PHE Weekly National Influenza Report

Summary of UK surveillance of influenza and other seasonal respiratory illnesses

4 April 2013 Week 14 report (up to week 13 data)

This report is published weekly on the HPA website. For further information on the surveillance schemes mentioned in this report, please see the HPA website and the related links at the end of this document. Figures (including all those found in this report) displaying data from these schemes are available to download in pdf format from the HPA website. Report contents: | Summary| GP consultation rates | Community surveillance | Microbiological surveillance | Severity indicators | Vaccination | International | Acknowledgements | Related links

Summary

Indicators of influenza activity across England are decreasing. GPs may still prescribe antiviral medicines for the prophylaxis and treatment of influenza in accordance with NICE guidance. Overall weekly influenza GP consultation rates across the UK o In week 13 (ending 31 March 2013), overall weekly influenza GP consultations decreased in England (7.7 per 100,000), Scotland (14.2 per 100,000) and Wales (9.5 per 100,000) and increased slightly in Northern Ireland (37.4 per 100,000). o In week 13 2013, the weekly proportion of NHS Direct calls for cold/flu and fever (5-14yrs) remained below their respective influenza thresholds of 1.6% and 11.7%. o 10 new acute respiratory disease outbreaks have been reported in the past seven days. Eight had a virological result available (four influenza A (unsubtyped), two A(H3) and two B). Virology o 134 influenza positive detections (54 A(H3), 40 A subtype not known, 25 B and 15 A(H1N1)pdm09) were recorded through the DataMart scheme (overall positivity of 14.9% compared to 19.1% the previous week). o The proportion of samples positive in DataMart (England) increased slightly for hMPV and remained stable for adenovirus, parainfluenza, RSV and rhinovirus. o 2 influenza positive detections were recorded through the two English GP-based sentinel schemes in week 13 (2 A(H1N1)pdm09), giving a positivity of 15.4% compared to 28.0% in week 12. Disease severity and mortality o 26 new admissions to ICU/HDU with confirmed influenza (15 A(subtype not known), six A(H3N2), four A(H1N1)pdm09 and one B were reported through the USISS mandatory ICU surveillance scheme across the UK (120 Trusts in England) in week 13. 38 new hospitalised confirmed influenza cases have been reported through the USISS sentinel hospital network across England (23 Trusts). o In week 13 2013, excess all-cause mortality was seen in England in 65+ year olds through the EuroMOMO algorithm. This data is provisional due to the time delay in death registration. International situation o During week 12 2013, influenza activity in Europe continued to decline or had already returned to baseline levels; after more than three months of active transmission, the 2012/13 influenza season is waning. o Influenza activity in North America continues to decrease overall. o Low levels of influenza activity were reported across the tropical regions of the world and activity in countries of the southern hemisphere remains at inter-seasonal levels. o Nine cases of human infection with influenza A(H7N9) in China have been reported by ECDC. Three of the cases have died and the remaining six are in a critical condition. To date no epidemiological link between the cases has been identified.

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Weekly consultation rates in national sentinel schemes

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In week 13 (ending 31 March 2013), overall weekly influenza GP consultations decreased in England, Scotland and Wales and increased slightly in Northern Ireland. Influenza/Influenza-Like-Illness (ILI) RCGP (England and Wales) -The overall ILI consultation rate from RCGP for England and Wales decreased from 11.6 to 7.7 in week 13 2013 (Figure 1). ILI rates remained stable in the Central region (from 7.0 to 6.2 per 100,000) and decreased in the North (from 7.5 to 3.2 per 100,000) and South (from 16.9 to 11.6 per 100,000).
Figure 1: RCGP ILI consultation rates , England and Wales

-The rate increased in the 1-4 year group which had the highest rate (from 5.5 to 13.5 per 100,000) and the 75+ year olds (from 0.0 to 4.0 per 100,000). The rate decreased or remained stable in the other age groups.

