Influenza

March 10, 2005

Influenza Summary Update ( Week ending February 26, 2005-Week 8)

During week 8 (February 20-26, 2005), influenza activity has declined in the United States (as well as Arkansas ). One thousand twenty-five (21.0%) specimens tested by U.S. World Health Organization (WHO) and National Respiratory and Enteric Virus Surveillance System (NREVSS) collaborating laboratories were positive for influenza viruses.

The proportion of patient visits to sentinel providers for influenza-like illness ( ILI ) has been above the national baseline for seven consecutive weeks. The proportion of deaths attributed to pneumonia and influenza is above the epidemic threshold for the second consecutive week. 

Thirteen pediatric deaths have been reported to CDC from ten states (California, Georgia, Maine, Massachusetts, Mississippi, New Jersey, New York, Ohio, Pennsylvania, and Vermont) since January; seven of which have been reported in the last two weeks.

CDC has antigenically characterized 378 influenza viruses collected by U.S. laboratories since October 1, 2004: 4 influenza A (H1) viruses, 284 influenza A (H3N2) viruses, and 90 influenza B viruses. The hemagglutinin proteins of the influenza A (H1) viruses were similar antigenically to the hemagglutinin of the vaccine strain A/New Caledonia/20/99.

One hundred thirty-four (47%) of the 284 influenza A(H3N2) isolates were characterized as antigenically similar to A/Wyoming/3/2003, which is the A/Fujian/411/2002-like (H3N2) component of the 2004-05 influenza vaccine.

One hundred fifty (53%) influenza A(H3N2) isolates had reduced titers to A/Wyoming/3/2003 and are most closely related to a recent reference strain, A/California/7/2004 (H3N2) [in next years vaccine].

Sixty-six of the influenza B viruses isolated this season belong to the B/Yamagata lineage and were characterized as B/Shanghai/361/2002-like, which is the influenza B component recommended for the 2004-05 influenza vaccine, and 5 showed somewhat reduced titers to ferret antisera produced against B/Shanghai/361/2002. Nineteen influenza B viruses belong to the B/Victoria lineage

During week 8, 30 states (Alaska, Colorado, Connecticut, Delaware, Florida, Georgia, Idaho, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Montana, Nebraska, Nevada, New Jersey, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Tennessee, Texas, Utah, Vermont, Virginia, Washington, and West Virginia) reported widespread activity. Sixteen states ( Arizona , Arkansas , California ,

Hawaii, Illinois, Indiana, Maine, Massachusetts, Minnesota, Mississippi, North Dakota, Rhode Island, South Carolina, South Dakota, Wisconsin, and Wyoming) and New York City reported regional influenza activity. Alabama , New Hampshire , New Mexico , and the District of Columbia reported local activity. Puerto Rico reported sporadic influenza activity. Missouri did not report.

Reports of influenza in Arkansas has decreased over the past few weeks with little change in previous numbers of positive cultures.

If you have any questions please feel free to contact Dr. Sandy Snow at 501-661-2102, or fax to 501-661-2300 or e-mail to ssnow@healthyarkansas.com

Thank you.

This is an official CDC Health Update
Distributed via Health Alert Network
December 08, 2004

Update on Flu Vaccine Allocation
CDC continues to work with state and local health officials to make vaccine available to high risk individuals as designated by the Advisory Committee for Immunization Practices (ACIP).  However, CDC is aware that geographic differences in vaccine distribution and demand remain across the nation. 

Some areas may have small amounts of vaccine scattered among private sector providers that would be difficult to redistribute. To ensure that no vaccine is lost or wasted, if a State Health Official determines that members of the state's high priority populations desiring to be immunized have indeed received vaccine, and additional vaccine is currently available on-hand in the private sector, the state may choose to recommend a limited expansion of eligibility for immunization with those existing private sector doses. 

Such an expansion might include individuals who would normally receive vaccine such as those between 50 and 65 years of age, household contacts of high priority individuals, or other populations deemed to be at risk by the state.  However, even if such a recommendation is made, private providers with a large volume of unused vaccine on hand should be encouraged, wherever practical, to work with the state to transfer such doses to other states with unmet high priority needs.

