Summer Influenza Surveillance and Increased RSV Activity June 28, 2021

Main Office Phone: (937) 390-5600 529 East Home Road Fax: (937) 390-5625 Springfield, OH 45503 Email: [email protected]

Clark County Combined Health District- Health Advisory Summer Influenza Surveillance and Increased RSV Activity June 28, 2021

PART 1: Summer Influenza Surveillance: Information for Clinicians The Ohio Department of Health (ODH) Bureau of Infectious Diseases (BID) and Clark County Combined Health District (CCCHD) are asking for your support in strengthening summer influenza viral surveillance by partnering with CCCHD to increase influenza-positive specimen submissions to ODH laboratory throughout the summer months. Please contact CCCHD at 937-390-5600 to report suspect novel influenza cases and to coordinate specimen submissions from any RT- PCR or rapid molecular tests which are positive for influenza A or B to ODH Laboratory for confirmatory testing and subtyping. This increased surveillance will continue through September 30, 2021. Although there is minimal influenza activity in Ohio at this time, the Centers for Disease Control and Prevention (CDC) is requesting continued testing of influenza specimens at state public health laboratories in order to maintain situational awareness and ensure adequate novel influenza surveillance. As Ohio’s agricultural fair season begins, it is important to be mindful of potential human infections with swine variant influenza (e.g. H3N2v, H1N1v, H1N2v) and avian influenza viruses. When animal influenza viruses infect people, they are considered novel influenza A infections, a Class A notifiable condition, and should be reported immediately by telephone to the local health department of residence. Novel influenza A should be considered in people with influenza-like illness (ILI) and recent contact to swine or poultry during the summer months. Specimens should be collected promptly, and you should contact CCCHD to arrange for specimen submissions to ODH Laboratory for any suspected novel influenza A infections. Please note that nasopharyngeal (NP) OR oropharyngeal (OP) swabs, bronchoalveolar lavages (BAL) and tracheal aspirates are all appropriate specimen types for submission to ODH laboratory. For each specimen to be sent, please include a completed ODH Laboratory Microbiology Submission Form with "INFLUENZA SUMMER SURVEILLANCE" written in the comments section. This form (with comments section note pre- populated) and ODH Collection and Submission of Influenza Specimens guidelines are attached to this message.

PART 2: Increased Interseasonal Respiratory Syncytial Virus (RSV) Activity Summary The Centers for Disease Control and Prevention (CDC) is issuing this health advisory to notify clinicians and caregivers about increased interseasonal respiratory syncytial virus (RSV) activity across parts of the Southern United States. Due to this increased activity, CDC encourages broader testing for RSV among patients presenting with acute respiratory illness who test negative for SARS-CoV-2, the virus that causes COVID-19. RSV can be associated with severe disease in young children and older adults. This health advisory also serves as a reminder to healthcare personnel, childcare providers, and staff of long-term care facilities to avoid reporting to work while acutely ill – even if they test negative for SARS-CoV- 2. Background RSV is an RNA virus of the genus Orthopneumovirus, family Pneumoviridae, primarily spread via respiratory droplets when a person coughs or sneezes, and through direct contact with a contaminated surface. RSV is the most common cause of bronchiolitis and pneumonia in children under one year of age in the United States. Infants, young children, and older adults with chronic medical conditions are at risk of severe disease from RSV infection. Each year in the United States, RSV leads to on average approximately 58,000 hospitalizations with 100-500 deaths among children younger than 5 years old and 177,000 hospitalizations with 14,000 deaths among adults aged 65 years or older. In the United States, RSV infections occur primarily during the fall and winter cold and flu season. In April 2020, RSV activity decreased rapidly, likely due to the adoption of public health measures to reduce the spread of COVID-

Clark County Combined Health District 1 of 3 Health Alert: Summer Influenza Surveillance_6.24.21

Main Office Phone: (937) 390-5600 529 East Home Road Fax: (937) 390-5625 Springfield, OH 45503 Email: [email protected]

Clark County Combined Health District- Health Advisory Summer Influenza Surveillance and Increased RSV Activity June 28, 2021