Figure 2: RCGP ILI consultation rates , by age group, E&W

Overall 5-14 years 65-74 years <1 y ear 15-44 years 75+ years 1-4 y ears 45-64 years

250
Rate per 100 000

1999/00

2009/10
2010/11

200 150
100 50

250
Rate per 100 000

2011/12
2012/13

200
150

100 50
0 40 44 48 52 4 8 12 16 20 24 28 32 36
Week number

0
40 44 48 52 4 8 12 16 20 24 28 32 36 Week number

Figure 3: GP ILI/influenza consultation rates in the UK

RCGP (England and W ales) Scotland Wales Northern Irel and 300 2012/13 season indicated by bold lines, 2011/12 season indicated by fainter 250 lines.

Northern Ireland -The combined influenza/ILI rate in Northern Ireland increased slightly from 32.1 per 100,000 in week 12 to 37.4 per 100,000 in week 13 (Figure 3). -The rate increased in the 1-4 year group (from 0.0 to 49.7 per 100,000), the 15-44 year group (from 33.3 to 38.7 per 100,00), the 65-74 year group (from 7.0 to 25.4 per 100,00) and the 75+ year olds who had the highest rate (from 25.9 to 108.0 per 100,000). The rate decreased or remained stable in the other age groups. Scotland -The Scottish ILI rate decreased slightly from 18.2 per 100,000 in week 12 to 14.2 per 100,000 in week 13 (Figure 3). -The rate increased in the under one year olds (from 0.0 to 3.7 per 100,000) and decreased or remained stable in all other age groups. The highest rate was reported in the 45-64 year group (from 23.3 to 19.8 per 100,000).

Rate per 100 000

200 150
100 50

0
40 44 48 52 4 8 12 16 20 24 28 32 36

Week number

Wales -The Welsh influenza rate decreased slightly from 13.3 per 100,000 in week 12 to 9.5 per 100,000 in week 13 (Figure 3). -The rate increased in the 65-74 year group (from 2.6 to 10.3 per 100,000) and the 75+ year olds (from 0.0 to 8.0 per 100,000). The rate decreased or remained stable in the other age groups and the highest rate was reported in the 15-44 year group (from 14.5 to 13.6 per 100,000).

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HPA/QSurveillance System (England, Wales and Northern Ireland) -Due to the current transition from the existing HPA & Nottingham University Division of Primary Care Collaborative National Surveillance System to a new PHE GP surveillance system (which started daily data monitoring on April 1) there is no data update available for week 13 2013.

Figure 4: QSurv ILI consultation rates , by region, E,W&NI

NE WM SEC NW EE WA YH LN SW EM SC NI

150
Rate per 100 000

100

50 0

40 44 48 52 4

8 12 16 20 24 28 32 36
Week number

Other respiratory indicators

Figure 5: RCGP AB consultation rates , by age group, E&W

<1 year 15-44 years 75+ years 1-4 y ears 45-64 years Overall 5-14 years 65-74 years

Pneumonia The overall weekly consultation rate for pneumonia from the HPA/QSurveillance system was at 1.4 per 100,000 in week 12.

Rate per 100 000

Acute bronchitis (AB) The overall weekly consultation rate for acute bronchitis (AB) in England and Wales through the RCGP scheme decreased slightly from 83.5 to 75.8 per 100,000 in week 13 (Figure 5). The rate decreased in under one year olds (from 503.2 to 324.9 per 100,000) and increased in 75+ year olds (from 184.2 to 229.5 per 100,000).

900 800 700 600 500 400 300 200 100 0 40 44 48 52 4 8 12 16 20 24 28 32 36

Week number

Community surveillance

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In week 13 2013, the weekly proportion of NHS Direct calls for cold/flu and fever (5-14yrs) remained below their respective influenza thresholds of 1.6% and 11.7%. 10 new acute respiratory disease outbreaks have been reported in the past seven days. Eight had a virological result available (four influenza A (unsubtyped), two A(H3) and two B).

