FluWatch report: April 21 to April 27, 2019 (Week 17)

Figure 1 - Text equivalent

Province	Influenza Surveillance Region	Activity Level
N.L.	Eastern	Localized
N.L.	Labrador-Grenfell	Sporadic
N.L.	Central	Sporadic
N.L.	Western	Localized
P.E.I.	Prince Edward Island	Sporadic
N.S.	Zone 1 - Western	Sporadic
N.S.	Zone 2 - Northern	Sporadic
N.S.	Zone 3 - Eastern	Localized
N.S.	Zone 4 - Central	Sporadic
N.B.	Region 1	Sporadic
N.B.	Region 2	Localized
N.B.	Region 3	Sporadic
N.B.	Region 4	Sporadic
N.B.	Region 5	No Activity
N.B.	Region 6	Sporadic
N.B.	Region 7	Sporadic
Que.	Nord-est	Sporadic
Que.	Québec et Chaudieres-Appalaches	Sporadic
Que.	Centre-du-Québec	Localized
Que.	Montréal et Laval	Localized
Que.	Ouest-du-Québec	Sporadic
Que.	Montérégie	Localized
Ont.	Central East	Localized
Ont.	Central West	Localized
Ont.	Eastern	Localized
Ont.	North East	Localized
Ont.	North West	No Activity
Ont.	South West	Localized
Ont.	Toronto	Localized
Man.	Northern Regional	No Activity
Man.	Prairie Mountain	Sporadic
Man.	Interlake-Eastern	Sporadic
Man.	Winnipeg	Sporadic
Man.	Southern Health	Sporadic
Sask.	North	Sporadic
Sask.	Central	Sporadic
Sask.	South	Sporadic
Alta.	North Zone	No Data
Alta.	Edmonton	No Data
Alta.	Central Zone	No Data
Alta.	Calgary	No Data
Alta.	South Zone	No Data
B.C.	Interior	Sporadic
B.C.	Fraser	Sporadic
B.C.	Vancouver Coastal	Sporadic
B.C.	Vancouver Island	Sporadic
B.C.	Northern	No Activity
Y.T.	Yukon	Sporadic
N.W.T.	North	Sporadic
N.W.T.	South	No Activity
Nvt.	Qikiqtaaluk	No data
Nvt.	Kivalliq	No data
Nvt.	Kitimeot	No data

Laboratory-Confirmed Influenza Detections

In week 17, the following results were reported from sentinel laboratories across Canada (Figures 2 and 3):

• The percentage of tests positive for influenza decreased from 16% to 15% in week 17.
• A total of 932 laboratory detections of influenza were reported, of which 80% were influenza A.
• Influenza A(H3N2) accounted for 81% of subtyped influenza A detections.

To date this season, 45,949 laboratory-confirmed influenza detections have been reported:

• 96% have been influenza A.
• Among the 15,549 influenza A viruses subtyped, 72% have been A(H1N1)pdm09.
• Influenza B often circulates later in the season in Canada (Feb-Apr). Fewer influenza B detections have been reported this season compared to recent seasons at this time of year. The percentage of tests positive for influenza B has not yet peaked, but it is not uncommon for low-level influenza B circulation to persist until early June in Canada.

To date this season, detailed information on age and type/subtype has been received for 36,824 laboratory-confirmed influenza cases (Table 1):

• 83% of all influenza A(H1N1)pdm09 detections have been reported in individuals younger than 65 years of age.
• 58% of all influenza A(H3N2) detections have been reported in adults 65 years of age and older.

For more detailed weekly and cumulative influenza data, see the text descriptions for Figures 2 and 3 or the Respiratory Virus Detections in Canada Report.

The shaded area indicates weeks where the positivity rate was at least 5% and a minimum of 15 positive tests were observed, signalling the period of seasonal influenza activity.

Data for week 14 excludes subtyping results from one jurisdiction due to batch reporting of subtype information. The results for week 14 should be interpreted with caution.

