Georgia Department of Community Health ● Division of Public Health ● District 1-1

BARTOW ● CATOOSA ● CHATTOOGA ● DADE ● FLOYD GORDON ● HARALSON ● PAULDING ● POLK ● WALKER

Please read the important public health information below and share with your constituency and community partners as you see fit.

Flu season is over. Before you heave a sigh of relief, I'm talking about the (official) 2008 - 2009 flu season, which ended August 30 in week 34 of the calendar year. Welcome to the new flu season, the one called 2009 - 2010. It promises to be, well, "interesting."

We continue to get calls from the news media and the public alike asking how many "cases" or "confirmed cases" of novel H1N1 we've had in (a) the state, (b) ______ county, (c) "my child's school," etc. This is the talking point we use to try to answer such questions:

Public health is no longer trying to get or keep a precise count of how many people are infected with novel H1N1 (also known as swine flu). It’s a largely irrelevant number at this stage in the pandemic, just the tip of the iceberg. How much of the tip we don't know. We do know the virus is circulating in our community and that it’s going to become more pervasive.

Initially, we were looking for the illness in our state and community. Now that we are aware of confirmed cases, we are looking for severe illness due to novel H1N1 to monitor for changes in the severity of illness, not to document every case of novel H1N1. We’re continuing to conduct surveillance on all influenza strains this flu season; however, the Georgia Public Health Lab (GPHL) is only accepting specimens for confirmatory testing from hospitalized patients with influenza-like illness ( ILI), clusters of patients with ILI and sentinels -- health care providers who help us monitor ILI each year.

Instead of worrying about how many novel H1N1 cases are in your community, accept as a given that the virus is or will be circulating everywhere, that it will almost certainly be pervasive and could become more severe. So take the necessary preventative measures to protect yourself and your family from getting or spreading flu. For information, go to www.panflu.gov or contact your local health department.

Keeping in line with guidance from the Centers for Disease Control and Prevention (CDC), Georgia now follows the CDC policy to only report numbers of hospitalized cases and number of deaths rather than individual case counts.

Time Frame	Hospitalizations	Total Number of Deaths
4/24 - 7/29/09 (cumulative)	44	1
7/30/09 - 8/5/09	8	0
8/6/09 - 8/12/09	22	2
8/13/09 - 8/19/09	27	1
8/20/09 - 8/26/09	46	0
8/27/09 - 9/2/09	50	1
9/3/09 - 9/8/09	46	4

Cumulative Total as of 9/8/09	238	9

This information is updated each Wednesday and available on the Georgia Division of Public Health's Website at: http://dch.georgia.gov/00/article/0,2086,31446711_134310023_146019323,00.html These are the officially recorded numbers, but once again, they are an underestimate, although not as much of an underestimate as the "case count" or "confirmed case count."

Along With the New H1N1, Some Nasty Traditional Strains Are Raising Concerns

· additional doses will be distributed to states weekly after the original supply is released

· news this week: possibility of some doses being available at the end of September.

o Guidance for Reporting Flu-Associated Hospitalizations and Deaths This Flu Season

o MMWR: “Oseltamivir-Resistant 2009 Pandemic Influenza A (H1N1) Virus Infection in Two Summer Campers Receiving Prophylaxis – North Carolina, 2009”

· The September 10, 2009, Early Release Morbidity and Mortality Weekly Report (MMWR) contains a summary of influenza activity in the United States from April-August, 2009 and explains CDC’s recommendations for the upcoming 2009-10 influenza season.

· Key findings from U.S. influenza activity from April-August include the following:

o Influenza activity associated with 2009 H1N1 virus peaked in the United States during May and June and declined during July and early August.

o Levels of influenza activity remained above normal levels for summer months, and focal outbreaks were reported throughout the summer.

o Since May 3, the majority of influenza viruses identified have been 2009 H1N1 viruses, and as of September 4, all of the influenza A (H1N1) viruses tested by CDC have been related to the reference strain chosen for the 2009 H1N1 vaccine.

o Of influenza viruses tested for antiviral resistance at CDC from ill people in the United States, 99.6% of 2009 H1N1 viruses have been susceptible to the antiviral drug, oseltamivir (brand name Tamiflu®). In addition, all viruses tested have been susceptible to the antiviral drug, zanamivir (brand name Relenza®).

o Total influenza hospitalization rates by age group for adults and children during April-August generally were similar to or lower than seasonal influenza hospitalization rates, but were higher than usual for that period.

o The proportion of all deaths attributed to pneumonia and influenza based on the 122 Cities Mortality Reporting System was within the bounds of what is expected in the summer. However, 47 deaths in children associated with laboratory confirmed 2009 H1N1 influenza occurred during April 26-August 29 and were reported to CDC. Deaths from influenza occurring during the summer are very rare in other summers.

o During the last two weeks of August, influenza activity increased in certain areas of the United States.

o Clinicians and public health officials should be aware that these recent increases might signal an early influenza season in the United States for the 2009-10 season.

Guidance for Reporting Flu-Associated Hospitalizations and Deaths This Flu Season

· The new reporting season for the 2009-2010 influenza season began on September 1, 2009.