HPA/NHS Direct syndromic surveillance system

Figure 6: NHS Direct % calls for colds/flu, E&W
<1 year 15-44 years Overall 1-4 years 45-64 years 5-14 years 65+ years

-The weekly national proportion of NHS Direct calls for cold/flu remained below the influenza threshold of 1.6% (1.1% in week 13) (Figure 6). -The weekly proportion of calls for fever in the 5-14 year group remained below the influenza threshold of 11.7% (5.5% in week 13). -PLEASE NOTE that due to the on-going transition of urgent care services across England, including the introduction of NHS 111, the volume of NHS Direct calls is gradually declining, particularly in those areas where NHS 111 is fully operational. Results should therefore be interpreted with caution. -For further information, please see the syndromic surveillance webpage.

18 16 14 12 10 8 6 4 2 0

Proportion of calls

40 44 48 52 4

8 12 16 20 24 28 32 36
Week number

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FluSurvey

Figure 8: FluSurvey ILI incidence by age group, UK

ILI incidence

-Internet-based surveillance of influenza in the general population is undertaken through the FluSurvey project (http://flusurvey.org.uk/) run by the London School of Hygiene and Tropical Medicine. The incidence of ILI reports in week 13 are low.

0.5
<20yrs 20-44yrs 45+yrs

0.4 0.3 0.2 0.1 0 48 50 52 2 4 6 8 10 12 14

Week number

Acute respiratory disease outbreaks

-10 new acute respiratory outbreaks (nine in care homes and one in a hospital) have been reported in the past seven days in Northern Ireland, Wales, East of England, Yorkshire and Humber, South East England and South West England. 8 had a virological result available (four influenza A (unsubtyped), two A(H3) and two B). So far this season, 166 outbreaks have been reported in schools (Figure 8) (where tested, majority influenza B); 176 in care homes (where tested, majority influenza A(unsubtyped)); 36 in a hospital (where tested, majority A(unsubtyped)) and 13 in other settings (where tested, majority A(H1N1)pdm09). -Outbreaks should be recorded on HPZone and reported to the local HPA HPU and Respcdsc@hpa.org.uk.

Figure 8: Number of acute respiratory outbreaks by institution, UK (n=263)*

50 40

Care home

Hospital

Other

School

Number

30

20 10 0 42 46 50 2 6 10 14 18 22 26 30 34 38
Week number of first case onset

*NB. Date of onset not known for 84 outbreaks

Microbiological surveillance

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In week 13 2013, 134 influenza positive detections (54 A(H3), 40 A subtype not known, 25 B and 15 A(H1N1)pdm09) were recorded through the DataMart scheme (overall positivity of 14.9% compared to 19.1% the previous week). 2 influenza positive detections were recorded through the two English GPbased sentinel schemes in week 13 (2 A(H1N1)pdm09). English DataMart
Figure 9: DataMart samples positive for influenza, England
Influ enza A (n) Influenza B (n)

Proportion positive

50
40 30 1000

20 10
0 40 44 48 52 4 8 12 16 20 24 28 32 36 Week number (of sample)

500
0

Figure 10: Datamart % RSV positive by age, England <5yrs 5-14yrs 15-44yrs 45+yrs Overall 80 70 60 50 40 30 20 10 0 40 44 48 52 4 8 12 16 20 24 28 32 36 Week number

Figure 11: Datamart % positive for other respiratory viruses, England Rhinovirus Parainfluenza hMPV Adenovirus 35 30 25 20 15 10 5 0 40 44 48 52 4 8 12 16 20 24 28 32 36 Week number

Proportion positive

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Proportion positive

Number of positive specimens

-134 (14.9%) of the 900 respiratory specimens reported to the English DataMart virological surveillance system as taken in week 13 were positive for influenza (54 A(H3), 40 A subtype not known, 25 B and 15 A(H1N1)pdm09), less than the positivity of 19.1% reported in week 12 (Figure 9). -In week 13, positivity increased for hMPV (from 5.3 to 6.8%) and remained stable for adenovirus (4.1%) parainfluenza (6.9%), RSV (2.2%) and rhinovirus (12.9%) (Figures 10 and 11).