Figure 2 - Text equivalent

Surveillance Week	A(Unsubtyped)	A(H3N2)	A(H1N1)pdm09	Influenza B
35	3	2	7	0
36	4	7	4	0
37	3	2	3	1
38	6	3	2	3
39	11	5	1	3
40	16	7	29	3
41	27	6	21	3
42	40	19	55	2
43	83	23	128	4
44	169	13	214	6
45	244	18	295	15
46	346	10	404	9
47	449	17	507	8
48	679	29	632	10
49	851	35	785	16
50	1368	35	828	14
51	1890	54	953	21
52	2292	55	903	26
1	2387	58	893	31
2	1985	93	1061	43
3	1613	101	585	40
4	1483	93	532	48
5	1449	112	433	43
6	1234	118	315	42
7	1116	128	244	33
8	1066	236	216	40
9	1172	285	213	64
10	1085	335	268	71
11	990	357	197	90
12	959	380	155	131
13	939	387	128	167
14	1091	292	41	169
15	756	514	121	157
16	619	273	40	175
17	484	234	52	190

Figure 3 - Text equivalent

Reporting provincesTable Figure 3 - Footnote 1	Week (April 21 to April 27, 2019)					Cumulative (August 26, 2018 to April 27, 2019)
	Influenza A				B	Influenza A				B	A & B Total
	A Total	A (H1N1)pdm09	A (H3N2)	A(UnS)Table Figure 3 - Footnote 3	B Total	A Total	A (H1N1)pdm09	A (H3N2)	A(UnS)Table Figure 3 - Footnote 3	B Total
BC	97	14	46	37	7	6216	3138	1472	1606	215	6431
AB	127	15	85	27	16	6736	3613	997	2126	250	6986
SK	18	1	4	13	3	2361	1384	124	853	91	2452
MB	18	5	9	4	12	1125	317	80	728	37	1162
ON	134	8	79	47	24	6088	2062	1551	2475	214	6302
QC	237	0	0	237	81	16624	0	0	16624	586	17210
NB	59	0	0	59	36	2781	230	34	2517	245	3026
NS	15	0	0	15	2	774	0	0	774	17	791
PEI	4	0	4	0	1	277	220	56	1	1	278
NL	30	0	0	30	0	1001	1	0	1000	4	1005
YT	10	8	0	2	0	109	62	12	35	0	109
N.W.T	1	1	0	0	0	176	174	2	0	1	177
NU	0	0	0	0	0	20	20	0	0	0	20
Canada	750	52	227	471	182	44288	11221	4328	28739	1661	45949
PercentageTable Figure 3 - Footnote 2	80%	7%	30%	63%	20%	96%	25%	10%	65%	4%	100%
Table Figure 3 - Footnote 1 Specimens from NWT, YT, and Nvt are sent to reference laboratories in other provinces. Return to Table Figure 3 - Footnote 1 referrer Table Figure 3 - Footnote 2 Percentage of tests positive for sub-types of influenza A are a percentage of all influenza A detections. Return to Table Figure 3 - Footnote 2 referrer Table Figure 3 - Footnote 3 Unsubtyped: The specimen was typed as influenza A, but no result for subtyping was available. Return to first Table Figure 3 - Footnote 3 referrer Discrepancies in values in Figures 2 and 3 may be attributable to differing data sources. Cumulative data includes updates to previous weeks.

Table 1 – Cumulative numbers of positive influenza specimens by type, subtype and age-group reported through case-based laboratory reporting, Canada, weeks 2018-35 to 2019-17

Age groups (years)	Cumulative (August 26, 2018 to April 27, 2019)
	Influenza A				B	Influenza A and B
	A Total	A(H1N1) pdm09	A(H3N2)	A (UnS)Table 1 – Note 1	Total	#	%
0-4	6632	1684	228	4720	235	6867	19%
5-19	5040	1391	442	3207	377	5417	15%
20-44	6741	2003	561	4177	260	7001	19%
45-64	6854	1961	592	4301	98	6952	19%
65+	10358	1462	2471	6425	229	10587	29%
Total	35625	8501	4294	22830	1199	36824	100%
Table 1 – Note 1 UnS: unsubtyped: The specimen was typed as influenza A, but no result for subtyping was available. Return to Table 1 – Note 1

Syndromic / Influenza-like Illness Surveillance

Healthcare Professionals Sentinel Syndromic Surveillance

In week 17, 0.6% of visits to healthcare professionals were due to influenza-like illness (ILI) (Figure 4).

