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