Influenza A (%)

Influenza B (%)

60

1500

RCGP/SMN sentinel swabbing schemes and devolved administrations

-2 out of 13 (15.4%) influenza positive detections Table 1: Sentinel influenza surveillance in the UK were recorded through the two English GP-based Week England Scotland Northern Ireland Wales sentinel schemes in week 13 (2 A(H1N1)pdm09), 09 48/117 (41.0%) 38/70 (54.3%) 5/9 (-) 2/3 (-) less than the 28.0% positivity reported in week 10 27/58 (46.6%) 21/54 (38.9%) 4/7 (-) 7/9 (-) 12. 6 out of 15 samples from Scotland were 11 26/72 (36.1%) 35/79 (44.3%) 5/10 (50.0%) 3/5 (-) positive for influenza (5 B and 1 A(H1N1)pdm09), 12 14/50 (28.0%) 20/50 (40.0%) 7/13 (53.8%) 1/4 (-) 7 out of the 11 samples from Northern Ireland 13 2/13 (15.4%) 6/15 (40.0%) 7/11 (63.6%) 0/2 (-) were positive for influenza (4 A(H3) and 3 NB. Proportion positive omitted when fewer than 10 specimens tested A(unsubtyped)) and none of the samples from Wales were positive for influenza (Table 1).

Virus characterisation

Antiviral susceptibility

-Since week 40 2012, the HPA Respiratory Virus Unit (RVU) has isolated and antigenically characterised 256 influenza A(H3N2) viruses, all similar to the A/Victoria/361/2011 vaccine strain, and 59 influenza A(H1N1)pdm09 viruses similar to the A/California/07/2009 vaccine strain. Of 368 influenza B viruses isolated, 93% belong to the B-Yamagata lineage, and are antigenically related to the influenza B vaccine strain, B/Wisconsin/1/2010, and 7% belong to the B-Victoria lineage. Antimicrobial susceptibility

-Since week 40 2012, three unlinked sporadic influenza A(H1N1)pdm09 viruses have been found to be resistant to oseltamivir at RVU and regional laboratories. Additionally one influenza B virus with an I221T amino acid substitution was detected in a community specimen. This virus exhibits reduced susceptibility to oseltamivir but retains sensitivity to zanamivir.

-In the 12 weeks up to 24 March 2013, 83% or greater of all lower respiratory tract isolates of Staphylococcus aureus, Streptococcus pneumoniae and Haemophilus influenzae reported as tested were susceptible to the antibiotics tetracycline and co-amoxiclav (Table 2). There have been no significant changes in susceptibility in recent years.

Table 2: Antimicrobial susceptibility surveillance in lower respiratory tract isolates, 12 weeks up to 24 Mar. 2013, E&W
Tetracyclines Organism S. aureus S. pneumoniae H. influenzae Co-amoxiclav

Specimens Specimens Specimens Specimens tested susceptible tested susceptible (N) (%) (N) (%) 3,316 2,437 10,910 92 83 98 189 2551* 10,363 85 91* 94

* S. pneumoniae isolates are not routinely tested for susceptibility to coamoxiclav, how ever laboratory results for benzyl-penicillin are extrapolated to determine sensitivity to other beta-lactams such as co-amoxiclav.

Disease severity and mortality data

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In week 13, 26 new admissions of confirmed influenza cases to ICU/HDU (15 A unknown subtype, six A(H3N2), four A(H1N1)pdm09) and one B and seven confirmed influenza deaths in ICU/HDU have been reported through the national USISS mandatory ICU scheme across the UK (120 Trusts in England). Thirty-eight new hospitalised confirmed influenza cases have been reported through the USISS sentinel hospital network across England (20 Trusts) (11 B, 10 A(H3N2), nine A(H1N1)pdm09, eight A(unknown subtype). A national mandatory collection (USISS mandatory ICU scheme) is operating in cooperation with the Department of Health to report the number of confirmed influenza cases admitted to Intensive Care Units (ICU) and High Dependency Units (HDU) and number of confirmed influenza deaths in ICU/HDU across the UK. A confirmed case is defined as an individual with a laboratory confirmed influenza infection admitted to ICU/HDU. In addition a sentinel network (USISS sentinel hospital network) of acute NHS trusts has been established in England to report weekly laboratory confirmed hospital admissions. Further information on these systems is available through the HPA website. Please note data in previously reported weeks are updated and so may vary by week of reporting.