The shaded area represents the maximum and minimum percentage of visits for ILI reported by week from seasons 2013-2014 to 2017-2018

Figure 4 - Text equivalent

Surveillance Week	2018-19	Average	Min	Max
35	0.6%	0.8%	0.5%	1.2%
36	0.7%	0.8%	0.7%	1.0%
37	0.6%	0.9%	0.7%	1.0%
38	0.5%	1.1%	1.0%	1.4%
39	1.8%	1.1%	0.9%	1.4%
40	0.6%	1.3%	0.9%	1.6%
41	1.1%	1.4%	0.9%	2.4%
42	1.0%	1.4%	1.0%	1.9%
43	0.9%	1.3%	1.0%	1.5%
44	0.8%	1.3%	0.9%	1.6%
45	1.3%	1.3%	1.2%	1.5%
46	1.3%	1.6%	1.0%	2.0%
47	1.3%	1.5%	1.1%	1.9%
48	1.5%	1.6%	0.8%	2.1%
49	1.6%	1.5%	1.0%	2.5%
50	1.5%	2.3%	1.3%	3.7%
51	1.0%	2.5%	1.6%	4.1%
52	3.2%	4.5%	1.7%	7.1%
1	2.8%	3.7%	1.7%	5.2%
2	1.8%	3.0%	1.1%	4.5%
3	1.1%	2.5%	1.3%	3.6%
4	1.3%	2.4%	1.7%	3.5%
5	1.4%	2.7%	2.0%	4.4%
6	0.9%	2.7%	2.1%	3.3%
7	0.8%	2.4%	1.7%	3.0%
8	0.9%	2.3%	1.9%	2.7%
9	1.0%	2.2%	1.8%	2.7%
10	1.1%	2.1%	1.8%	2.7%
11	0.5%	2.1%	1.7%	2.7%
12	1.0%	1.8%	1.1%	2.7%
13	1.2%	1.7%	1.2%	2.6%
14	1.0%	1.8%	1.3%	2.4%
15	0.9%	1.6%	0.9%	1.9%
16	0.8%	1.5%	1.0%	1.9%
17	0.6%	1.5%	0.9%	2.2%

Participatory Syndromic Surveillance

In week 17, 1,986 participants reported to FluWatchers, of which 45 (2.3%) reported symptoms of cough and fever (Figure 5).

Among the 45 participants who reported fever and cough:

• 20% consulted a healthcare professional;
• 78% reported days missed from work or school, resulting in a combined total of 100 missed days of work or school.

Figure 5 - Text equivalent

Surveillance Week	% cough and fever
40	2.6%
41	2.5%
42	1.7%
43	1.5%
44	1.3%
45	1.7%
46	2.0%
47	1.3%
48	2.4%
49	2.0%
50	3.7%
51	3.9%
52	3.6%
1	3.4%
2	2.8%
3	2.5%
4	2.9%
5	3.0%
6	2.6%
7	2.7%
8	2.5%
9	2.7%
10	3.1%
11	2.6%
12	2.4%
13	2.4%
14	2.3%
15	1.8%
16	2.4%
17	2.3%

Influenza Outbreak Surveillance

In week 17, 18 new laboratory-confirmed influenza outbreaks were reported: long-term care facilities (LTCF) (10) acute care facilities (1) and other settings (7). No new ILI outbreaks were reported. Among the outbreaks with available information (14), 13 were associated with influenza A (of which 4 were associated with A(H3N2)), and one outbreak was associated with influenza B.

To date this season, 801 laboratory-confirmed influenza outbreaks have been reported (Figure 6): 

• 474 (59%) outbreaks were in LTCF, 30 were in schools and daycares, 116 in acute care facilities, and 181 were in other settings.
• Among the 717 outbreaks for which the influenza type was available, 98% (701) were associated with influenza A.
• Among the 304 outbreaks for which the influenza A subtype was available, 57% (173) were associated with influenza A(H3N2);

To date this season, 151 ILI outbreaks have been reported; 85 occurred in LTCF, 61 in schools, one in other settings and four in acute care facilities.