Furthermore, until such time as all ACIP-designated high priority individuals in all states have had the opportunity to be immunized, vaccine currently held in the public sector and apportioned vaccine that has not yet been delivered should continue to be directed only to these high priority populations.  All vaccine that has not yet been delivered should be made available only to those states with unmet demand among the priority groups.  CDC will conduct a second re-allocation to facilitate this availability. 

As CDC has done since the influenza vaccine shortage was announced in early October, it will continue to work with the Association of State and Territorial Health Officials (ASTHO) to assess the vaccine supply situation to ensure that all high priority individuals wishing to receive vaccine have the opportunity to do so.  If subsequent additional adjustments in distribution appear warranted, they will be made at that time . 

UPDATES TO INFORMATION AND GUIDANCE
The following updates were made to CDC information and guidance
during the period of November 26—December 3, 2004 , or reflect
this week's current events.  If you have any questions on these or other
clinical issues, please call our toll-free Clinician Information Line at
877-554-4625 or write to us at coca@cdc.gov .

INFLUENZA
Influenza Prevention Toolkit
This Flu Prevention Toolkit includes selected printable resources and
supplemental materials addressing flu prevention. There are also anecdotes
from real people with their respective flu related problems and
corresponding solutions.http://www.cdc.gov/flu/toolkit/

Flu Activity
This page includes information on:

• Weekly U.S. flu reports
• Weekly influenza activity maps
• International flu surveillance
  http://www.cdc.gov/flu/weekly/fluactivity.htm

Weekly Report: Influenza Summary Update
During November 21-27, 2004, influenza activity overall was low in
the United States . Twenty-nine specimens tested by U.S. World Health
Organization (WHO) and National Respiratory and Enteric Virus
Surveillance System (NREVSS) collaborating laboratories were positive
for influenza. The proportion of patient visits to sentinel providers for
influenza-like illness ( ILI ) and the proportion of deaths attributed to
pneumonia and influenza were below national baseline values. One state
reported regional influenza activity and two states reported local activity.
Thirty-five states, the District of Columbia , and New York City reported
sporadic influenza activity and 12 states reported no influenza activity.
http://www.cdc.gov/flu/weekly/

Program for Reallocation of Influenza Vaccine

This is an official CDC Health Update
Distributed via Health Alert Network
November 24, 2004

Since Chiron Corporation's October announcement, that the company could not provide vaccine for distribution in the United States for the 2004-2005 influenza season, CDC has worked closely with vaccine manufacturer Aventis Pasteur and State Health Officials to distribute available vaccine to the most vulnerable individuals and those who care for them.

CDC appreciates the tremendous efforts from states and urban areas to distribute and administer influenza vaccine to those most in need. CDC discourages use of vaccine for individuals not considered high-priority until we have met the demand for the priority population in every state. CDC will reallocate vaccine from states or urban areas that report having more than enough vaccine to serve their targeted populations to the remaining states or urban areas. High priority populations identified by the Advisory Committee for Immunization Practices (ACIP) for vaccination with inactivated influenza vaccine are identified at http://www.cdc.gov/flu/protect/whoshouldget.htm

By early October, Aventis Pasteur had already shipped 33 million of its expected total 58 million vaccine doses.  Together, CDC and Aventis Pasteur decided to fill orders placed with Aventis Pasteur and Chiron distributors that were easily identifiable as intended for providers serving substantial numbers of high risk patients. 

These orders included:

· State and Local Public Health Departments via federal, state, or multistate contracts
· Vaccines for Children's Program orders
· Aventis Pasteur's preservative-free influenza vaccine orders
· Federal Veteran's Administration and Indian Health Service orders
· Long-term care facility and acute care hospital orders placed with Aventis Pasteur
· Pediatric provider orders placed directly with Aventis Pasteur
· Visiting Nurse Associations of America orders
· Department of Defense orders

As these orders were being processed and shipped, ongoing discussions about vaccine allocation with State and Local Public Health Officials resulted in a consensus that those best suited to guide allocation of remaining vaccine were State and Local Public Health Officials working collaboratively within each state. 

