FluWatch report: March 1 to 7, 2015 (Week 9)

Influenza/ILI Activity (geographic spread)

In week 09, no widespread activity was reported. Seventeen regions reported localized activity: AB, ON(7), QC, NB(3), NS(4), and NL. Twenty-seven regions reported sporadic activity: in YK, BC(5), AB(4), SK(2), MB(3), QC(5), NB(3), NS(2), PE and NL. No activity was reported in fourteen regions: NU(3), NT(2), SK, MB(2), NB, NS(3) and NF(2). When compared to the previous week, there was an overall decrease in influenza activity as there were less regions reporting activity and no regions reporting widespread activity.

Influenza and Other Respiratory Virus Detections

In week 09, the number of positive influenza tests (1,081) and the percentage positive for influenza A (8.6%) continued to decline from the previous week (Figure 2). The percentage of positive influenza B tests continued to increase and was 7.7% in week 09. Influenza B detections were greater than influenza A detections in many provinces (BC, AB, SK, MB, QC and PE). To date, 92% of influenza detections have been influenza A, and 99.4% of those subtyped have been A(H3N2) (Table 1). To date this season, detailed information on age and type/subtype has been received for 31,623 cases (Table 2). Adults ≥65 years of age have predominantly been affected by influenza A, accounting for 62% of influenza A detections. Influenza B, while much smaller in numbers, is mainly affecting individuals less than 64 years of age, accounting to 63% of influenza B detections.

In week 09, detections of all respiratory viruses decreased from the previous week (figure 3). Detections of respiratory syncytial virus (RSV) in week 09 were greater than the detections of influenza A with 757 detections (vs 572 detections of influenza A). In recent weeks, weekly detections of adenovirus, coronavirus, rhinovirus and parainfluenza have been greater than those reported in each of the past three seasons. Weekly detections of hMPV this season have been lower compared to the previous three seasons.

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

Antiviral Resistance

During the 2014-2015 influenza season, the NML has tested 857 influenza viruses for resistance to oseltamivir and 853 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 1,062 influenza A viruses (99.9%) were resistant to amantadine (Table 3).

Influenza Strain Characterizations

During the 2014-2015 influenza season, the National Microbiology Laboratory (NML) has characterized 305 influenza viruses [149 A(H3N2), 3 A(H1N1) and 153 influenza B].

Influenza A (H3N2): When tested by hemagglutination inhibition (HI) assay (n=149), one virus was antigenically similar to A/Texas/50/2012, five showed reduced titers to A/Texas/50/2012 and 143 were antigenically similar to A/Switzerland/9715293/2013, which is the influenza A(H3N2) component recommended for the 2015 Southern Hemisphere influenza vaccine. Additionally, 893 A(H3N2) viruses were unable to be tested by HI assay; however, sequence analysis showed that 891 belonged to a genetic group that typically shows reduced titers to A/Texas/50/2012.
Influenza A(H1N1): Three A(H1N1) viruses characterized were antigenically similar to A/California/7/2009.
Influenza B: Of the 153 influenza B viruses characterized, 146 viruses were antigenically similar to B/Massachusetts/2/2012, three viruses showed reduced titers against B/Massachusetts/2/2012, and four were B/Brisbane/60/2008-like (Figure 4).

Influenza-like Illness (ILI) Consultation Rate

The national influenza-like-illness (ILI) consultation rate decreased to 50.5 consultations per 1,000, which is above expected levels for week 09 (Figure 5). The rate was highest among the 5 to 19 years of age group (61.3 consultations per 1,000) and lowest among the adults ≥65 years of age (41.4 consultations per 1,000).

Influenza Outbreak Surveillance

In week 09, 33 new outbreaks of influenza were reported. The majority of the outbreaks occurred in the Central and Atlantic provinces. Twenty-two outbreaks were reported in long-term care facilities (LTCF), six in hospitals and five in institutional or community settings  (Figure 6). An additional five outbreaks of ILI were reported in schools. Among the outbreaks in which the influenza subtype was known, three LTCF outbreaks were associated with A(H3N2) and one outbreak was associated with influenza B. To date this season, 1,061 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.

Pharmacy surveillance

During week 09, the proportion of prescriptions for antivirals decreased to 147.3 antiviral prescriptions per 100,000 total prescriptions (from 150.1 per 100,000). The rate for antivirals since week 48 has been higher than the previous three seasons (Figure 7). The rate in all age groups except infants decreased in week 09. The rate was highest among seniors at 210.1 per 100,000 total prescriptions and lowest among infants at 64.9 per 100,000 total prescriptions.

