FluWatch report: August 2 to August 15, 2015 (Weeks 31 & 32)

Overall summary

  • Overall, there is little to no influenza activity in Canada; however, in week 32, there were low levels of influenza activity reported in regions of British Columbia and Ontario.
  • There was one influenza outbreak in a long term care facility reported in week 32.
  • Rhinovirus was the most commonly detected respiratory virus in weeks 31 and 32
  • As of week 32, 8,008 hospitalizations and 604 deaths have been reported from participating regions, which is more than were reported last year at this time (5,442 hospitalizations and 342 deaths).

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Organization: Public Health Agency of Canada

Date published: 2015-08-21

Influenza/ILI Activity (geographic spread)

In week 32, sporadic and/or localized activity was reported BC and ON. Overall, there is low influenza/ILI activity in Canada.

Figure 1. Map of overall influenza/ILI activity level by province and territory, Canada, Week 32

Figure 1

Note: Influenza/ILI activity levels, as represented on this map, are assigned and reported by Provincial and Territorial Ministries of Health, based on laboratory confirmations, sentinel ILI rates and reported outbreaks. Please refer to detailed definitions at the end of the report. Maps from previous weeks, including any retrospective updates, are available on the Flu Activity website.

Figure 1 Map of overall influenza/ILI activity level by province and territory, Canada, Week 32 - Text Description
In week 32, sporadic and/or localized activity was reported BC and ON. Overall, there is low influenza/ILI activity in Canada.

Influenza and Other Respiratory Virus Detections

LInfluenza detections are at inter-seasonal levels. For the past six weeks, less than 1% of tests were positive for influenza (Figure 2). Most jurisdictions (with the exception of BC, AB and ON) reported no influenza detections in week 32 (Table 1). To date this season, detailed information on age and type/subtype has been received for 37,468 cases (Table 2). Adults ≥65 years of age have predominantly been affected by influenza A, accounting for 62% of influenza A detections.

Figure 2. Number of positive influenza tests and percentage of tests positive, by type, subtype and report week, Canada, 2014-15

Figure 2
   Figure 2 Number of positive influenza tests and percentage of tests positive, by type, subtype and report week, Canada, 2014-15 - Text Description

Influenza detections are at inter-seasonal levels. For the past six weeks, less than 1% of tests were positive for influenza. Most jurisdictions (with the exception of BC, AB and ON) reported no influenza detections in week 32.

Detections for all other respiratory viruses have continued to decline and have been at inter-seasonal levels for the past weeks (figure 3). In weeks 31 and 32, rhinovirus was the predominant virus among other respiratory viruses.

For more details, see the weekly Respiratory Virus Detections in Canada Report.

Figure 3. Number of positive laboratory tests for other respiratory viruses by report week, Canada, 2014-15

Figure 3
RSV: Respiratory syncytial virus; hMPV: Human metapneumovirus
Figure 3 Number of positive laboratory tests for other respiratory viruses by report week, Canada, 2014-15 - Text Description
Detections for all other respiratory viruses have continued to decline and have been at inter-seasonal levels for the past weeks.
Table 1: Weekly and cumulative numbers of positive influenza specimens by type, subtype and province, Canada, 2014-15
Reporting provincesFootnote 1 Weekly (August 2 to August 15, 2015) Cumulative(August 24 to August 15, 2015)
Influenza A B Influenza A B
A Total A(H1)pdm09 A(H3) A Footnote (Uns) B Total A Total A(H1)pdm09 A(H3) A(UnS) B Total
BC 2 0 2 0 0 3564 28 2661 875 507
AB 1 0 1 0 0 3716 14 3547 155 1007
SK 0 0 0 0 0 1320 0 841 479 412
MB 0 0 0 0 0 1124 1 390 733 228
ON 1 0 1 0 0 11219 53 4754 6412 1555
QC 0 0 0 0 0 11464 4 422 11038 3914
NB 0 0 0 0 0 1196 0 193 1003 536
NS 0 0 0 0 0 511 1 123 387 263
PE 0 0 0 0 0 131 1 128 2 109
NL 0 0 0 0 0 629 0 123 506 81
Canada 4 0 4 0 0 34874 102 13182 21590 8612
Percentage Footnote 2 100.0% 0.0% 100.0% 0.0% 0.0% 80.2% 0.3% 37.8% 61.9% 19.8%
Table 2. Weekly and cumulative numbers of positive influenza specimens by type, subtype and age-group reported through case-based laboratory reportingFootnote 1,Footnote 3, Canada, 2014-15
Age groups (years) Weekly August 2 to August 15, 2015 Cumulative (August 24 to August 15, 2015)
Influenza A B Influenza A B Influenza A and B
A Total A(H1) pdm09 A(H3) A Footnote (Uns) Total A Total A(H1) pdm09 A(H3) A (UnS) Total # %
<5 0 0 0 0 0 2095 23 811 1261 570 2665 7.1%
5-19 0 0 0 0 0 1786 6 959 821 809 2595 6.9%
20-44 1 0 1 0 0 3466 18 1685 1763 1154 4620 12.3%
45-64 3 0 2 1 0 3897 23 1673 2201 1845 5742 15.3%
65+ 0 0 0 0 0 18787 13 7318 11456 2932 21719 58.0%
Unknown 0 0 0 0 0 120 0 101 19 7 127 0.3%
Total 4 0 3 1 0 30151 83 12547 17521 7317 37468 100.0%
PercentageFootnote 2, 100.0% 0.0% 75.0% 25.0% 0.0% 80.5% 0.3% 41.6% 58.1% 19.5%    