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Number of new admissions and fatal confirmed influenza cases in ICU/HDU (USISS mandatory ICU scheme), UK (week 13)

-In week 13, 26 new admissions to ICU/HDU with confirmed influenza infection (15 A unknown subtype, six A(H3N2), four A(H1N1)pdm09 and one B) were reported across the UK (120/163 Trusts in England) through the USISS mandatory ICU scheme (Figures 12 and 13). A total of 820 admissions (286 B, 245 A unknown subtype, 145 A(H3N2) and 144 A(H1N1)pdm09) have been reported since week 40 2012. Seven new confirmed influenza deaths were reported in week 13 2013. Ninety-nine confirmed influenza deaths (33 A(H3N2), 31 B, 22 A(H1N1)pdm09 and 13 A unknown subtype) have been reported across the UK in ICU/HDU since week 40 (Figure 12).
Figure 12: Weekly ICU influenza admissions and deaths (USISS mandatory) by week of admission/death, UK, since week 40 2012 100 Number of ICU admissions 90 80 Number of ICU deaths 70 60 50 40 30 20 10 0 40 44 48 52 4 8 12 16 20
Week number

Number

Number

Figure 13: Cumulative ICU influenza admissions (USISS mandatory) by age group and flu type, UK, since week 40 2012 300 A(H1N1)pdm09 A(H3N2) 250 A unknown subtype A not subtypable 200 B 150 100

50 0 <1 1-4 5-14 15-44 45-64 65+

Age group (years)

USISS sentinel weekly hospitalised confirmed influenza cases, England (week 13)

-A total of 1169 hospitalised confirmed influenza admissions (447 B, 308 A(H3N2), 258 A unknown subtype and 156 A(H1N1)pdm09) have been reported since week 40 2012. -153 (13.1%) of the hospitalised cases from the USISS sentinel hospital network since week 40 2012 are reported to have been admitted to HDU/ICU. The median age of cases sent to ICU is 46 years (range from 0-88yrs) and 50 were positive for influenza B, 40 influenza A(H3N2), 33 influenza A(H1N1)pdm09 and 27 influenza A(unknown subtype).

Number of hospitalised confirmed cases

-In week 13, 38 new hospitalised confirmed influenza cases (11 B, 10 A(H3N2), nine A(H1N1pdm09) and eight A(unknown subtype)) were reported from the USISS sentinel hospital network from 23 NHS Trusts across England (Figure 14) compared to 59 in week 12.

Figure 14: Weekly hospitalised cases (USISS sentinel) by flu type, England, since week 40 2012 A(H1N1)pdm09 A(H3N2) 120 A unknown subtype A not subtypable B 100

80
60

40
20

0 40 44 48 52 4 8 12 16 20
Week number

Excess overall all-cause mortality, England and Wales

Figure 15: Observed & predicted all-cause death registrations, E&W

Estimated number of death registrations

-In week 12 2013, an estimated 11,075 all-cause deaths were registered in England and Wales (source: Office for National Statistics). This is less than the 11,075 estimated death registrations in week 11 and is slightly above the 95% upper limit of expected death registrations for this time of year as calculated by the HPA (Figure 15). This excess coincides with continued circulating influenza and low temperatures.

14,000
12,000 10,000

8,000 6,000
4,000 2,000 0

Prediction Upper limit Total deaths all ages

40 44 48 52 4 8 12 16 20 24 28 32 36 Week number

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Excess all-cause mortality by age group and HPA region, England, Wales, Scotland and Northern Ireland

-In week 13 2013, excess mortality by date of death above the upper 2 z-score threshold was seen in 65+ year olds in England after correcting ONS disaggregate data for reporting delay with the standardised EuroMOMO algorithm (Figure 16, Table 3). By region, this excess was seen in the North West, West Midlands, East Midlands, East of England, South East and the South West. This excess coincides with continued circulating influenza and low temperatures. This data is provisional due to the time delay in registration and so numbers may vary from week to week. Since week 40 2012, excess has been reported in Scotland in weeks 52 2012 to 2 2013 and week 4 2013, and in Northern Ireland in 2013 in week 10 2013 (Table 4).