· The first numbers for the 2009-2010 influenza season will be reported in the September 11 FluView.

· CDC’s regular flu surveillance runs year-round, but is usually “re-set” each October in anticipation of a new flu season.

· In anticipation of an early flu season, CDC decided to “re-set” the 2009-2010 season one month earlier than normal, in order to capture the breadth of the season in the United States.

· The number of reported hospitalizations and deaths was “re-set” to zero on September 1, 2009.

· The numbers of hospitalizations and deaths from 2009 H1N1 reported to CDC over the spring and summer of 2009 will be archived on the CDC website at http://www.cdc.gov/h1n1flu/updates/.

· The first counts of influenza-associated hospitalizations and deaths for the 2009-2010 season will appear in FluView (at http://www.cdc.gov/flu/weekly/fluactivity.htm) on September 11, 2009.

· These will be total national counts for all influenza-related hospitalizations and deaths (2009 H1N1 and seasonal influenza viruses.)

· Hospitalization and death reports will not be broken down by influenza virus sub-type because influenza is so widespread there would be too many samples to test.

· Virologic data about what influenza viruses are circulating will be used to interpret what viruses are causing the most illness. (For example, more than 98% of currently circulating viruses have been 2009 H1N1.)

· Routine seasonal surveillance does not count individual flu cases, hospitalizations or deaths (except for pediatric influenza deaths), but instead monitors activity levels and trends and virus characteristics through a nationwide surveillance system.

· This season, CDC and states are conducting additional surveillance of flu-related hospitalizations and deaths in order to get more information about the burden of serious flu illness and deaths during this pandemic.

· CDC has provided guidance for states on how to count and report these cases in “Interim Guidance for State and Local Health Departments for Reporting Influenza-Associated Hospitalizations and Deaths for the 2009-2010 Season” available at http://www.cdc.gov/H1N1flu/hospitalreporting.htm.

· CDC has asked states to report either laboratory confirmed hospitalizations and deaths or syndromic cases, i.e. cases of presumed influenza and/or pneumonia based on ICD-9 coded hospitalizations or death reports, each week.

· CDC has developed a web-based data application with which states can submit their influenza-associated hospitalization and death reports.

· Data from each reporting week runs from Sunday to Saturday, which is consistent with the Morbidity and Mortality Weekly Report (MMWR).

· Data from Sunday through Saturday is reported to CDC by midnight on Tuesday of the next week and reported in the FluView report three days later, on Friday.

· Influenza activity – almost all of it 2009 H1N1 – has been ongoing over the summer and has begun to increase in some parts of the country but is still below baseline nationally.

· It’s uncertain whether the current increase in activity in parts of the country signals the start of the flu season.

· Typically, CDC determines that the influenza season has begun once influenza-like illness activity has been above baseline for three consecutive weeks.

· The decision to re-set surveillance measures for September 1 indicates that CDC is prepared to begin surveillance for the upcoming season, not necessarily that flu season has begun.

o The percentage of specimens tested for influenza that are positive for influenza;

2. Sentinel physician surveillance for influenza-like illness (ILI), which monitors the percentage of doctor visits for symptoms that could be the flu.

3. Hospitalization surveillance, which tracks numbers of hospitalizations with laboratory-confirmed flu infections among adults and children.

4. Summary of the geographic spread of flu, which tracks the number of states affected by flu and the degree to which they are affected.

5. Deaths from 122 Cities that report the total number of deaths and the percentage of those that are coded as influenza or pneumonia.

· CDC’s flu surveillance is reported in a weekly publication called FluView. The Epidemiology and Prevention Branch in the Influenza Division at CDC collects, compiles and analyzes information on flu activity in the U.S. year-round to produce and publish FluView every Friday. Usually FluView is published from October through mid-May, but in response to the ongoing novel H1N1 flu spread, weekly publication of FluView continued throughout the summer months.

· Flu surveillance data collection is based on a reporting week that starts on Sunday and ends on Saturday of each week. Each surveillance participant is requested to summarize weekly data and submit it to CDC by Tuesday afternoon of the following week. Those data are then downloaded, compiled, and analyzed at CDC and published on-line 3 days later, on Fridays.

MMWR: “Oseltamivir-Resistant 2009 Pandemic Influenza A (H1N1) Virus Infection in Two Summer Campers Receiving Prophylaxis – North Carolina, 2009.”

· The September 11, 2009, Morbidity and Mortality Weekly Report (MMWR) describes confirmed oseltamivir-resistant 2009 H1N1 virus infection in two previously healthy adolescents who were cabin mates and recipients of oseltamivir in a mass influenza prevention program during an outbreak of influenza-like illness (ILI) at a summer camp.

· This is the first report of oseltamivir resistance in close contacts with confirmed 2009 H1N1 influenza infection.

· On August 21, 2009, North Carolina reported that two campers had been infected with an oseltamivir-resistant 2009 H1N1 influenza virus. The laboratory testing to identify oseltamivir resistance was performed at CDC on August 14 and 19, 2009.