Antiviral Resistance

During the 2014-2015 influenza season, the NML has tested 1,925 influenza viruses for resistance to oseltamivir and 1,923 influenza viruses for resistance to zanamivir. All viruses were sensitive to zanamivir and one influenza A(H3N2) virus was resistant to oseltamivir. A total of 1,492 influenza A viruses (99.9%) were resistant to amantadine (Table 3).

Table 3. Antiviral resistance by influenza virus type and subtype, Canada, 2014-15
Virus type and subtype Oseltamivir Zanamivir Amantadine
# tested # resistant (%) # tested # resistant (%) # tested # resistant (%)
A (H3N2) 978 1 976 0 1468 1467 (99.9%)
A (H1N1) 25 0 25 0 25 25 (100%)
B 922 0 922 0 NATable 3 - Footnote * NA Table 3 - Footnote *
TOTAL 1925 1 1923 0 1493 1492

Influenza Strain Characterizations

During the 2014-2015 influenza season, the National Microbiology Laboratory (NML) has characterized 1,162 influenza viruses [216 A(H3N2), 24 A(H1N1) and 922 influenza B].

Influenza A (H3N2): When tested by hemagglutination inhibition (HI) assay (n=216), one virus was antigenically similar to A/Texas/50/2012, five showed reduced titers to A/Texas/50/2012 and 210 were antigenically similar to A/Switzerland/9715293/2013, which is the influenza A(H3N2) component recommended for the 2015 Southern Hemisphere influenza vaccine. Additionally, 1,224 A(H3N2) viruses were unable to be tested by HI assay; however, sequence analysis showed that 1,222 belonged to a genetic group that typically shows reduced titers to A/Texas/50/2012. Influenza A(H1N1): 24 A(H1N1) viruses characterized were antigenically similar to A/California/7/2009. Influenza B: Of the 922 influenza B viruses characterized, 811 viruses were antigenically similar to B/Massachusetts/2/2012, three viruses showed reduced titers against B/Massachusetts/2/2012, and 108 were B/Brisbane/60/2008-like (Figure 4).

Figure 4. Influenza strain characterizations, Canada, 2014-2015, N = 1,162

Figure 4

The NML receives a proportion of the number of influenza positive specimens from provincial laboratories for strain characterization and antiviral resistance testing. Characterization data reflect the results of haemagglutination inhibition (HAI) testing compared to the reference influenza strains recommended by WHO.

   Figure 4 Influenza strain characterizations, Canada, 2014-2015, N = 1,162 - Text Description
Strain Number of specimens Percentage
A/Texas/50/2012-like 1 0%
reduced titres to A/Texas/50/2012 5 1%
A/California/07/2009-like 24 2%
A/Switzerland/97 15293/2013-like 210 18%
B/Massachusetts/2/2012-like 811 70%
reduced titres to B/Massachusetts/2/2012 3 0%
B/Brisbane/60/2008-like 108 9%

Influenza-like Illness (ILI) Consultation Rate

The national influenza-like-illness (ILI) consultation rate decreased from 10.4 consultations per 1,000 in week 30 to 7.5 per 1,000 in week 31 and 5.1 per 1,000 in week 32 (Figure 5). The rates for week 31 to 32 have been slightly above the expected range for this time of year.