CDC and State and Local Public Health Officials developed a needs-based formula to apportion the remaining vaccine across states so that they could direct vaccine to providers and facilities serving high risk patients within their jurisdiction.  This formula included estimates of the size of the target populations and the number of doses that had been shipped to the Aventis Pasteur customers in each state and was based on the best available information at the time. 

This information was incomplete, however, and may have overestimated the needs in some states and underestimated the needs in others.  CDC continues to receive reports from some states that they have significant unmet needs to provide influenza vaccine for their priority populations as identified by the ACIP.  However, other states have reported that they have or will have received supplies exceeding demand for their priority populations.  

In response to these reports from the states, the Association of State and Territorial Health Officials (ASTHO) and CDC conducted a survey to assess the current national status of Aventis Pasteur influenza vaccine distribution on a state-by-state basis. The preliminary results of the survey indicate that need for vaccine continues to exceed the available supply. A few states reported an adequate supply of vaccine or a small amount of vaccine in excess of their needs. CDC will work collaboratively with these states to reapportion the excess amount to the other states. 

The goal of the reapportionment is to reach as many individuals in the target populations as possible. Based on the results of the ASTHO/CDC survey, CDC will work closely with states to reapportion vaccine. In addition, CDC will contact states that report excess vaccine in the state to facilitate the transfer of vaccine to states with insufficient vaccine to meet priority groups. Because a substantial number of states reported being uncertain about the sufficiency of their apportionment, ASTHO/CDC will conduct a follow up survey in the near future to obtain additional detail to help with the reallocation of available vaccine. 

UPDATES TO INFORMATION AND GUIDANCE

The following updates were made to CDC information and guidance
during the period of November 5 – November 12, 2004 , or reflect this week's
current events.  If you have any questions on these or other clinical issues,
please call our toll-free Clinician Information Line at 877-554-4625
or write to us at coca@cdc.gov .

INFLUENZA

Flu Activity
This page includes information on:

• Weekly U.S. flu reports
• Weekly influenza activity maps

· International flu surveillance
http://www.cdc.gov/flu/weekly/fluactivity.htm

Weekly Report: Influenza Summary Update
During October 31 – November 6, 2004, influenza activity was low in
the United States . Six specimens tested by U.S. World Health Organization
(WHO) and National Respiratory and Enteric Virus Surveillance System
(NREVSS) collaborating laboratories were positive for influenza. The
proportion of patient visits to sentinel providers for influenza-like illness
( ILI ) and the proportion of deaths attributed to pneumonia and influenza were
below baseline values. Twenty-eight states, New York City , and the District
of Columbia reported sporadic influenza activity and 20 states reported no
influenza activity.
http://www.cdc.gov/flu/weekly/

CDC Guidelines for Large-Scale Influenza Vaccination Clinic
Planning, 2004-2005
This document provides guidelines to facilitate the most efficient and safe
delivery of available vaccine to the priority groups, and to assist with
planning large-scale influenza vaccination clinics by public and private
vaccination groups. 

http://www.cdc.gov/flu/professionals/vaccination/pdf/vaxclinicplanning0405.pdf

HHS/CDC FluMist Patient Screening Form

Attached is the FluMist patient screening form to enable self-screening
by patients visiting health care providers to receive an influenza vaccination.
It should be especially useful in influenza clinics. The form is based on the
most-current ACIP recommendations for this influenza season and will
help providers to more easily screen potential vaccinees. In influenza clinics,
the form may help to reduce long lines by enabling the early identification of
those who should not be vaccinated during this influenza season. These persons
could take themselves out of line or seek clarification or answers from clinic staff
before leaving the clinic area.