Figure 6 - Text equivalent

Surveillance Week	Acute Care Facilities	Long Term Care Facilities	Other	Schools and Daycares	Remote and/or Isolated Communities
35	0	0	0	0	0
36	0	0	0	0	0
37	0	0	0	0	0
38	0	0	0	0	0
39	0	0	0	0	0
40	0	2	0	1	0
41	0	0	0	0	0
42	0	2	1	0	0
43	0	3	1	0	0
44	0	1	1	2	0
45	0	2	1	3	0
46	2	5	1	3	0
47	2	4	0	1	0
48	2	6	1	5	0
49	1	2	3	1	0
50	3	9	5	4	0
51	3	12	4	2	0
52	4	25	5	0	0
1	5	40	11	0	0
2	8	38	7	0	0
3	3	27	10	0	0
4	6	19	10	1	0
5	5	24	7	0	0
6	9	21	7	0	0
7	6	20	7	0	0
8	5	30	11	4	0
9	9	23	13	2	0
10	12	26	8	1	0
11	4	24	14	0	0
12	9	22	14	0	0
13	8	23	11	0	0
14	3	21	5	0	0
15	6	18	7	0	0
16	0	15	9	0	0
17	1	10	7	0	0

Severe Outcomes Influenza Surveillance

Provincial/Territorial Influenza Hospitalizations and Deaths

To date this season, 3,010 influenza-associated hospitalizations have been reported by participating provinces and territories^{Footnote 1}.

Hospitalizations (Table 2):

• 98.0% (2,950) were associated with influenza A
• Among the 1,684 cases for which the influenza subtype was available, 1,408 (84%) were associated with A(H1N1)pdm09.
• The highest estimated rate of hospitalization is among adults over 65 years of age.

Intensive Care Unit (ICU) cases and deaths:

• To date this season 549 ICU admissions and 171 deaths have been reported.
  • 42% (225) of reported ICU admissions were in adults aged 45-64 years.
  • All but six ICU admissions were associated with influenza A.
  • All but one of the deaths were associated with influenza A.

Table 2 – Cumulative number and estimated rate of hospitalizations by age-group reported by participating provinces and territories^{Footnote 1}, Canada, weeks 2018-35 to 2019-17

Age Groups (years)	Cumulative (August 26, 2018 to April 27, 2019)
	Influenza A	Influenza B	Rate per 100,000 population
0-4	387	19	85.30
5-19	234	18	18.16
20-44	348	8	12.51
45-64	765	6	35.43
65+	1216	9	100.69
Total	2950	60	-
%	98.0%	2.0%	-
Table 2 – Note 1 Influenza-associated hospitalizations are reported by Alberta, Manitoba, New Brunswick, Newfoundland and Labrador, Northwest Territories, Nova Scotia, Prince Edward Island and Yukon. Only hospitalizations that require intensive medical care are reported by Saskatchewan. The cumulative rate of hospitalizations is calculated using the total population by age-group in participating provinces and territories. Return to Table 2 – Note 1

Pediatric Influenza Hospitalizations and Deaths

To date this season, 1,246 pediatric hospitalizations have been reported (Figure 7 & 8):

• 66% of cases were in children under 5 years of age.
• 94% (1,173) of cases have been associated with influenza A.
• Among the 370 cases for which the influenza subtype was available, 304 (82%) were associated with A(H1N1)pdm09.

To date this season, 239 ICU admissions, and 10 deaths have been reported.

• 58% (139) of ICU admissions were in children under 5 years of age.
• All but 11 of the ICU admissions have been associated with influenza A.
• 80% (8) of deaths occurred in children 2 to 4 years of age.
• All deaths have been associated with influenza A.

The shaded area represents the maximum and minimum number of cases reported by week from seasons 2010-11 to 2017-18

Figure 7 - Text equivalent

Surveillance week	2018-19	Average	Min	Max
35	0	0	0	0
36	0	0	0	1
37	0	0	0	2
38	0	0	0	2
39	0	1	0	3
40	0	0	0	2
41	1	1	0	2
42	5	1	0	4
43	12	1	0	3
44	15	3	1	6
45	37	3	2	4
46	41	5	1	13
47	37	4	0	9
48	40	9	2	23
49	46	15	3	28
50	51	23	4	47
51	84	32	4	72
52	89	47	7	92
1	91	40	5	75
2	62	35	4	62
3	65	38	4	67
4	66	35	7	47
5	49	40	11	59
6	47	38	15	79
7	46	40	17	120
8	45	47	25	139
9	35	50	13	153
10	45	48	17	135
11	42	41	18	118
12	42	33	13	89
13	29	32	14	67
14	34	24	12	56
15	28	23	13	56
16	33	20	10	41
17	29	16	8	37

Figure 8 - Text equivalent

Age Group	Total
0-5 mo	136
6-23 mo	314
2-4 yr	375
5-9 yr	275
10-16 yr	146

Adult Influenza Hospitalizations and Deaths

Surveillance of laboratory-confirmed influenza-associated adult (≥16 years of age) hospitalizations by the Canadian Immunization Research Network (CIRN) Serious Outcomes Surveillance (SOS) network began on November 1^st for the 2018-19 season.

