BC Influenza Surveillance Bulletin: Sporadic Influenza Activity throughout Summer in BCSep182015

BC Influenza Surveillance Bulletin: Weeks 18-36 (May 3 – Sept 12, 2015)

Back-to-School Update: Sporadic Influenza Activity throughout Summer in BC

In weeks 18-36 (May 3 to September 12, 2015), community-based surveillance indicators for influenza remained at inter-seasonal levels throughout the province.

However, sporadic cases of influenza A(H3N2) and influenza B continued to be detected, driven in part by cases among out-of-province residents associated with cruise ship travel.

Also, in week 32, VCHA reported a lab-confirmed outbreak of influenza A(H3N2) in a long-term care facility (LTCF). Summer reporting of LTCF influenza outbreaks is atypical. Since 2009 this has occurred only during the A(H3N2)-dominant 2014-15 season during which an outbreak was reported in week 33, followed by additional LTCF outbreak reports in weeks 39-43. Monitoring for possible early season activity is thus warranted for the 2015-16 season.

At the BC provincial laboratory, overall influenza positivity was 8%, fluctuating between 0% and 18% during this period. Entero/rhinoviruses were the most commonly detected respiratory viruses; however, unlike last year, no EV-D68 has been detected thus far in BC despite enhanced surveillance by the provincial laboratory since August 1, 2015.

You can download the BC Influenza Surveillance Bulletins from the BCCDC website.

Please remember to notify BCCDC of any ILI outbreak occurring in your region by sending an e-mail to ilioutbreak@bccdc.ca. You are welcome to contact the BCCDC Influenza & Emerging Respiratory Pathogens Team with any questions.


Emerging Respiratory Virus UpdateSep182015


With the annual Hajj approaching (September 21-26) and as we enter the regular autumn respiratory virus surveillance period, below is an update on recent trends in emerging respiratory viruses globally, including MERS-CoV and novel avian influenza A viruses.

For our most recent seasonal influenza bulletin for BC (report no. 22, also posted on-line today), see: http://www.bccdc.ca/dis-cond/DiseaseStatsReports/influSurveillanceReports.htm



While the number of MERS-CoV cases associated with the May-June nosocomial outbreak in South Korea has subsided (no new cases since July 4), more recent hospital outbreaks have been reported in Saudi Arabia, including a large outbreak at King Abdulaziz Medical Centre in Riyadh (115 cases and at least 38 deaths since early July), and in Jordan.

From September 21-26, the annual Hajj pilgrimage to Mecca will take place in Saudi Arabia. With increased travel through the region, importation of MERS-CoV cases to countries outside of the Arabian Peninsula may be anticipated. Enhanced awareness and monitoring are warranted. WHO travel advice for pilgrimages: http://www.who.int/ith/updates/20150714/en/

Latest (August 27) ECDC Rapid Risk Assessment, including list of affected countries to date: http://ecdc.europa.eu/en/publications/Publications/MERS-CoV-rapid-risk-assessment-August-2015.pdf

Avian Influenza A(H7N9)

Avian influenza A(H7N9) remains at inter-seasonal levels in eastern China. Five human cases with symptom onset in May-June were reported since our last update.

Other Novel Influenza

Three human cases of swine-origin variant influenza A were reported over the summer months (July-August) in the United States: two cases of H3N2v and one case of H1N1v.

Although the risk to Canadians from these emerging respiratory pathogens remains low, clinicians should remain vigilant and consult their local Medical Health Officer for advice related to diagnostic testing, infection control and follow up where a novel emerging pathogen may be suspected.

More detailed epidemiologic information, risk assessment, action and advice are provided below.


A. Middle East Respiratory Syndrome Coronavirus (MERS-CoV)

As of September 17, a total of 1,569 MERS-CoV cases globally, including at least 554 related deaths, have been reported to the WHO. Cases have primarily accrued in Saudi Arabia but there have also been travel-related importations to other countries sometimes culminating in nosocomial outbreaks as described for recent events below.

a. South Korea

Following the importation of a single MERS-CoV case to South Korea from the Middle East in May, 2015, 186 confirmed cases, including one travel-related case in China, and 36 deaths have been reported in association with the South Korean outbreak – highlighting the extent to which a MERS-CoV importation can amplify in the nosocomial setting if not identified and intervened upon early (reminiscent of SARS-CoV).