Figure 5. Influenza-like-illness (ILI) consultation rates by report week, compared to the 1996-97 through to 2012-13 seasons (with pandemic data suppressed), Canada, 2014-2015

Figure 5

No data available for mean rate for weeks 19 to 39 for the 1996-1997 through 2002-2003 seasons. Delays in the reporting of data may cause data to change retrospectively. The calculation of the average ILI consultation rate over 17 seasons was aligned with influenza activity in each season. In BC, AB, and SK, data is compiled by a provincial sentinel surveillance program for reporting to FluWatch. Not all sentinel physicians report every week.

   Figure 5 Influenza-like-illness (ILI) consultation rates by report week, compared to the 1996-97 through to 2012-13 seasons (with pandemic data suppressed), Canada, 2015-16 - Text Description

The national influenza-like-illness (ILI) consultation rate decreased from 10.4 consultations per 1,000 in week 30 to 7.5 per 1,000 in week 31 and 5.1 per 1,000 in week 32.

Influenza Outbreak Surveillance

In week 32, one new outbreak of influenza in a long term care facility (LTCF) was reported (Figure 6). To date this season, 1,281 outbreaks in LTCFs have been reported and the majority of those with known subtypes were attributable to A(H3N2). There have been a higher number of reported influenza outbreaks to date this season compared to the same period in previous seasons.

Figure 6: Overall number of new laboratory-confirmed influenza outbreaks by report week, Canada, 2014-2015

Figure 6

1 All provinces and territories except NU report outbreaks in long-term care facilities. All provinces and territories with the exception of NU and QC report outbreaks in hospitals. Outbreaks of influenza or influenza-like-illness in other facilities are reported to FluWatch but reporting varies between jurisdictions. Outbreak definitions are included at the end of the report.

   Figure 6 Overall number of new laboratory-confirmed influenza outbreaks by report week, Canada, 2015-2016 - Text Description
Report week Hospitals Long Term Care Facilities Other
35 0 0 0
36 0 0 0
37 0 0 0
38 0 1 0
39 0 5 1
40 0 0 0
41 0 2 0
42 0 3 0
43 0 2 0
44 0 1 0
45 0 2 0
46 0 3 0
47 0 16 1
48 3 17 1
49 2 32 3
50 2 57 13
51 9 94 22
52 8 114 21
53 9 122 35
1 12 152 31
2 8 118 19
3 6 54 12
4 13 64 16
5 7 51 13
6 4 60 10
7 2 45 9
8 0 24 7
9 6 22 10
10 0 32 19
11 5 49 11
12 0 31 4
13 1 19 9
14 1 20 9
15 0 19 2
16 0 15 2
17 0 8 0
18 0 11 3
19 0 8 2
20 0 2 2
21 2 3 1
22 0 1 0
23 0 0 1
24 0 0 0
25 0 0 0
26 0 0 0
27 0 0 0
28 0 0 0
29 0 0 0
30 0 1 0
31 0 0 0
32 0 1 0

Pharmacy surveillance

Pharmacy surveillance for sales of influenza antivirals has ended for the 2014-2015 influenza season (Figure 7).

Figure 7. Proportion of prescription sales for influenza antivirals by age-group and week, Canada, 2014-15

Figure 7

Note: Pharmacy sales data are provided to the Public Health Agency of Canada by Rx Canada Inc. and sourced from major retail drug chains representing over 2,500 stores nationwide (excluding Nunavut) in 85% of Health Regions. Data provided include the number of new antiviral prescriptions (for Tamiflu and Relenza) and the total number of new prescriptions dispensed by Province/Territory and age group. Age-groups: Infant: 0-2y, Child: 2-18y; Adult: 19-64y, Senior: ≥65y

   Figure 7 Proportion of prescription sales for influenza antivirals by age-group and week, Canada, 2015-16 - Text Description

Pharmacy surveillance has ended for the 2014-15 season.

Sentinel Hospital Influenza Surveillance

Paediatric Influenza Hospitalizations and Deaths (IMPACT)

In weeks 31 and 32, no laboratory-confirmed influenza-associated paediatric (≤16 years of age) hospitalizations were reported by the Immunization Monitoring Program Active (IMPACT) network. No ICU admissions were reported.