To date this season, 926 hospitalizations, 107 ICU admissions and 50 deaths have been reported (Figure 9):

• 862 (93%) hospitalizations were associated with influenza A.
• A greater proportion of hospitalizations have been reported among  adults ≥65 years of age (60%) compared to adults <65 years of age (40%).
• Among the 198 cases for which the influenza subtype was available, 106 ( 54%) were associated with A(H1N1)pdm09.
• 88% of hospitalized cases reported more than one type of comorbid condition.  
• The most commonly reported comorbidity was endocrine disorders, which were reported in 85% of hospitalized cases.

Figure 9 - Text equivalent

Age Group	Total
20-34 yr	89
35-49 yr	83
50-64 yr	197
65-79 yr	270
80+ yr	287

Influenza Strain Characterizations

Since September 1, 2018, the National Microbiology Laboratory (NML) has characterized 2,057 influenza viruses ( 384 A(H3N2), 1,565 A(H1N1) and 108 B) that were received from Canadian laboratories. 

Genetic Characterization of Influenza A(H3N2):

170 influenza A(H3N2) viruses did not grow to sufficient hemagglutination titer for antigenic characterization by hemagglutination inhibition (HI) assay. Therefore, NML has performed genetic characterization to determine the genetic group identity of these viruses.

Sequence analysis of the HA gene of the viruses showed that:

• 20 viruses belonged to genetic group 3C.2a.
• 145 viruses belonged to subclade 3C.2a1.
• Four viruses belonged to 3C.3a.
• One isolate could not be sequenced.

A/Singapore/INFIMH-16-0019/2016-like virus belongs to genetic group 3C.2a1 and is the influenza A(H3N2) component of the 2018-19 Northern Hemisphere influenza vaccine.

Antigenic Characterization:

Influenza A (H3N2):

• 130 influenza A(H3N2) viruses were antigenically characterized as A/Singapore/INFIMH-16-0019/2016-like by HI testing using antiserum raised against egg-propagated A/Singapore/INFIMH-16-0019/2016.
• 84 viruses showed reduced titer with ferret antisera raised against egg-propagated A/Singapore/INFIMH-16-0019/2016.
• A/Singapore/INFIMH-16-0019/2016-like virus is the influenza A(H3N2) component of the 2018-19 Northern Hemisphere influenza vaccine.
• 81 influenza A(H3N2) viruses characterized belonged to genetic group 3C.2a1. 18 viruses belonged to genetic group 3C.2a and 96 to 3C.3a. Sequencing is pending for the remaining isolates.

Influenza A(H1N1):

• 1,522 A(H1N1) viruses characterized were antigenically similar to A/Michigan/45/2015, which is the influenza A(H1N1) component of the 2018-19 Northern Hemisphere influenza vaccine.
• 43 viruses showed reduced titer with ferret antisera raised against cell culture-propagated A/Michigan/45/2015

Influenza B:

Influenza B viruses can be divided into two antigenically distinct lineages represented by B/Yamagata/16/88 and B/Victoria/2/87 viruses. The recommended influenza B components for the 2018-19 Northern Hemisphere influenza vaccine are B/Colorado/06/2017 (Victoria lineage) and B/Phuket/3073/2013 (Yamagata lineage).

• 19 influenza B viruses were characterized as B/Colorado/06/2017, which belong to the Victoria lineage and are included as an influenza B component of the 2018-19 Northern Hemisphere influenza vaccine.
• 66 viruses showed reduced titer with ferret antisera raised against cell culture-propagated B/Colorado/06/2017. Sequence analysis showed that 64 viruses that showed reduced titer had a three amino acid deletion (162-164) in the HA gene.
• 23 influenza B viruses were characterized as B/Phuket/3073/2013-like, which belongs to the Yamagata lineage and is included as an influenza B component of the 2018-19 Northern Hemisphere quadrivalent influenza vaccine.

