ProMED: Unconfirmed reports of influenza in vaccinated indiviuals in the Pacific Northwest, at least one fatality

[alert]

http://www.promedmail.org/

Published Date: 2012-04-08 16:50:16
Subject: PRO/EDR> Influenza (25): H3N2 surveillance Canada (BC), USA
Archive Number: 20120408.1093983

INFLUENZA (25): H3N2 SURVEILLANCE CANADA (BRITISH COLUMBIA), USA
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[1]Date: Sat 7 Apr 2012
From: Danuta Skowronski


Re: Influenza in previously vaccinated children (USA Pacific Northwest)
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In response to Dr. Wilson's ProMED posting of 6 Apr 2012 [Influenza (24): USA (Pacific NW) 20120406.1092588] querying variation in recent influenza A/H3N2 viruses away from the A/Perth/16/2009-like vaccine strain component of the seasonal trivalent influenza vaccine (TIV) since 2010-11 we would like to share findings from the sentinel surveillance system in Canada. Our findings for 2010-11, currently in press with Clinical Infectious Diseases [1], are also relevant to Dr. Wilson's queries for the 2011-12 season.

During the 2010-11 season, H3N2 viruses dominated among influenza detections in Canada and through phylogenetic analysis we identified two variant clades among strains circulating through the sentinel system [1]. Viruses belonging to the A/Hong Kong/2121/2010 clade comprised nearly 90% and those belonging to the A/Victoria/208/2009 clade about 10% of sequenced strains. Based on phylogenetic analysis, few belonged to the A/Perth/16/2009 vaccine clade. Both variant clades showed substantial amino acid substitutions away from the vaccine strain in key antigenic sites, meeting genetic criteria for potential antigenic drift [2]. Consistent with this, we measured suboptimal vaccine effectiveness for the H3N2 component of TIV that season [1].

For the 2011-12 northern and 2012 southern hemisphere influenza seasons, the A/Perth/16/2009 vaccine strain was retained as H3N2 component but has been replaced for the 2012-13 TIV by A/Victoria/361/2009 [3]. The latter belongs to the A/Victoria/208/2009 clade we identified through sentinel surveillance in Canada in 2010-11, but has accumulated further mutations in antigenic sites [1].

In British Columbia, we have identified more significant contribution from the A/Victoria phylogenetic clade this season and given our geographic proximity, the same may also be anticipated in the USA Pacific Northwest. The most recent surveillance bulletin for Washington state reports that 10/22 H3N2 viruses characterized to date for 2011-12 show reduced titres with antiserum produced against the A/Perth/16/2009 vaccine strain [4]. In that regard, suboptimal protection among vaccinated children this season may not be unexpected. It would be informative if the viruses detected by Dr. Wilson and colleagues were also strain characterized and sequenced to better elucidate their identity.

We should point out that influenza B has also been a contributor to influenza activity in British Columbia in recent weeks, with some lineage-level mismatch to the vaccine component noted among characterized strains, a finding also in common with Washington state [4].

References:

1. Skowronski DM, Janjua NZ, De Serres G, et al. A sentinel platform to evaluate influenza vaccine effectiveness and new variant circulation, Canada 2010-11 season. Clinical Infectious Diseases [in press].

2. Bush RM, Bender CA, Subbarao K, Cox NJ, Fitch WM. Predicting the evolution of human influenza A. Science 1999;286:1921-5.

3. World Health Organization. Recommended composition of influenza virus vaccines for use in the 2012-2013 northern hemisphere influenza season. Available at:

http://www.who.int/influenza/vaccines/virus/recommendations/201202_recommendation.pdf

4. Washington State Department of Health. Communicable Disease Epidemiology Influenza
Update. 2012 CDC Week 13 (3/25/12 - 3/31/12). Available at:

http://www.doh.wa.gov/EHSPHL/Epidemiology/CD/fluupdate.pdf

--
Danuta M Skowronski MD, FRCPC
Naveed Z Janjua MBBS, DrPH
Jennifer L Gardy PhD
Communicable Disease Prevention and Control Services

and

Suzana Sabaiduc BSc
Martin Petric PhD, FCCM
BC Public Health Microbiology and Reference Laboratory
BC Centre for Disease Control
Vancouver, British Columbia, Canada

*****
[2]
Date: 7 Apr 2012
From: James M. Wilson V


We have report of another metropolitan hospital in the Pacific NW seeing influenza in previously vaccinated children.

Here in western Colorado, we saw the death of an elderly woman who had a prior medical history of chronic pulmonary disease. Both she and her husband were vaccinated for influenza, but the husband was the first to be infected, then the wife who later succumbed.

--
James M. Wilson V, M.D.
Delta Pediatrics
Delta County Memorial Hospital
-and-
Chief of Station
Ascel Bio Black Canyon Infectious Disease Forecast Station #1

[ProMED thanks Dr. Skowronski and colleagues for their communication supporting antigenic drift of influenza A strains as one of the factors responsible for infection in vaccinated individuals in the adjacent Northwestern USA, such as those noted by Dr. Wilson. - Mod.LM

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/r/1*kk.]