To date this season, 714 hospitalizations have been reported by the IMPACT network, 511 (72%) of which were cases of influenza A. Among cases for which the influenza A subtype was reported, 98% (164/167) were A(H3N2) (Table 4). To date, 104 cases were admitted to the ICU, of which 58 (56%) were 2 to 9 years of age (Figure 9a). A total of 68 ICU cases reported to have at least one underlying condition or comorbidity. Five deaths have been reported.

Note: The number of hospitalizations reported through IMPACT represents a subset of all influenza-associated paediatric hospitalizations in Canada. Delays in the reporting of data may cause data to change retrospectively.

Adult Influenza Hospitalizations and Deaths (CIRN)

Surveillance has ended for the 2014-2015 influenza season.

This season, 2,228 cases have been reported; 1,912 (86%) with influenza A. The majority of cases (81%) were among adults ≥65 years of age (Table 5). One hundred and seventy two ICU admissions have been reported and 128 cases were adults ≥65 years of age. Among the 172 ICU admissions, 27 were due to influenza B (12 in adults 45 to 64 years of age and 15 in adults over the age of 65). A total of 123 ICU cases (72%) reported to have at least one underlying condition or comorbidity. Of the 123 ICU cases with known immunization status, 40 (33%) reported not having been vaccinated this season. One hundred and thirty-five deaths have been reported, 124 (92%) of the deaths were adults >65 years of age (Figure 9B).

Note: The number of hospitalizations reported through CIRN represents a subset of all influenza-associated adult hospitalizations in Canada. Delays in the reporting of data may cause data to change retrospectively.

Table 4 - Cumulative numbers of paediatric hospitalizations with influenza reported by the IMPACT network, Canada, 2014-15
Age groups Cumulative (Aug. 24, 2014 to August 15, 2015)
Influenza A B Influenza A and B
A Total A(H1) pdm09 A(H3) AFootnote (Uns) Total # (%)
0-5m 84 0 19 65 16 100 (14.0%)
6-23m 115 2 37 76 44 159 (22.3%)
2-4y 122 1 39 82 52 174 (24.4%)
5-9y 129 0 44 85 55 184 (25.8%)
10-16y 61 0 25 36 36 97 (13.6%)
Total 511 3 164 344 203 714
% Footnote 1 71.6% 0.6% 32.1% 67.3% 28.4% 100.0%
Table 5 - Cumulative numbers of adult hospitalizations with influenza reported by the CIRN network, Canada, 2014-15
Age groups Cumulative (November 15, 2014 to May 2, 2015)
Influenza A B Influenza A and B
A Total A(H1) pdm09 A(H3) AFootnote (Uns) Total # (%)
16-20 3 0 1 2 1 4 (%)
20-44 106 1 56 49 16 122 (5%)
45-64 217 3 99 115 76 293 (13%)
65+ 1586 4 760 822 223 1809 (81%)
Total 1912 8 916 988 316 2228
% Footnote 1 86% 0% 48% 52% 14% 100%

Figure 8 - Number of cases of influenza reported by sentinel hospital networks, by week, Canada, 2014-15

8A) Paediatric hospitalizations (≤16 years of age, IMPACT)

Figure 8A
   Figure 8A Number of cases of influenza reported by sentinel hospital networks, by week, Canada, 2015-16 - Text Description
Report week Influenza A Influenza B
35 0 0
36 0 0
37 2 0
38 1 0
39 1 0
40 1 0
41 2 0
42 1 0
43 3 1
44 4 0
45 4 0
46 9 3
47 8 1
48 15 4
49 30 2
50 41 2
51 56 1
52 64 2
53 47 2
1 54 5
2 43 2
3 34 1
4 25 1
5 12 3
6 9 9
7 15 10
8 5 6
9 6 12
10 4 12
11 6 12
12 0 22
13 1 11
14 2 12
15 2 14
16 2 7
17 0 10
18 0 7
19 0 4
20 0 8
21 0 5
22 1 4
23 0 4
24 1 2
25 0 0
26 0 2
27 0 0
28 0 0
29 0 0
30 0 0
31 0 0
32 0 0