Table 3: Excess mortality by age group,England*

Age group Excess detected Cumulative excess since (years) in week 13 2013? week 40 2012 <5
Figure 16 Excess mortality in 65+ year olds by week of death, EuroMOMO, E&W 10,000

0 8 0 6,470

5-14 15-64 65+

Estimated number of deaths

8,000 6,000
4,000

* Excess mortality is calculated as the observed minus the expected number of deaths in weeks above threshold
Baseline Upper 2 z score limit Deaths (corrected)

2,000
0 40 44 48 52 4

Table 4: Excess mortality by UK country*

Country Excess detected Cumulative excess in week 13 2013? since week 40 2012 4,423 0 592 43

8 12 16 20 24 28 32 36

Week number

England Wales Scotland Northern Ireland

* Excess mortality is calculated as the observed minus the expected number of deaths in weeks above threshold NB. Separate total and age-specific models are run for England which may lead to a discrepancy in figures between Tables 3 + 4

Vaccination

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Provisional data from the final fourth monthly collection of seasonal influenza vaccine uptake from 99.3% of GP practices is available. Up to 31 January 2013, the provisional proportion of people in England aged 65 years and over who had received the 2012/13 influenza vaccine was 73.4%, while in those aged under 65 years in a clinical risk group it was 51.3%. Amongst pregnant women, the uptake was 40.3%. Provisional data from the final fourth monthly collection of influenza vaccine uptake by frontline healthcare workers show 45.6% were vaccinated by 31 January 2013 from 97.7% of Trusts (including PCTs). A mid-season analysis assessing the effectiveness of the trivalent influenza vaccine in the UK in this season (2012/13) has been published in Eurosurveillance. An overall adjusted vaccine effectiveness of 51% (95% confidence interval 27% - 68%) was reached against all laboratory-confirmed influenza in primary care which is within the expected range of effectiveness of a trivalent influenza vaccine. For further information please see the article. At the end of the season more precision in the estimates will be available along with the ability to obtain age-stratified estimates. WHO have published the recommended composition of influenza virus vaccines for use in the 2013/14 northern hemisphere influenza season. It is recommended trivalent vaccines contain the following strains: an A/California/7/2009 (H1N1)pdm09-like virus, an A(H3N2) virus antigenically like the cell-propagated prototype virus A/Victoria/361/2011 (with a recommendation for A/Texas/50/2012) and a B/Massachusetts/2/2012-like virus (Yamagata lineage). For further information please see the full report.
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International Situation

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During week 12 2013, influenza activity in Europe continued to decline or had already returned to baseline levels; after more than three months of active transmission, the 2012/13 influenza season is waning. Influenza activity in North America continues to decrease overall. Low levels of influenza activity were reported across the tropical regions of the world and activity in countries of the southern hemisphere remains at inter-seasonal levels. Europe 28 March 2013 (European Centre for Disease Prevention and Control report)

During week 12 2013, 12 countries reported medium intensity and 15 countries reported low intensity. No country reported high intensity. The geographic pattern of influenza activity was reported as widespread by nine countries, seven of which also reported medium intensity. Regional, local or sporadic activity was reported by 16 countries. Only Cyprus and Poland reported no activity. Decreasing or stable trends were reported by all reporting countries except Poland which reported an increasing trend but low influenza activity. In week 12 2013, of 826 sentinel specimens tested, 375 (45%) were positive for influenza virus: 111 (30%) were type A and 264 (70%) were type B. Since the peak of 61% positive specimens in week 5 2013, the proportion has decreased over seven weeks reflecting the slow decline in influenza activity which has remained high. Of the 14,148 influenza virus detections in sentinel specimens since week 40 2012, 6,700 (47%) were type A and 7,448 (53%) type B viruses. Of 5,952 influenza A viruses subtyped, 3,778 (63%) were A(H1)pdm09 and 2,174 (37%) A(H3). Of the 2,618 type B viruses for which lineage was determined, 2,373 (91%) were B/Yamagata/16/88-lineage and 245 (9%) B/Victoria/2/87-lineage. United States of America 29 March 2013 (Centre for Disease Control report)

