & influenza in adults were at 7.0%, below the epidemic threshold of 7.3% for week #6 (death reports often aren’t reported for data purposes the same week and are typically reported by the CDC a week behind.

There were another seven (7) pediatric deaths attributed to flu reported this week, for a total of 41 for this flu season.

Flu in Canada, Europe & the World:

Canada:
According to the Public Health Agency of Canada (PHAC), influenza activity continued to diminish slowly throughout Canada during Week #07, ending 2/16/19.  The flu continued to circulate in the Eastern Regions, while influenza appeared to be past the peak in most of the Western Regions of the country.  They also reported that it seems that peak activity has passed, with most indicators showing decreased levels of flu activity, at least when grouped as a nation   Influenza A(H1N1)pdm09 was the most dominant flu virus circulating with very little influenza B identified this season.

Widespread Activity in 0 Regions:
Localized Activity in 15 Regions:  Alta. (1), Ont. (6), Que. (2), N.S. (4), and N.B. (2)
Sporadic Activity in 32 Regions:  B.C. (5), Alta. (4), Man. (4), Ont. (1), Que (4), N.B. (5), N.L. (4), P.E.I (1), Nvt. (2), N.W.T. (1), and Y.T. (1)
No Activity in 3 Regions:   Man. (1), N.W.T. (1), Nvt. (1)

For more specific information see: 
On flu activity:  https://www.canada.ca/en/public-health/services/publications/diseases-conditions/fluwatch/2018-2019/week7-february-10-february-16-2019.html

Canadian Flu Information:
https://www.canada.ca/en/public-health/services/diseases/flu-influenza.html

General Page for Canadian Flu Watch Surveillance with links to different components:
https://www.canada.ca/en/public-health/services/diseases/flu-influenza/influenza-surveillance.html

About the Canadian Influenza Activity Surveillance System:
https://www.canada.ca/en/public-health/services/diseases/flu-influenza/influenza-surveillance/about-fluwatch.html

Europe:
According to the European Center for Disease Prevention & Control (ECDC), for Week # 7 (Feb 11 – 17, 2019), Influenza activity was widespread throughout the European Region. The samples taken from those with ILI or ARI (acute respiratory illness), by sentinel primary healthcare sites, showed 53% positive for flu viruses, the same as last week.  The majority of circulating viruses remained Influenza A, with A(H1N1)pdm09 detected a bit more than A(H3N2) and very little influenza B viruses found.  Mortality from 22 Member States reported excess mortality in elderly populations overall, as well as those in the 15 – 64 age group.

For more information see:  http://flunewseurope.org/

WorldThe World Health Organization (WHO) provides info on Influenza in Member Countries here:
https://www.who.int/influenza/surveillance_monitoring/en/

First Responder Specific Information

There are many websites that may be helpful in planning and managing seasonal flu within First Responder organizations.  A few of those websites are included here:  

NIOSH on Flu for Employers/Employees:
https://www.cdc.gov/niosh/topics/flu/

Protection from Flu:
https://www.cdc.gov/flu/protect/habits/index.htm  

Weekly Flu Map:
https://www.cdc.gov/flu/weekly/usmap.htm 

World Map Showing Flu & Other Infectious Diseases:
http://www.healthmap.org/en/

Other Actions First Responders Should Consider

  • First Responders should be vaccinated for Flu each season to prevent getting flu themselves, taking it home to family members, or transmitting it to patients in their care. Family members and patients may be at increased risk of complications from flu.
  • Perform proper hand hygiene including frequent handwashing and the use of hand sanitizers in general, and particularly when providing patient care or after touching surfaces.
  • Masks (N95 or N100) should be used in the presence of patients with cough and/or fever; preferably before being within 6 feet of the patient. This becomes even more important if droplet producing procedures are being performed (i.e. suctioning, nebulizer treatments, BVM, intubation).
  • Care should be taken to avoid touching your own face and mucous membranes (eyes, mouth, nose) since the flu virus is frequently found on surfaces such as door knobs, writing & recording tools (pens and tablets), cot and equipment handles, phones, light switches, as well as clothing, bed clothes, etc.
  • Report signs/symptoms of flu to your physician or other appropriate provider for early assessment and care. Alert your employer per policy.
  • Cough and sneeze into your sleeve, if a tissue is not available, and not onto your hands. Watch this Youtube video for a humorous but educational approach on the subject. https://www.youtube.com/watch?v=CtnEwvUWDo0
  • Stay away from others if you are sick.
  • Be aware of your exposure risk and history to prevent exposing others. Take extra precautions or avoid those with immunocompromise, when possible, if you have a known or likely exposure.
  • Antivirals may be indicated for the treatment of flu, particularly for those in high risk groups, those who are hospitalized or have severe, complicated or progressing flu. Those that present with 48 hours of the onset of symptoms may also be given antivirals, based on PCP judgement but make sure the practitioner is aware of their First Responder Role.  See https://www.cdc.gov/flu/antivirals/whatyoushould.htm

And, for consideration when looking at yourself, your family and friends, or your patients, consider the following information regarding complications of flu:

Flu is much more worrisome for the very young and the elderly, as well as those who fit into one of the high risk categories see this link for the list: https://www.cdc.gov/flu/about/disease/high_risk.htm . Signs of ILI/Flu in this group requires careful assessment to rule out complications and these groups are much more likely to need medical oversight to assure adequate care.  Young children and those over 65 are typically at greater risk for complications, hospitalization, and even death.

Consideration should be given to perhaps monitoring these groups more closely, with inclination for more comprehensive assessment and transport for further evaluation, when presented with possible flu and any signs of complications.

Complications of flu, sometimes requiring hospitalization and even leading to death, tend to occur after the person has begun to get better from the flu and then appears to relapse.  EMS personnel may want to look more closely at those patients when the call is not about the initial signs and symptoms of flu, but about increasing or different signs that have appeared, often from five days to two weeks after the initial flu symptoms began.

A study was published by the Institute for Clinical Evaluative Sciences in NEJM (New England Journal of Medicine).  See details below:

Study confirms importance of flu vaccination

Image courtesy of ICES/PHO

“The researchers add that patients should not delay medical evaluation for heart symptoms particularly within the first week of an acute respiratory infection.”  (Lisa Schnirring, News Editor:  CIDRAP News ;Jan 25, 2018)

For more information on Influenza and the Heart Attack Study, please see the link below.

https://www.eurekalert.org/pub_releases/2018-01/pho-rcl011818.php

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