Figure 8B - Number of cases of influenza reported by sentinel hospital networks, by week, Canada, 2014-15

8B) Adult hospitalizations (≥16 year of age, PCIRN-SOS)

Figure 8B Note: Data for week 46 is based on data collected for 1 day only and do not represent the number of hospitalizations for the entire week.
   Figure 8B Number of cases of influenza reported by sentinel hospital networks, by week, Canada, 2015-16 - Text Description
Report week Influenza A Influenza B Untyped
35 n/a n/a n/a
36 n/a n/a n/a
37 n/a n/a n/a
38 n/a n/a n/a
39 n/a n/a n/a
40 n/a n/a n/a
41 n/a n/a n/a
42 n/a n/a n/a
43 n/a n/a n/a
44 n/a n/a n/a
45 n/a n/a n/a
46 3 0 0
47 10 0 0
48 34 0 0
49 43 0 0
50 99 4 0
51 139 0 1
52 239 3 0
53 236 3 0
1 228 2 0
2 159 0 0
3 145 4 1
4 99 9 0
5 118 5 0
6 79 13 0
7 67 18 1
8 68 20 2
9 51 27 0
10 30 38 1
11 14 31 1
12 20 31 0
13 11 27 0
14 10 33 0
15 8 23 0
16 2 20 0
17 0 5 0
18      
19      
20      
21      
22      
23      
24      
25      
26      
27      
28      
29      
30      
31      
32      

Figure 9 - Percentage of hospitalizations, ICU admissions and deaths with influenza reported by age-group, Canada, 2014-15

9A) Paediatric hospitalizations (≤16 years of age, IMPACT)

Figure 9a
   Figure 9A Percentage of hospitalizations, ICU admissions and deaths with influenza reported by age-group, Canada, 2014-15 A) Paediatric hospitalizations (≤16 years of age, IMPACT) - Text Description
Age-group (years) Hospitalizations(n=714) ICU admissions(n=104)
0-5m 14.0% 3.8%
6-23m 22.3% 21.2%
2-4y 24.4% 31.7%
5-9y 25.8% 24.0%
10-16y 13.6% 19.2%

9B) Adult hospitalizations (≥16 year of age, PCIRN-SOS)

Figure 9b
   Figure 9B Percentage of hospitalizations, ICU admissions and deaths with influenza reported by age-group, Canada, 2014-15 B) Adult hospitalizations (≥16 year of age, CIRN) - Text Description
Figure 9 B) Adult hospitalizations (≥16 year of age, PCIRN-SOS)
Age-group (years) Hospitalizations (n=2228) ICU admissions(n=172) Deaths (n=135)
16-20 0.2% 0.0% 0.0%
20-44 5.5% 5.2% 2.2%
45-64 13.2% 20.3% 5.9%
65+ 81.2% 74.4% 91.9%

Provincial/Territorial Influenza Hospitalizations and Deaths

In week 32, 34 laboratory-confirmed influenza-associated hospitalizations were reported from participating provinces and territoriesFootnote *. These hospitalizations likely represent case updates due to delayed reporting. Of the 34 hospitalizations, 10 (29%) were due to influenza A and 20 (59%) were in patients ≥65 years of age.

Since the start of the 2014-15 season, 8,008 hospitalizations have been reported; 6,843 (86%) with influenza A. Among cases for which the subtype of influenza A was reported, 99.1% were A(H3N2). The majority of cases (70%) were ≥65 years of age (Table 6). A total of 396 ICU admissions have been reported to date: 52% (n=205) were in adults ≥65 years of age and 75% were due to influenza A. A total of 604 deaths have been reported since the start of the season: three children <5 years of age, five children 5-19 years, 47 adults 20-64 years, and 549 adults ≥65 years of age. Influenza A has been reported in 91% of deaths. Adults 65 years of age or older represent 91% of all deaths reported this season. Detailed clinical information (e.g. underlying medical conditions) is not known for these cases.