UPDATES TO INFORMATION AND GUIDANCE

The following are mid-week flu updates to CDC's information and guidance for November 3, 2004.   If you have any questions on these or other clinical issues, please call our toll-free Clinician Information Line (CIL) at 877-554-4625 or write to us at:  coca@cdc.gov .

INFLUENZA UPDATES

Press Release (10/29/04): Over 4.2 Million Influenza Vaccine Doses Shipped This Week to Health Providers Serving High-Priority Groups
Over 4.2 million influenza vaccine doses were shipped this week to health providers serving high-priority groups as part of the plan announced on October 12 by the Centers for Disease Control and Prevention (CDC) and Aventis Pasteur.
http://www.cdc.gov/od/oc/media/pressrel/r041029.htm

Colleges and Universities: 2004-05 Influenza Season
This page provides information for college health services, including:

· Vaccine redistribution
· Other ways to prevent the flu
· Additional resources

http://www.cdc.gov/flu/school/college.htm

Influenza Update NetConference
Reminder that this NetConference is scheduled for November 19, 2004.  Agenda is now available.
http://www.cdc.gov/flu/professionals/training/novnetconf.htm

Influenza Antiviral Medications:
2004-05 Interim Chemoprophylaxis and Treatment Guidelines
This document provides revised information on antiviral use in children.
http://www.cdc.gov/flu/professionals/treatment/0405antiviralguide.htm

Tools to Prevent Spread of Flu in the Workplace
Provides various resources including important telephone numbers, web pages, and poster/flyer links.
http://www.cdc.gov/flu/pdf/flu-tools.pdf

New Q&As

Flu Prevention:

· How long can human influenza viruses remain viable on inanimate items (such as books and doorknobs)?
· What kills influenza virus?

http://www.cdc.gov/flu/about/qa/preventing.htm

Flu Disease:

· How does CDC monitor the progress of the flu season?

· If I got the flu last year, will I have immunity against the flu this year?
http://www.cdc.gov/flu/about/qa/disease.htm

PPE and LAIV:

· What personal protective equipment is recommended for health-care       workers who are giving LAIV?
http://www.cdc.gov/flu/about/qa/nasalspray.htm

Vaccine:

· If I got a vaccine last year, will that protect against the flu for this year?

http://www.cdc.gov/flu/about/qa/fluvaccine.htm

Brochure: Questions about the pneumococcal shot brochure
http://www.cdc.gov/flu/professionals/flugallery/flyers.htm#questions

Be sure to look at our "What's New" web page for the latest flu updates and translations.
www.cdc.gov/flu/whatsnew.htm

Influenza Antiviral Medications:
2004-05 Interim Chemoprophylaxis and Treatment Guidelines
This is an official CDC Health Advisory
October 19, 2004

State Working On Flu-Vaccine Policy
The Arkansas Department of Health said officials there are trying to determine how it will distribute the 107,500 doses of influenza vaccine it has available for the 2004-2005 flu season.

The Health Department will provide approximately 45,000 doses to nursing homes statewide.

The department is working with the Arkansas Hospital Association and private providers to decide how it will distribute the remaining supplies.

The agency is conferring with hospitals, physicians and other health providers to determine the number of doses available in the private sector. Officials will also determine how people most vulnerable to the flu and health professionals involved in direct patient care will be vaccinated.

The Health Department's vaccine supply will be distributed to local health unit offices around the first week of November. When local health units have vaccine available for use, they will notify local media to publicize dates and times when immunizations will be available.

As a result of the national vaccine shortage, local health units will be giving influenza vaccinations to high-risk groups only. People who are not in a high-risk category will not be eligible to receive vaccine.

High-risk categories include:

• People 65 years of age and older.
• Children ages 6 months to 23 months.
• Adults and children 2 years of age and older with chronic lung or heart disorders including heart disease and asthma.
• Pregnant women.
• Adults and children 2 years of age and older with chronic metabolic diseases (including diabetes), kidney diseases, blood disorders (such as sickle cell anemia), or weakened immune systems, including persons with HIV/AIDS.