Fortunately, over the summer months, the outbreak in South Korea subsided considerably, with no new MERS-CoV cases reported since July 4. However, the outbreak will not be officially declared over until two incubation periods (28 days) have passed after the last patient has cleared virus or died according to the World Health Organization (WHO). As of September 16, eight confirmed cases remain under treatment, of whom seven have tested negative for MERS-CoV and are being treated in general wards.

b. Saudi Arabia

Since the first week of July, 190 cases and 57 MERS-CoV deaths have been reported to the WHO from Saudi Arabia, mostly from the Riyadh region (n=161, 85%) where 115/161 (71%) cases and at least 38 deaths have been linked to the ongoing hospital outbreak at King Abdulaziz Medical Centre. A further five cases have been linked to a smaller outbreak at another unnamed hospital in Riyadh.

Among the 161 recent Riyadh cases, at least 91 are epidemiologically linked, while 26 reported no recognized contact with cases in the community or hospital and 44 had exposure history under review at the time of report. Epidemiological characteristics remain similar to previous outbreaks, affecting mainly older adult men with underlying comorbidity (median age=57 years; 63% male). Twenty-seven cases are healthcare workers. An additional five cases from Riyadh were reported this past week by the Saudi Ministry of Health that have not yet been officially confirmed by the WHO.

A recent WHO mission to Saudi Arabia in response to the Riyadh outbreak at the King Abdulaziz Medical Centre on August 23 concluded that most nosocomial cases involved patient-to-patient infection, facilitated by overcrowding in the emergency room and breaches in compliance with infection control measures among patients, visitors and healthcare workers. For more information: http://www.emro.who.int/surveillance-forecasting-response/surveillance-news/who-mission-on-middle-east-respiratory-syndrome-coronavirus-merscov-in-saudi-arabia.html.

This past week, the WHO confirmed a third nosocomial outbreak in Saudi Arabia, this time in the holy city of Medina. To date, six epidemiologically linked cases (median age=45; 67% male) have been reported to the WHO associated with this outbreak, including three healthcare workers. Earlier this week, the Saudi Ministry of Health reported an additional two cases from Medina; however, these cases have not yet been officially confirmed by the WHO.

These ongoing nosocomial outbreaks are occurring at a time when millions of international travellers will visit Saudi Arabia for the annual Hajj pilgrimage, taking place from September 21-26 this year. Although no cases of MERS-CoV were detected in association with the 2013 or 2014 Hajj, several travel-associated cases have been reported previously in pilgrims returning from Umrah, a religious pilgrimage that occurs throughout the year. Due to the increased travel to the affected region in the coming weeks, clinicians are reminded to elicit a travel history or other possible epidemiological links to affected areas in the Middle East from patients presenting with severe acute respiratory illness (SARI). The median incubation period for MERS-CoV is estimated at 5-6 days, but could be up to 14 days.

c. Jordan

Jordan is also experiencing a nosocomial outbreak at a private hospital in Amman city, following the importation of a single case with recent travel to Jeddah, Saudi Arabia.

Eleven cases and five deaths (including the index case) have been reported to the WHO from Jordan since late August. Ages range from <1-78 years (median age=56 years) and 55% are male. Of the ten locally acquired cases, five had healthcare-related exposures at the hospital where the MERS-CoV outbreak is currently occurring, four are household contacts of confirmed cases (two asymptomatic), and one had exposure history under review at the time of report; none are healthcare workers.

A total of 32 cases have been reported in Jordan since the emergence of MERS-CoV in March/April 2012.

d. Other countries

Over the summer period (June-August), travel-related cases were also reported by the Philippines (ex. Saudi Arabia) and Thailand (ex. Oman). No further indigenous human-to-human transmission was reported by either country.