During week 12 2013, influenza activity decreased in the United States. Nationwide, 1.8% of patient visits reported through the US Outpatient Influenza-Like Illness Surveillance Network (ILINet) were due to influenza-like illness (ILI) in week 12 2013 which was below the national baseline of 2.2%. 3/10 regions reported ILI at or above region-specific baseline levels. One state experienced moderate activity; three states and New York City experienced low activity; 46 states experienced minimal activity, and the District of Columbia had insufficient data. Six states reported widespread influenza activity; Puerto Rico and eight states reported regional influenza activity; the District of Columbia and 23 states reported local influenza activity; 11 states reported sporadic influenza activity, Guam and one state reported no influenza activity, and the U.S. Virgin Islands and one state did not report. The proportion of deaths attributed to pneumonia and influenza (P&I), 7.5%, was at the epidemic threshold of 7.5% for week 12 2013. Five influenza-associated paediatric deaths were reported to CDC during week 12 2013. One death was associated with an influenza A (H3) virus and occurred during week 3 and two were associated with influenza A viruses for which the subtype was not determined and occurred during weeks 50 and 1. Two were associated with influenza B viruses and occurred during weeks 11 and 12. Of 5,332 specimens tested and reported by U.S. World Health Organization (WHO) and National Respiratory and Enteric Virus Surveillance System (NREVSS) collaborating laboratories during week 12, 702 (13.2%) were positive for influenza. By type, 186 (26.5%) were influenza A (11 (5.9%) A(H1N1)pdm09, 114 subtyping not performed and 61 (32.8%) A(H3)) and 516 (73.5%) were influenza B. Canada 28 March 2013 (Public Health Agency report)

In week 12, overall influenza activity continues to decline. No regions reported widespread activity and 12 regions reported localised activity. The number of regions reporting widespread or localized activity decreased compared to the previous week and continued to follow the overall decline in influenza/ILI activity from the peak in early January. Nine new influenza outbreaks were reported in week 12: four in long-termcare facilities, and five in other facilities or communities. The percentage of positive influenza tests increased slightly from 11.7% in week 11 to 12.3% in week 12. Of the influenza viruses detected in week 12 (n=490), 34.7% were positive for influenza A viruses (of which 17.6% were A(H1N1)pdm09, 14.7% were A(H3) and 67.6% were A unsubtyped) and 65.3% were influenza B viruses (the proportion of which has increased over the past nine weeks). Cumulative influenza virus detections by type/subtype to date are as follows: 92.0% influenza A [34.8% A(H3), 4.0% A(H1N1)pdm09 and 61.2% A(unsubtyped)] and 8.0% influenza B. In week 12, 100 laboratory-confirmed influenza-associated hospitalizations were reported from participating provinces and territories. The majority of cases were influenza A (58; 58.0%). The highest proportion of hospitalisations continued to be adults 65 years of age (46.0%) and ch ildren 0-4 years of age (21.0%). Two
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deaths were reported: both adults 65 years of age, one with influenza B and one with A(H3). To date this season 4,044 influenza-associated hospitalizations have been reported; of which 94.1% have been influenza A. Of those subtyped (48.3%), influenza A(H3) was the predominant influenza strain. The cumulative proportion of hospitalizations in cases with influenza B continues to increase (5.9% in Week 12). To date, 273 deaths have been reported. The national ILI consultation rate decreased from 21.5 ILI consultations per 1,000 patient visits in week 11 to 13.1 in week 12 and is below the expected range for this time of year.