CDC/Aventis Pasteur Collaborate to Ship More than 2 Million Doses
of Influenza Vaccine to Providers Who Serve High-Priority Groups

HHS Secretary Urges States to Aggressively
Prosecute Flu Vaccine Price Gouging
HHS Secretary Tommy G. Thompson sent a letter to the Attorney General of
each state on October 14th urging them to thoroughly investigate reports of
price gouging involving the flu vaccine and to prosecute those found to betaking advantage of the vaccine shortage.  For more information, please go to http://www.hhs.gov/news/press/2004pres/20041014b.html

AHA Quality Advisory on Influenza Vaccine Shortage

CDC Gives Further Guidance on Flu Vaccine Shortage
The Centers for Disease Control and Prevention (CDC) October 14 advised hospitals, nursing homes and other providers to coordinate with their local health department if they have excess flu vaccine they would like to redistribute or are in need of additional vaccines. The agency also urged providers without sufficient vaccines to cover high-risk groups to contact their vaccine distributor on the status of their supply, and ensure that their “voice is heard” as remaining vaccines are allocated in the coming weeks.

CDC said it has not developed recommendations to help providers in short supply of vaccines prioritize among at-risk groups, which include children between 6 and 23 months, seniors 65 and older, pregnant women, health care workers with direct patient contact, and people with chronic health conditions; however, the agency advised providers to “stay tuned.”

Anxiety Grows Over Flu Vaccine Shortage
There is growing anxiety throughout Arkansas about the shortage of influenza vaccine. Many hospitals, clinics, and physician offices have not received the vaccine. However, the CDC and Aventis Pasteur (the only company now manufacturing the vaccine) have announced the first phase of a plan to allocate vaccine in response to the recently announced loss of half of the nation's expected flu vaccine supply.

The plan calls for CDC to work closely with Aventis to distribute, in phases, 22.4 million doses of unshipped vaccine to identified areas of need in Arkansas and throughout the United States. Beginning immediately, about 14.2 million doses will be allocated over the next 6 to 8 weeks to high priority vaccine providers including hospitals and nursing homes.

The Arkansas Department of Health (ADH) estimates that about 300,000 people in the state fit into the “high risk” category of those who should have priority in getting a flu shot. Usually, only about 50% of these high-risk individuals elect to receive the vaccine, which leaves Arkansas with about 150,000 high-risk individuals who will seek immunization.

While the ADH has ordered 225,000 doses, it has thus far received only 95,000. The ADH hopes to have vaccine distributed to all of its health units by the first week of November. The department is waiting to determine exactly how much vaccine it will receive prior to apportioning it. The department plans to begin vaccinations throughout Arkansas on the same day and these vaccinations will be widely publicized.

It is clear, though, that Arkansas will not receive enough vaccine to immunize all of the state's high-risk individuals. Therefore, it is imperative that hospitals, physician offices, and other providers follow the CDC guidelines for vaccine distribution so that many of those most vulnerable receive the vaccine. These guidelines take precedent over earlier CDC recommendations and are as follows:

• All children age 6-23 months
• Adults age 65 and over
• Persons age 2-64 years with underlying chronic medical conditions
• All women who will be pregnant during the influenza season
• Residents of nursing homes and long-term care facilities
• Children age 6 months to 18 years on chronic aspirin therapy
• Healthcare workers involved in direct hands-on patient care
• Out-of-home caregivers and household contacts of children under 6 months of age

Here are some commonly-asked questions (and answers) that are arising in light of the vaccine shortage:

Q: If I can't get vaccine, what's the next best thing I can do to prevent flu?

A: Flu viruses spread in droplets when infected people cough or sneeze, or they can spread on the hands that covered the cough or sneeze. Doctors say the most important rule is frequent hand-washing.

Q: Are there drugs I can take to prevent flu?

A: Antiviral drugs would have to be taken daily to prevent flu. But if taken within 48 hours after symptoms start, prescription antivirals can reduce the severity of flu.

Q: Should I get a prescription for an antiviral drug ahead of time, just in case?