On September 2, the International Health Regulations (IHR) Emergency Committee regarding MERS-CoV met for the tenth time and concluded that the MERS-CoV situation still does not constitute a Public Health Emergency of International Concern (PHEIC). The Committee did, however, emphasize ongoing concerns related to insufficient awareness about the urgent dangers posed by this virus, insufficient engagement by all relevant sectors and insufficient implementation of scalable infection control measures, especially in healthcare settings such as emergency departments. More information is available from: www.who.int/mediacentre/news/statements/2015/ihr-emergency-committee-mers/en/.

B. Avian Influenza A(H7N9), China

Human case reports of avian-origin influenza A(H7N9) in eastern China remained at inter-seasonal levels over the summer months. Five additional laboratory-confirmed cases and three deaths, with symptom onset between May 26 and June 18, were reported in mid-July in China. Ages range from 58-77 years (median age=65 years) and all are male. All five cases reported exposure to live poultry-related environments. No new cases have been reported with onset in July-September; however, further cases are anticipated during the winter seasonal period.

As of July 17, a total of 677 laboratory-confirmed human cases of avian influenza A(H7N9) have been reported to the WHO, including four cases reported from Taiwan, 13 from Hong Kong, one from Malaysia and two from British Columbia, Canada.

C. Other Novel Influenza, United States

Over the summer months (July-August), three additional human cases of swine-origin variant influenza A were reported in the United States, including two cases of influenza A(H3N2) variant (H3N2v) (one in July in a child with a history of cancer in Minnesota and one in August in Michigan) and one case of influenza A(H1N1) variant (H1N1v) in August in Iowa. All three cases were hospitalized as a result of their illness and all reported direct contact with swine in the week prior to illness onset.

These are the first two cases of H3N2v and the third case of H1N1v to be reported in the United States in 2015. Previously in 2015, two H1N1v cases (one fatal) were reported in Minnesota and Ohio. Since December 2005, a total of 353 cases of H3N2v and 19 cases of H1N1v have been reported in the United States.


Clinicians should obtain relevant travel, animal (direct or indirect), or other contact exposure history from patients presenting with acute illness that could be due to infectious disease, notably severe acute respiratory illness (SARI). In the event of links to affected areas in the two weeks prior to symptom onset (i.e. residence, travel history or contact with someone with such history), clinicians should notify their local health authority/Medical Health Officer and consult a virologist or microbiologist at the BC Public Health Microbiology & Reference Laboratory (PHMRL) to arrange advance notification and direct shipping of diagnostic specimens, indicating relevant travel or other exposure history. Given a spectrum of illness inclusive of milder or atypical presentations, clinicians are encouraged to use their judgement and/or consult local public health and infection control for guidance where the index of suspicion (e.g. based on contact, comorbidity or clustering history) and exposure risk may be higher.

For diagnostic testing for suspected MERS-CoV or avian influenza, lower respiratory specimens (e.g. sputum, endotracheal aspirate, or bronchoalveolar lavage) are recommended where possible and clinically indicated. Follow strict infection prevention and control guidelines when collecting respiratory specimens.

Health care workers should implement respiratory precautions immediately, and cases should be managed in respiratory isolation with contact and droplet precautions. Airborne precautions are warranted in the event of aerosol-generating procedures or conditions Facilities should be mindful of the protection of other patients and visitors, in addition to healthcare workers, to minimize nosocomial transmission and risk.


BCCDC puts call out for more doctors and nurses to help monitor for fluSep152015

Vancouver – Experts at the BC Centre for Disease Control (BCCDC) are already gearing up to monitor flu-like illness for the coming season and they’re looking for more community doctors and nurses to help.

Influenza viruses constantly change, and each season the flu shot has to be updated to match the new strains that are most likely to make people sick. Last year, influenza got off to an early start and the 2014-15 flu season proved to be a difficult one, in part because of the vaccine mismatch. In BC, that translated into the highest number of care facility outbreaks in more than a decade.

“A changed strain of H3N2 virus that didn’t match the vaccine caused most of the influenza illness last winter,” says Dr. Danuta Skowronski, an influenza expert at BCCDC.  “H3N2 viruses tend to cause more illness, especially in older people, which is why it is so important to monitor this virus closely every year.”