Table 6. Cumulative number of hospitalizations with influenza reported by the participating provinces and territories, Canada, 2014-15
Age groups Cumulative (24 August 2014 to 15 August 2015)
Influenza A B Influenza A and B
A Total A(H1) pdm09 A(H3) AFootnote (Uns) Total # (%)
0-4 years 443 7 154 282 100 543 (7%)
5-19 years 266 0 123 143 106 372 (5%)
20-44 years 335 4 178 153 93 428 (5%)
45-64 years 748 13 368 367 226 974 (12%)
65+ years 4997 5 2389 2603 616 5613 (70%)
Unknown 54 0 51 3 24 78 (1%)
Total 6843 29 3263 3551 1165 8008
Percentage Footnote 1 85.5% 0.4% 47.7% 51.9% 14.5% 100.0%

See additional data on Reported Influenza Hospitalizations and Deaths in Canada: 2009-10 to 2014-15 on the Public Health Agency of Canada website.

Emerging Respiratory Pathogens

Human Avian Influenza
Influenza A(H7N9): There have been no reported cases of human infection with avian influenza A(H7N9) since July 20, 2015. Globally to August 20, 2015, the WHO reported a total of 678 laboratory-confirmed human cases with avian influenza A(H7N9) virus, including 275 deaths. Documents related to the public health risk of influenza A(H7N9), as well as guidance for health professionals and advice for the public is updated regularly on the following websites:

PHAC - Avian influenza A(H7N9)
WHO - Avian Influenza A(H7N9)

Middle East Respiratory Syndrome Coronavirus (MERS-CoV)
Since the last FluWatch report, a number of confirmed cases of MERS-CoV have been reported in Saudi Arabia. Most of these cases have been associated with a hospital outbreak in the Riyadh Region.

There have been no new cases reported in South Korea since July 4, 2015.

Globally, from September 2012 to August 20, 2015, the WHO has reported a total of 1,432 laboratory-confirmed cases of infection with MERS-CoV, including 507 deaths.

Documents related to the public health risk of MERS-CoV, as well as guidance for health professionals and advice for the public is updated regularly on the following websites:

International Influenza Reports


FluWatch definitions for the 2014-2015 season

Abbreviations: Newfoundland/Labrador (NL), Prince Edward Island (PE), New Brunswick (NB), Nova Scotia (NS), Quebec (QC), Ontario (ON), Manitoba (MB), Saskatchewan (SK), Alberta (AB), British Columbia (BC), Yukon (YT), Northwest Territories (NT), Nunavut (NU).

Influenza-like-illness (ILI): Acute onset of respiratory illness with fever and cough and with one or more of the following - sore throat, arthralgia, myalgia, or prostration which is likely due to influenza. In children under 5, gastrointestinal symptoms may also be present. In patients under 5 or 65 and older, fever may not be prominent.

ILI/Influenza outbreaks

Schools:
Greater than 10% absenteeism (or absenteeism that is higher (e.g. >5-10%) than expected level as determined by school or public health authority) which is likely due to ILI.
Note: it is recommended that ILI school outbreaks be laboratory confirmed at the beginning of influenza season as it may be the first indication of community transmission in an area.
Hospitals and residential institutions:
two or more cases of ILI within a seven-day period, including at least one laboratory confirmed case. Institutional outbreaks should be reported within 24 hours of identification. Residential institutions include but not limited to long-term care facilities ( LTCF) and prisons.
Workplace:
Greater than 10% absenteeism on any day which is most likely due to ILI.
Other settings:
two or more cases of ILI within a seven-day period, including at least one laboratory confirmed case; i.e. closed communities.

Note that reporting of outbreaks of influenza/ILI from different types of facilities differs between jurisdictions.

Influenza/ILI activity level

1 = No activity: no laboratory-confirmed influenza detections in the reporting week, however, sporadically occurring ILI may be reported

2 = Sporadic: sporadically occurring ILI and lab confirmed influenza detection(s) with no outbreaks detected within the influenza surveillance region Footnote

3 = Localized:

  1. evidence of increased ILIFootnote * and
  2. lab confirmed influenza detection(s) together with
  3. outbreaks in schools, hospitals, residential institutions and/or other types of facilities occurring in less than 50% of the influenza surveillance regionFootnote

4 = Widespread:

  1. evidence of increased ILIFootnote * and
  2. lab confirmed influenza detection(s) together with
  3. outbreaks in schools, hospitals, residential institutions and/or other types of facilities occurring in greater than or equal to 50% of the influenza surveillance regionFootnote

Note: ILI data may be reported through sentinel physicians, emergency room visits or health line telephone calls.

We would like to thank all the Fluwatch surveillance partners who are participating in this year's influenza surveillance program.

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