A: Doctors are unwilling to recommend this because they fear that the drugs could be used inappropriately. They're effective only against flu viruses, not other causes of upper respiratory illness, and they fear that if everyone tried to stockpile them, there could be shortages. People who get symptoms — sudden fever, headache, fatigue, cough — during flu outbreaks can call their doctors and get a prescription quickly.

Q: What should I do to protect my children?

A: If children are 6 months to 23 months old or have an underlying medical condition such as asthma or diabetes, they are in a priority group to receive a flu shot. If not, parents should pay attention to hand-washing, avoid exposing kids to tobacco smoke and keep children, especially babies, away from ill people.

Q: If I have had flu vaccine in previous years, will it help protect me this year?

A: It might. Every year, a new vaccine is made to match the strains of flu in circulation. That's why we need annual shots. But, even though immunity wanes a few months after the flu shot, your body does have a collective memory, so if you take the vaccine every year, you'll have a rich portfolio of influenza antibodies in your blood that may provide some protection.

Physicians and hospitals can help citizens who do not receive vaccine by educating them on good health habits:

• Avoid close contact.
  Avoid close contact with people who are sick. When you are sick, keep your distance from others to protect them from getting sick too.
• Stay home when you are sick.
  If possible, stay home from work, school, and errands when you are sick. You will help prevent others from catching your illness.
• Cover your mouth and nose.
  Cover your mouth and nose with a tissue when coughing or sneezing. It may prevent those around you from getting sick.
• Clean your hands.
  Washing your hands often will help protect you from germs.
• Avoid touching your eyes, nose or mouth.
  Germs are often spread when a person touches something that is contaminated with germs and then touches his or her eyes, nose, or mouth.

Health Alert Network (HAN)
The following links contain official CDC Health Alerts, Health Advisory, Health Updates Or Info Service Messages from the Health Alert Network (HAN):

Flu Gallery
CDC announces the opening of the "2004-05 Flu Gallery", where you can view and download all of this season's influenza education materials, including posters, flyers and brochures from the web for the following audiences:

• Healthcare providers
• Seniors
• Pregnant women
• Parents of 6-23 month olds and other kids at high risk
• People 18 or older with high risk conditions

Most materials are in English and Spanish.  You can print most on office printers, and separate files can be taken to a professional (offset) printer. 

Avian Influenza: Interim Recommendations for Persons with Possible Exposure to Avian Influenza During Outbreaks Among Poultry in the United States
February 24, 2004

Avian Influenza A (H5N1) and SARS - Update: Interim Recommendations for Enhanced U.S. Surveillance, Testing, and Infection Control
February 3, 2004

Avian Influenza A (H9N2) Virus Infection
December 10, 2003

Influenza - Recommendations for Prevention
December 10, 2003

Influenza - Assessing Vaccine Supplies
December 5, 2003

Influenza Activity in the United States, 2003-04 Season
November 21, 2003

Influenza (New Website)
CDC has created a new website for all influenza-related information.  Whereas in the past information on influenza was separated into a disease-related section and a vaccine related section, all this material is no combined on one site: www.cdc.gov/flu.  

The following link will take clinicians directly to the section for health professionals: www.cdc.gov/flu/professionals/overview.htm.

Influenza Summary Update
Influenza activity in the United States continued to increase during week 49 (November 29 – December 6, 2003). One thousand four hundred nine (36.8%) of 3,834 specimens collected from throughout the United States and tested by U. S. World Health Organization (WHO) and National Respiratory and Enteric Virus Surveillance System (NREVSS) collaborating laboratories were positive for influenza.

The proportion of patient visits to sentinel providers for influenza-like illness (ILI) overall was 5.1%, which is above the national baseline of 2.5%. The proportion of  deaths attributed to pneumonia and influenza was 7.0%, which is below the epidemic threshold for the week. 

Twenty-four state health departments reported widespread influenza activity, 15 states and New York City reported regional activity, 6 states reported local influenza activity, and 5 states and Guam reported sporadic influenza activity. www.cdc.gov/ncidod/diseases/flu/weekly.htm