Global influenza update 2 April 2013 (WHO website)

Influenza activity in North America continued to decrease overall, though activity remained high in some areas. Proportionally influenza B increased although influenza A(H3N2) was the most commonly detected virus in North America overall for this season. In the United States of America this season has been more severe than any since 2003-4 as reflected in numbers of pneumonia and influenza deaths with the highest impact for individuals over the age of 65 years. Influenza activity continued to decline in the most part of Western Europe, while it remained elevated in the eastern part of the region. The proportion of subtypes of viruses circulating was not uniform across the continent and has changed through the season. It has been notably different from North America with a mix of A(H3N2) and A(H1N1)pdm09 and B viruses. Influenza B mainly reported in western and northern countries and influenza A in eastern and central Europe. Excess mortality in most countries has been moderate and most deaths occurred among people aged 65 and older. Influenza activity throughout the temperate region of Asia decreased overall with the exception of Mongolia where activity levels were sustained but still within seasonal tolerance levels. Low levels of influenza activity continued to be reported across the tropical regions of the world and activity in countries of the southern hemisphere remained at inter-seasonal levels. Since the start of the season a few viruses with reduced susceptibility to neuraminidase inhibitors have been detected in the countries performing antiviral resistance testing. The majority of characterized influenza viruses were antigenically similar to the 2012-13 northern hemisphere vaccine viruses.

Avian Influenza 3 April 2013 (WHO website)

Influenza A(H5N1) From 2003 through 12 March 2013, 622 human cases of H5N1 avian influenza have been officially reported to WHO from 15 countries, of which 371 (60%) died. Influenza A(H7N9) Since 31 March 2013, nine cases of human infection with influenza A(H7N9) in China have been reported by ECDC. Three of the cases have died and the remaining six are in a critical condition. To date there is no epidemiological link between the cases and there is currently no evidence of human-to-human transmission of the influenza A(H7N9) virus. For further updates please see the WHO website and for advice on clinical management please see information available on the HPA website.

Novel coronavirus 27 March 2013

In February 2013, three cases of novel coronavirus were diagnosed in UK residents in the UK. The first case had recently travelled to the Middle East and Pakistan. The two further cases were family members in contact with the first case, with no recent travel history. In this cluster, the index case and one of the family members subsequently died following severe respiratory illness, while the second family member recovered from a mild respiratory illness. 135 close contacts have been identified and followed up and no further PCR confirmed secondary cases have been identified to date. Further information is available in a recent publication in Eurosurveillance. A total of four cases of novel coronavirus have been confirmed in England. On-going surveillance has identified a further 49 cases that have been investigated for novel coronavirus and tested negative. A further 13 cases have been confirmed internationally (nine in Saudi Arabia, two in Jordan and two exported to Germany from the Middle East) resulting in a global total of 17, 11 of which have died. Further information on management and guidance of possible cases is available on the HPA website.
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Acknowledgements

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This report was prepared by Helen Green and Richard Pebody. We are grateful to all who provided data for this report including the RCGP Research and Surveillance Centre, the HPA Real-time Syndromic Surveillance team, the HPA Respiratory Virus Unit, the HPA Modelling and Statistics unit, the HPA Dept. of Healthcare Associated Infection & Antimicrobial Resistance, HPA regional microbiology laboratories, NHS Direct, ONS, the Department of Health, Health Protection Scotland, National Public Health Service (Wales), the Public Health Agency Northern Ireland, the Northern Ireland Statistics and Research Agency, QSurveillance and EMIS and EMIS practices contributing to the QSurveillance database.

Related links Weekly consultation rates in national sentinel schemes Sentinel schemes operating across the UK RCGP scheme Northern Ireland surveillance (Public Health Agency) Scotland surveillance (Health Protection Scotland) Wales surveillance (Public Health Wales) Real time syndromic surveillance (including HPA/QSurveillance scheme, NHS Direct)

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Community surveillance Outbreak reporting FluSurvey MOSA

Disease severity and mortality data USISS system EuroMOMO mortality project Vaccination 2012/13 seasonal influenza vaccine programme (Department of Health Green Book) WHO 2012/13 vaccine recommendations

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