· This finding echoes previous findings from other countries that occasionally resistance can develop while receiving oseltamivir for prevention.

· CDC recommends that antiviral medicines for prevention (chemoprophylaxis) after exposure be used predominantly for persons at higher risk for influenza-related complications who are close contacts of a person with suspected or confirmed 2009 H1N1 influenza.

· Judicious use of antiviral medications for prophylaxis is recommended because:

o Most persons with influenza, including 2009 H1N1 influenza, have a self-limited, non-severe illness,

o Widespread use of chemoprophylaxis might increase the risk for the emergence and spread of antiviral resistant 2009 H1N1 viruses, and

o There is potential for adverse reactions to antiviral medications, such as nausea, stomach aches, and headaches.

· CDC discourages health care providers from prescribing chemoprophylactic doses of influenza antiviral medicines to healthy children or adults based on potential exposures in school, camp, or other community settings.

· As of September 4, 2009, 9 instances of oseltamivir resistant 2009 H1N1 viruses had been confirmed in U.S. surveillance specimens.

· Other sporadic cases of 2009 H1N1 influenza viruses resistant to the antiviral drug oseltamivir have been reported worldwide.

· All of the oseltamivir resistant viruses have the genetic mutation in the neuraminidase gene, known to be associated with resistance to oseltamivir. (H275Y)

· Results from ongoing testing of 2009 influenza A (H1N1) viruses indicate that oseltamivir resistance remains very rare worldwide.

· Oseltamivir resistant influenza viruses with the H275Y mutation are known to be sensitive (susceptible) to zanamivir.

· There is no evidence of genetic reassortment with seasonal influenza A (H1N1) viruses among the cases of oseltamivir resistant 2009 influenza A (H1N1) viruses.

· CDC recommends judicious use of antiviral medications to reduce the possibilities of the development and spread of antiviral resistant influenza viruses

o Use of zanamivir or oseltamivir should be focused on treatment of persons with suspected or confirmed 2009 H1N1 influenza who are 1) hospitalized or 2) at higher risk for complications due to influenza, even if hospitalization is not required.

o CDC’s Updated Interim Recommendations for the Use of Antiviral Medications in the Treatment and Prevention of Influenza for the 2009-2010 Season can be found at http://www.cdc.gov/h1n1flu/recommendations.htm

o Furthermore, on July 9, CDC issued a Health Alert Network (HAN) Info Service Message following detection of the first Three Reports of Oseltamivir Resistant 2009 Influenza A (H1N1) Viruses globally (available at http://www.cdc.gov/h1n1flu/HAN/070909.htm).

· The few people who have been infected with oseltamivir-resistant viruses have had illness similar to that caused by oseltamivir-sensitive viruses. Illness has not been more severe, and infections with oseltamivir-resistant viruses have not been identified among close contacts.

· Surveillance for the detection of antiviral resistance in 2009 H1N1 influenza among domestic and international isolates submitted to CDC is ongoing.

· There are two influenza antiviral medications recommended for use against 2009 H1N1 influenza. These are oseltamivir (trade name Tamiflu ®) and zanamivir (trade name Relenza ®). Either medication can be used.

· Highest priority should be placed on treating patients hospitalized with influenza or those who are ill with influenza who have an age or medical factor placing them at higher risk for more severe illness or influenza-related complications, including young children, pregnant women, people with certain chronic medical conditions and people 65 years and older.

· Antiviral resistance means that a virus has changed in such a way that the antiviral drug is less effective in treating or preventing illnesses caused by the virus.

· Influenza viruses constantly change as the virus makes copies of itself. Some changes can result in the viruses being resistant to one or more of the antiviral drugs that are used to treat or prevent influenza.

· CDC and its WHO partners continue to conduct surveillance for antiviral resistance. The data indicate that the prevalence of oseltamivir resistant viruses is low.

· Information on resistance of influenza viruses to the four antiviral medications is updated weekly on the CDC FluView surveillance report which is found at: http://www.cdc.gov/flu/weekly/fluactivity.htm

· Influenza antiviral medications are prescription medicines (pills, liquid or an inhaled powder) with activity against influenza viruses, including 2009 H1N1 influenza viruses.

· Antiviral drugs work by decreasing the replication of flu viruses in the respiratory tract.

· Influenza antiviral medications work best when started soon after illness onset (within 2 days), but treatment with antiviral drugs should still be considered after 48 hours of symptom onset particularly for hospitalized patients or people at high risk for influenza-related complications.

· There are four influenza antiviral medications approved for use in the United States. The four antiviral drugs are oseltamivir (brand name Tamiflu ®); zanamivir (brand name Relenza ®); amantadine (Symmetrel®, generic); and rimantadine (Flumadine®, generic).

o This 2009 (H1N1) influenza virus is sensitive (susceptible) to the neuraminidase inhibitor antiviral medications, zanamivir and oseltamivir (other than the rare viruses described above). It is resistant to the adamantane antiviral medications, amantadine and rimantadine.

· Antiviral drugs should be taken as prescribed by a health care provider (Do not change the dose, frequency or length of time taken from what your health care provider directs.)