[alert]

Re: ProMED: Reports of seasonal H3N2 influenza in vaccinated indiviuals in the Pacific Northwest, at least one fatality

http://www.promedmail.org/

Published Date: 2012-04-16 23:23:30
Subject: PRO/EDR> Influenza (31): USA (WA, NV, CO) surveillance
Archive Number: 20120416.1103337

INFLUENZA (31): USA (WASHINGTON STATE, NEVADA, COLORADO), SURVEILLANCE
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Date: Tue 10 Apr 2012 [ProMED-mail apologises for an inadvertent delay in posting this report]
From: James Wilson [edited]


Physicians reporting across several hospitals in King County [WA] report an abrupt increase in patient volume of both pediatric and adult patients where tests were positive for type A (mostly) and some type B influenza. A substantial portion of these patients were previously vaccinated. Additionally, their house staff were vaccinated for influenza at the 90 percent level. At the same time, they saw an abrupt influx of patients; they saw many of their vaccinated healthcare staff infected and off duty. This was significant enough to engage infection control to issue an internal advisory.

1. Our sources in King County are board-certified, astute, practicing clinicians. We also have sources in nursing, clinical laboratories, infection control, veterinary medicine, wildlife medicine, and a multitude of others throughout the Pacific NW including Canada.

2. The sources that reported influenza activity in King County are scattered across 7 medical campuses and 5 emergency departments, including both adult and pediatric ones.

3. Our clients are healthcare providers who receive our forecasts as 30-60 day pre-event products, rolling on a monthly basis. What this does is prompt them to review (e.g. CME) for topics such as human metapneumovirus, review infection control protocols, order laboratory diagnostic tests based on the forecast and what they are seeing clinically, and ask the right questions at the right time if what is forecasted does not match what they are seeing. The latter is how we rapidly recognized one of the worst hMPV/RSV [human metapneumovirus/respiratory syncytial virus] seasons ever documented at our hospital. The clinicians in King County were responding to one of these forecast reports. It is a highly agile social network of astute clinicians, a network designed like the one that supported reporting in Haiti (i.e. the Haiti Epidemic Advisory System).

4. The tests used are rapid tests backed by EIA, with samples forwarded to the state lab. They are aware of the low sensitivity of these tests and suspect much higher case counts.

5. Vaccination history is recorded in EPIC and is therefore retrievable/credible.

6. Case presentation has been within 24 hours of initial symptoms, with T105 and intractable coughing. There has been a large demand for Tamiflu.

7. They have been dealing -- like many in the area -- with the pertussis epidemic, in which they have had infant fatalities, and also with a substantial case load of RSV.

We have received similar reporting from Spokane (WA) and now Las Vegas (NV). A fatality in the Western Slope (CO) was previously reported.

--
James M. Wilson V, M.D.
Delta Pediatrics
Delta County Memorial Hospital
and
Co-Founder, Ascel Bio LLC
Chief of Station
Ascel Bio Black Canyon Infectious Disease Forecast Station
Ascel Bio Haiti Infectious Disease Forecast Station
Ascel Bio SE Asia Infectious Disease Regional Forecast Station


[James Wilson added the following: "Ongoing dialog with public health officials indicate some degree of frustration interpreting this information. The reason is that there is no real-time surveillance capability to do so in a manner that enables one to rapidly compare baseline statistics. The US CDC and WHO do not report this information in their weekly updates. From a medical point of view, this information is crucial when attempting to forecast medical infrastructure strain and when communicating with patients."

The interactive HealthMap of the United States of America can be accessed at: http://healthmap.org/r/01bw. - Mod.CP]

[alert]

Re: ProMED: Reports of seasonal H3N2 influenza in vaccinated indiviuals in the Pacific Northwest, at least one fatality

This is the original post which I missed which apparently started this discussion:

http://www.promedmail.org/direct.php?id=20120406.1092588

Published Date: 2012-04-06 17:17:58
Subject: PRO/EDR> Influenza (24): USA (Pacific NW)
Archive Number: 20120406.1092588

INFLUENZA (24): UNITED STATES OF AMERICA (PACIFIC NORTH WEST)
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International Society for Infectious Diseases

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Date: Thu 5 Apr 2012

From: James Wilson [edited]







Influenza in Previously Vaccinated Children (USA Pacific Northwest)


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We have report of a significant bump in influenza-positive pediatric patients presenting to a major metropolitan hospital in the Pacific NW, USA, over the last 2-3 weeks. Of note, many of these patients were previously vaccinated for influenza at the start of the school year (September 2011).



Differential diagnosis (in order of probability):



1. Waning immunity as the predominant type A influenza circulating is H3N2 in the Pacific NW. Waning immunity over the course of a routine influenza season is an expected phenomenon. Our team forecasted a moderate vaccine drift probability for A/H3N2 this season several months ago.



2. Waning immunity as there are still significant levels of circulating A/H1N1 (2009) in the Pacific NW. We believe this is highly unlikely and forecasted very low probabilities of vaccine drift for A/H1N1.



3. Possible emergence of other type A influenza viruses such as A/H3N2-variant. While we believe this is unlikely, we cannot exclude it. One of the key indicators we have been monitoring is the appearance of influenza in patients who were previously vaccinated.



--

James M. Wilson V, M.D.

Department of Pediatrics

Delta County Memorial Hospital

and

Chief of Station

Ascel Bio Black Canyon Infectious Disease Forecast Station

[Perhaps of relevance to the above is the the Eurosurveillance Weekly influenza surveillance overview -- 5 Apr 2012 (http://ecdc.europa.eu/en/publication...2-SUR-WISO.pdf) where it was reported that the 2011/12 influenza season started late and has been without any clear geographic progression across Europe. Furthermore, In relation to the situation in the Pacific Northwest described above, it was concluded that there has been a degree of heterogeneity in the antigenicity of the A(H3) viruses this season and an imperfect fit with the A(H3) component in the seasonal vaccine. - Mod.CP

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/r/1hiS.]