19. Compared with previous years, RSV activity remained relatively low from May 2020 to March 2021. However, since late March, CDC has observed an increase in RSV detections reported to the National Respiratory and Enteric Virus Surveillance System (NREVSS), a nationwide passive, laboratory-based surveillance network. CDC noted increases in laboratory detections and in the percentages of positive detections for both antigen and PCR testing in parts of HHS Region 4 (Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee) and Region 6 (Arkansas, Louisiana, New Mexico, Oklahoma, and Texas). Due to limited testing outside of the typical RSV season, data are limited in some jurisdictions and may be incomplete for the most recent weeks. Since this elevated interseasonal activity is a deviation in the typical circulation patterns for RSV, at this time it is not possible to anticipate the likely spread, peak, or duration of activity with any certainty. Health officials also identified increased interseasonal RSV circulation in parts of Australia during late 2020 and in South Africa in early 2021. Still, RSV did not reach seasonal peak levels in most regions or result in widespread circulation. Due to reduced circulation of RSV during the winter months of 2020–2021, older infants and toddlers might now be at increased risk of severe RSV-associated illness since they have likely not had typical levels of exposure to RSV during the past 15 months. In infants younger than six months, RSV infection may result in symptoms of irritability, poor feeding, lethargy, and/or apnea with or without fever. In older infants and young children, rhinorrhea and decreased appetite may appear one to three days before cough, often followed by sneezing, fever, and sometimes wheezing. Symptoms in adults are typically consistent with upper respiratory tract infections, including rhinorrhea, pharyngitis, cough, headache, fatigue, and fever. There is no specific treatment for RSV infection other than symptom management. Recommendations 1. Clinicians and caregivers should be aware of the typical clinical presentation of RSV for different age groups. 2. Clinicians should consider testing patients with a negative SARS-CoV-2 test and acute respiratory illness or the age-specific symptoms presented above for non-SARS-CoV-2 respiratory pathogens, such as RSV. Real-time reverse transcription-polymerase chain reaction (rRT-PCR) is the preferred method for testing for respiratory viruses. 3. Clinicians should report laboratory-confirmed RSV cases and suspected clusters of severe respiratory illness to local and state health departments according to their routine reporting requirements. 4. Healthcare personnel, childcare providers, and staff of long-term care facilities should avoid reporting to work while acutely ill – even if they test negative for SARS-CoV-2. 5. Clinicians can review weekly updates to the NREVSS website and refer to surveillance data collected by local hospitals and health departments for information on RSV circulation trends in their area. For More Information • CDC – RSV Information for Healthcare Providers • CDC – RSV National Trends – NREVSS • CDC – RSV Trends and Surveillance • CDC – RSV Symptoms and Care Attachments • Collection and Submission of Influenza Specimens, ODH • ODH Laboratory Microbiology Specimen Submission For • CDC Health Alert Network (HAN) Health Alert 443 - Increased Interseasonal Respiratory Syncytial Virus (RSV) Activity in Parts of the Southern United States

Clark County Combined Health District 2 of 3 Health Alert: Summer Influenza Surveillance_6.24.21

Main Office Phone: (937) 390-5600 529 East Home Road Fax: (937) 390-5625 Springfield, OH 45503 Email: [email protected]

Clark County Combined Health District- Health Advisory Summer Influenza Surveillance and Increased RSV Activity June 28, 2021

If you are receiving this health advisory via fax, please visit the CCCHD website to view a digital copy with clickable links. In the future, if you wish receive health alerts electronically, please contact [email protected].

Alert Details Date: 6/28/21 Time Sensitivity: Moderate To: Medical offices, Urgent Cares, Clinics, Hospitals, Laboratories and ICPs Target Audience: Physicians, PA, NP, Nurses, Medical Staff, ICP staff, and Laboratorians From: Clark County Combined Health District

Subject: Summer Influenza Surveillance and Increased RSV Activity Relevance to Public Health: High

Clark County Combined Health District 3 of 3 Health Alert: Summer Influenza Surveillance_6.24.21

Collection and Submission of Influenza Specimens

When to collect influenza specimens • Within three days of symptom onset, preferably as soon as possible after onset. Specimens collected up to 10 days after onset of symptoms may be submitted if necessary.

How to collect influenza specimens Collect one nasopharyngeal (NP) specimen with viral transport media from each patient, using the following methods: Nasopharyngeal Swab • Use swabs with a synthetic tip (e.g., polyester or Dacron®) and an aluminum or plastic shaft. • Assure that the transport media used for specimen collection is not expired. • Insert a dry swab into one nostril straight back (not upwards) and back to the nasopharynx. • The distance from the patient’s nose to the ear gives an estimate of the distance the swab should be inserted. • Allow swab to remain in place for a few seconds to absorb secretions. • Rotate the swab gently 2-3 times and withdraw slowly. • Place the swab in container with viral transport media, break off end of swab so that it fits in container. o Types of acceptable transport media are: viral transport media (VTM), universal transport media (UVT), M4, or M5 media. • Label the container with patient name, patient date of birth, date of collection, and type of specimen. This information must match the information on the submission form. • Specimens may be refrigerated (4°C) for up to five days before shipping. If specimens cannot be shipped within 5 days, specimens should be frozen and shipped on dry ice.