Antiviral Resistance

Antiviral Resistance – Amantadine:

439 influenza A (85 A(H3N2) and 354 A(H1N1)) viruses were tested for resistance to amantadine and it was found that:

• All 439 influenza A viruses were resistant to amantadine.

Antiviral Resistance – Oseltamivir:

1,213 influenza viruses ( 140 A(H3N2), 1,005 A(H1N1) and 68 B) were tested for resistance to oseltamivir and it was found that:

• All 140 A(H3N2) viruses were sensitive to oseltamivir.
• Of the 1,005 A(H1N1) viruses tested, 1,001 were sensitive to oseltamivir and four viruses were resistant to oseltamivir with a H275Y mutation.
• All 68 B viruses were sensitive to oseltamivir.

Antiviral Resistance – Zanamivir:

1,212 influenza viruses ( 140 A(H3N2), 1,004 H1N1 and 68 B) were tested for resistance to zanamivir and it was found that:

• All 1,212 influenza viruses were sensitive to zanamivir.

Vaccine Monitoring

Vaccine monitoring refers to activities related to the monitoring of influenza vaccine coverage and effectiveness.

Vaccine Coverage

The Seasonal Influenza Immunization Coverage Survey is an annual telephone survey conducted between January and February that collects information related to the influenza vaccine in Canada. This survey measures vaccine coverage, which is the percentage of people who received the annual seasonal influenza vaccine in a specific influenza season.

In the 2018-19 influenza season, coverage was:

• 34% among adults aged 18 to 64 years.
  • 31% among adults aged 18-64 wihout chronic diseases.
  • 43% among adults aged 18 to 64 years with chronic diseases.
• 70% among seniors (aged 65 years and older).

Table 3 – Influenza vaccine coverage among adults (≥ 18 years of age) by age group, gender and chronic disease^{Table 3 – Note 1}, Seasonal Influenza Vaccination Coverage Survey, Canada, October 2018-February 2019

Age group (years)	Male		Female		Combined
	Total	Vaccine Coverage (%)	Total	Vaccine Coverage (%)	Total	Vaccine Coverage (%)
All adults (≥18)	1568	36.6	2150	46.8	3726	41.8
18-64	1252	28.6	1640	39.9	2898	34.3
without chronic diseases	948	25.8	1171	36.1	2124	30.8
with chronic diseases	304	36.3	465	48.5	770	42.8
≥65	316	69.0	510	70.9	828	69.9
Table 3 – Note 1 Excluded from stratified analysis: eight people who did not disclose their gender and four people (18-64 years old) who did disclose whether they had any chronic diseases. Return to Table 3 – Note 1

Vaccine Effectiveness

Vaccine effectiveness (VE) is a measure of how well the influenza vaccine is able to prevent influenza illness. Throughout the influenza season, surveillance networks estimate how well the influenza vaccine is working. Estimates can vary depending on several factors such as the study methods; the population, setting and outcomes that are being studied; the type and mix of vaccine products; the stage of the season and the kinds of influenza viruses that are circulating when the study is conducted.

The community-based Canadian Sentinel Practitioner Surveillance Network (SPSN) published an interim VE estimate in January 2019 for A(H1N1)pdm09. Subsequently, given an atypical late-season wave of influenza A(H3N2),SPSN has undertaken an additional interim analysis to assess effectiveness of the 2018/19 influenza vaccine against medically-attended outpatient A(H3N2) illness. Vaccine effectiveness (VE) monitoring methods and results are available at the SPSN website.

Based on data collected as of March 30^th, 2019 from more than 2800 patients from B.C., Alta., Ont., and Que., the 2018/19 northern hemisphere vaccine effectiveness has varied depending on the strain.

• A(H1N1)pdm09: In the first interim analysis, VE against A(H1N1)pdm09 was 72% (95% CI: 60 to 81) overall, with substantial protection observed in all age groups. In the most recent analysis as of March 30th, estimates against A(H1N1)pmd09 have remained stable at approximately 70%.
• A(H3N2): In the most recent analysis, VE against A(H3N2) was 23% (95% CI: -9 to 46) overall. As the confidence interval crosses zero, this estimate does not provide evidence of vaccine protection against medically-attended outpatient A(H3N2) illness.

The SPSN continues to monitor and will further update VE estimates at end of season.