Preparing for the Next Pandemic - VA Enhances Flu Vaccination and Surveillance Programs

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Preparing for the Next Pandemic - VA Enhances Flu Vaccination and Surveillance Programs Cont

Categorized in: 2012 Compendium of Federal Medicine, Department of Veterans Affairs (VA)

DoD’s Surveillance System Helped Detect, Respond to Influenza Pandemic
The initial detection of the novel A/H1N1 influenza in the United States and several other countries resulted from surveillance networks established by the Armed Forces Health Surveillance Center’s Division of Global Emerging Infections Surveillance and Response System (AFHSC-GEIS). Viruses isolated from those cases were used as seed strains for the 2009 pandemic influenza vaccine.1
AFHSC-GEIS keeps track of emerging infectious diseases, including respiratory diseases, of concern to DoD, using a global network of partners for disease surveillance.
During the H1N1 pandemic, those partner agencies provided diagnostic laboratory training and capacity building in their home countries, adapted U.S.-approved methods for diagnosing the influenza virus in a variety of settings and helped estimate seasonal vaccine effectiveness against the illness.
DoD established the Global Emerging Infections Surveillance and Response System (DoD-GEIS) in 1997, in response to a presidential directive. Its mission was to monitor newly emerging and re-emerging infectious diseases among U.S. servicemembers and dependent populations. Over time, a great deal of the focus has been on respiratory ailments.
Respiratory infections are responsible for 25% to 30% of both outpatient illness and hospitalizations among U.S. military personnel, with influenza and adenovirus infections among the biggest contributors to morbidity and mortality in military members.
This is nothing new. During the 1918 influenza pandemic, the U.S. military experienced attack rates as high as 25%and case-fatality rates averaging 5 %.
AFHSC-GEIS provides direction, funding and oversight to a network of global partners, including approximately 500 sites in 70 countries.
AFHSC also maintains a database containing up-to-date and historical data on medical encounters, vaccinations and personnel and demographic data about servicemembers from all military services.
That database, the Defense Medical Surveillance System (DMSS), uses ICD-9 codes from hospitalization and outpatient
encounters and influenza vaccination data.
Weekly summaries track influenza-like illness (ILI) and pneumonia and influenza (P&I) for health system beneficiaries by geographic regions. That includes both servicemembers and their families.
The summary report includes electronic, medical and lab-based surveillance data from the MHS as well as surveillance data from the DoD's overseas research laboratories and their partners.
AFHSC also receives standardized case reports of RME from all services and goes beyond the Centers for Disease Control and Prevention’s Nationally Notifiable Diseases Surveillance System. Unlike the CDC system, AFHSC requires that the reporting of respiratory illnesses that meet a clinical case definition, including sudden onset of fever >102.2°F, respiratory symptoms, myalgia and headache, and are laboratory-confirmed as influenza.

1: Burke RL, Vest KG, Eick AA, Sanchez JL, et al. Department of Defense influenza and other respiratory disease surveillance during the 2009 pandemic. BMC Public Health. 2011 Mar 4;11 Suppl 2:S6. Review. PubMed PMID: 21388566; PubMed Central PMCID: PMC3092416.

As a result, one goal for improving surveillance has been to simplify and automate communication, although there are drawbacks, says Martinello. “Electronic systems are incredibly helpful, but there is no replacement for people who have their hands in the matter.”

That personal communication goes two ways, he said. “In the Public Health Office, we may notice aberrations in the data coming from HAIISS. That would prompt us to reach out to national clinical leadership and the local facility to see what is actually going on.

“If someone at a facility has reason to believe an outbreak may be occurring, they may call us directly. If they have strong relationships with local and state departments of public health, they may call them first. We do not yet have a formal structure for that. Either way, the goal is to communicate what is happening so that our network offices, local and state public health, VA leadership and front-line clinicians know what’s being seen. That knowledge can help physicians identify whether a patient likely has influenza, indicate what tests should be done and what treatment is effective.”

Beyond identifying that a patient probably has influenza, clinicians need to know what strain they are battling. Larger facilities can send samples to their virology laboratories, but smaller facilities, long-term care and outpatient centers typically need to send specimens to labs at larger facilities or to state or local public health departments.

“If we’re seeing unusual cases, we gather resources within the VA — infectious disease specialists in the region and nationally, our public health resources and experts in infection prevention and influenza — and contact the CDC to develop plans and advise individual healthcare providers how to deal with the situation,” Martinello said.

If VA laboratories in larger centers are unable to determine the strain or subtype, “they may have an atypical strain, which is how the 2009 pandemic virus was first recognized,” said Martinello. “The test being used was unable to identify the strain, so it was sent to the CDC.”

That scenario could unfold at any time. In December, the CDC issued interim guidance for influenza surveillance to detect additional cases of influenza A(H3N2)v, a variant virus that affected 12 people in five states (Indiana, Iowa, Maine, Pennsylvania and West Virginia) in the last half of 2011. This variant appears to be transmitted primarily from swine but also has shown limited human-to-human transmission. The influenza virus is highly mutagenic, and influenza A(H3N2)v or other strains could quickly become much more transmissible.

The CDC notes that molecular assays “may give an influenza A ‘unsubtypable’ result,” even when using assays that can detect all currently circulating influenza subtypes. Alternatively, assays may give a false positive result for human influenza A(H3) virus. The sensitivity and specificity of rapid influenza diagnostic tests and immunofluorescence tests for influenza A (H3N2)v virus are unknown and may give false positives or false negatives. The CDC advises labs with unusual results or specimens from especially severe cases to forward them to a public-health department for further evaluation.

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