In 2004, Dr. Skowronski’s team pioneered a study, known as the “test-negative design” for monitoring influenza vaccine effectiveness, a cost-effective approach that is used each year in Canada and has since been adopted by approximately 20 countries around the world. Yearly findings based on the test-negative design are submitted to the World Health Organization (WHO) to help decide whether changes to the influenza vaccine are needed.

“Last year showed the lowest vaccine effectiveness we have recorded in more than ten years,” says Dr. Skowronski. “The WHO has replaced last year’s H3N2 vaccine with a new one and we want to check that it gives better protection for the coming season. We rely on doctors and nurses in the community who belong to our monitoring network to help with that.”

The Canadian Sentinel Practitioner Surveillance Network (SPSN) is the only system in Canada to monitor how well the influenza vaccine protects people from influenza viruses circulating in the community each year. The SPSN uses the test-negative design, drawing on swabs and information collected from patients seeking care for flu-like illness at one of several hundred community practitioners belonging to the network.

“The SPSN has grown to include sites in Alberta, Ontario and Quebec but we need more family doctors and nurses to contribute from BC,” says Skowronski, the lead SPSN investigator. “After last year’s findings, monitoring flu viruses and vaccine protection is more important than ever.”   

Throughout September, the BCCDC team will be packaging and sending out hundreds of special swab kits to existing sentinel sites in BC, but the team is also recruiting more family doctors and nurses to join the network for the coming season. Family practitioners in BC who would like to join are asked to contact the BCCDC team at SentinelNetwork@bccdc.ca or 1-888-881-8886. Patients can also encourage their own family doctors to join by sharing information about the network with them.

General practitioners in Alberta, Ontario and Quebec are also encouraged to apply to join the Canadian SPSN network for flu virus and vaccine effectiveness monitoring. See www.bccdc.ca/SentinelNetwork for details.

Learn more:

Sentinel Practitioner Surveillance Network 

BC influenza surveillance bulletins 


The BC Centre for Disease Control, an agency of the Provincial Health Services Authority, provides provincial and national leadership in public health through surveillance, detection, treatment, prevention and consultation services. The Centre provides both direct diagnostic and treatment services for people with diseases of public health importance and analytical and policy support to all levels of government and health authorities.


PICNet welcomes Linda HoangSep102015

Dr. Linda Hoang has joined PICNet as Medical Co-Lead, following the retirement of Dr. Judy Isaac-Renton. This medical leadership position is a shared position with Dr. Elizabeth Bryce to lead and deliver the strategic goals of PICNet.

Linda is the Program Head of the Public Health Advanced Bacteriology & Mycology for the  BC Public Health Microbiology & Reference Laboratory, which is part of the BC Centre for Disease Control. She is also a Clinical Associate Professor in the Department of Pathology & Laboratory Medicine, UBC.

Dr. Hoang received her Master’s and Medical Degrees from UBC and is FRCPC qualified in Medical Microbiology (UBC). She also obtained a Diploma in Tropical Medicine and Hygiene from the London School of Hygiene and Epidemiology, UK. She enjoys teaching and is the BCCDC site-supervisor for the UBC Medical Microbiology Residency Training Program. 

Linda has been actively participating in PICNet projects for many years, especially as part of the Surveillance Steering Committee, and has led the implementation of the Surveillance Protocol for Carbapenemase Producing Organisms (CPO) in British Columbia. We hope you will join us in welcoming her into her new leadership position.



Dr. Linda Hoang


Dr. Elizabeth Bryce

Happy Retirement to Judy Isaac-Renton

We would also like to thank Dr. Judy Isaac-Renton for her ten years of contribution to PICNet. Judy was instrumental in bringing PICNet into existence. Her public health lens brought a balance to the network’s strategic direction, and her leadership helped navigate PICNet through many challenges. We thank her for her hard work and dedication during PICNet’s first decade, and wish her all the best for her retirement.

Dr. Judy Isaac-Renton