Sentinel Hospital Influenza Surveillance

Paediatric Influenza Hospitalizations and Deaths (IMPACT)

In week 09, seventeen laboratory-confirmed influenza-associated paediatric (≤16 years of age) hospitalizations were reported by the Immunization Monitoring Program Active (IMPACT) network: six cases of influenza A and eleven cases of influenza B (Figure 8a). A greater proportion of cases have been reported with influenza B in recent weeks, following the trend in laboratory detections. Among the reported cases, five (29%) were <2 years of age, nine (53%) were 2 to 9 years of age and three (17%) were 10-16 years of age. No ICU admissions were reported.

To date this season, 565 hospitalizations have been reported by the IMPACT network, 496 (88%) of which were cases of influenza A. Among cases for which the influenza A subtype was reported, 99% (159/161) were A(H3N2) (Table 4). To date, 69 cases were admitted to the ICU, of which 36 (52%) were 2 to 9 years of age (Figure 9a). A total of 38 ICU cases reported to have at least one underlying condition or comorbidity. Three 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)

In week 09, 63 laboratory-confirmed influenza-associated adult (≥16 years of age) hospitalizations were reported by the PHAC/CIHR Influenza Research Network (PCIRN) Serious Outcomes Surveillance (SOS) network. Among the cases in week 09, 46 cases (73%) were in adults over the age of 65 and 43 cases (68%) had influenza A (Figure 8b).  

To date this season, 1,898 cases have been reported; 1,801 (95%) with influenza A. The majority of cases (82%) were among adult ≥65 years of age (Table 5). One hundred and forty ICU admissions have been reported and 107 cases were adults ≥65 years of age. A total of 99 ICU cases (71%) reported to have at least one underlying condition or comorbidity. Of the 99 ICU cases with known immunization status, 35 (35%) reported not having been vaccinated this season. One hundred and six deaths have been reported, 97 (92%) of the deaths were adults >65 years of age (Figure 9b).

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

Provincial/Territorial Influenza Hospitalizations and Deaths

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): Since the last FluWatch report, 59 new laboratory-confirmed cases of human infection with avian influenza A(H7N9) virus were reported by the World Health Organization. Globally to March 13, 2015, the WHO reported a total of 631 laboratory-confirmed human cases with avian influenza A(H7N9) virus, including 221 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)

Influenza A(H5N6): Since the last FluWatch report, no new cases of human infection with avian influenza A (H5N6) virus from China has been reported by the World Health Organization. Globally to March 13, 2015, the WHO has been informed of a total of three cases of avian influenza A (H5N6) virus, including two deaths.

Middle East Respiratory Syndrome Coronavirus (MERS-CoV)
Since the last FluWatch report, 20 new laboratory-confirmed cases of MERS-CoV have been reported by the World Health Organization. Globally, from September 2012 to March 13, 2015, the WHO has been informed of a total of 1,060 laboratory-confirmed cases of infection with MERS-CoV, including 394 deaths. All cases have either occurred in the Middle East or have had direct links to a primary case infected in the Middle East. The public health risk posed by MERS-CoV in Canada remains low (see the PHAC Assessment of Public Health Risk) and for the latest global risk assessment posted by the WHO on February 5, 2015: WHO MERS-CoV.

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:

• PHAC - Middle East respiratory syndrome coronavirus (MERS-CoV)
• WHO - Coronavirus infections

Avian Influenza A(H5)
As of March 9, 2015, the CFIA has removed the avian influenza Primary Control Zone PCZ in British Columbia. Permits are no longer required for the movement of birds and bird products in British Columbia. Surveillance by the CFIA has not detected the H5N2 and H5N1 strains of the virus in domestic poultry since February 2, 2015.

• CFIA - Notifiable Avian Influenza

For the latest Travel Health Notice on Avian Influenza (H5N1) visit the following webpage: PHAC - Travel Health Notice.

International Influenza Reports

• World Health Organization influenza update
• World Health Organization FluNet
• WHO Influenza at the human-animal interface
• Centers for Disease Control and Prevention seasonal influenza report
• European Centre for Disease Prevention and Control - epidemiological data
• South Africa Influenza surveillance report
• New Zealand Public Health Surveillance
• Australia Influenza Report
• Pan-American Health Organization Influenza Situation Report

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 ILI^{Footnote *} 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 region^{Footnote †}

4 = Widespread:

1. evidence of increased ILI^{Footnote *} 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 region^{Footnote †}

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.