How to submit specimens to the ODH Laboratory • Call the ODH Bureau of Infectious Diseases at 614-995-5599 between 8:00 am and 5:00 pm on weekdays for approval for specimen submission. • Complete the Ohio Department of Health Laboratory Microbiology Specimen Submission Form for each specimen (fill out a separate form for each NP specimen) as completely as possible. o Indicate in the comments section why the specimen was submitted • Place collected specimen (primary media container) and one frozen cold pack in a sealed plastic bag (or other watertight secondary packaging). • If the specimen is frozen it is preferable that it is shipped on dry ice (use a shipping container suitable for shipping dry ice). • Place sealed plastic bag in a rigid third container, such as a fiberboard box. • Overnight shipment is preferred for receipt within 24 hours. Specimens collected on a Friday should be held for shipment until the following Monday. Follow protocols for standard interstate shipment of etiologic agents. All shipments must comply with current DOT/IATA regulations for Category B Biological Substances, as listed above. • Mail package to the following address: Ohio Department of Health Laboratory Attn: Virology 8995 E. Main St., Building # 22 Reynoldsburg, OH 43068 • If you have any questions, please call the ODH Bureau of Infectious Diseases at 614-995-5599. • For situations that need immediate attention, please contact ODH Infectious Disease On-Call (IDOC) at 614- 722-7221 per normal procedures. Do not call IDOC to notify ODH of specimen submissions.

Revised 6/2/2021

Ohio Department of Health Laboratory CLIA Certification # 36D0655844 8995 East Main Street Phone: 888-634-5227 Building 22 Fax: 614-387-1505 Reynoldsburg, OH 43068 Email: [email protected] Microbiology Specimen Submission Form Note: Fields marked with an asterisk (*) must be completed. Please print. Section 1: Patient Information Patient Name* Date of Birth* (Last, First, MI) (mm/dd/year) Address County Sex* 0 Female 0 Male

City State Zip Chart or* Patient ID# Section 2: Submitter Information Agency* Contact* Name Name Address Fax* Number City State Zip Phone* Number Section 3: Specimen Information (Complete all that apply) Collection* Onset* ODH Date Date Outbreak# Submitter* Agent* Specimen* Type 0 Clinical 0 Isolate Specimen ID# Suspected *Specimen Site (Check all that apply) 0 Abscess-Specify (0 Aspirate 0 Swab) 0 Respiratory, Upper-Specify (0 NP swab 0 OP swab) 0 Tissue-Specify:______

0 Blood-Specify (0 Plasma 0 Whole) 0 Respiratory, Lower-Specify Below: 0 Urine

0 Sputum (0 Induced 0 Expectorated) 0 BAL 0 TA 0 Body Fluid-Specify Below: 0 Wound-Specify:______For mycobacteria only: 0 Processed 0 Unprocessed 0 CSF 0 Other:______0 Other: 0 Stool-Specify Below: 0 Cary Blair 0 Enteric Broth 0 10% Formalin 0 Bulk 0 Serum-Specify (0 Acute 0 Conv.) Section 4: Exam Requested (Check all that apply) **ODH approval required prior to submission; Contact 614-995-5599 Microbiology 0 Biothreat Agent-Specify Below: 0 Clostridium botulinum** 0 Neisseria meningitidis 0 Shigella

0 Enteric Pathogen Panel** 0 Norovirus** 0 Vibrio

0 Bacterial Strain Typing** 0 Escherichia coli (STEC) 0 Salmonella 0 Yersinia

0 Campylobacter 0 Listeria monocytogenes 0 Other: Mycobacteriology 0 Mycobacterial Smear and Culture 0 M. tuberculosis Nucleic Acid Amplification (NAA) 0 M. tuberculosis , Genotyping only

0 Mycobacterial Identification 0 M. tuberculosis Susceptibility Testing (SM, INH, RIF, EMB, PZA) 0 Other: Parasitology Virology 0 Cryptosporidium 0 Giardia 0 Other: 0 Respiratory Virus 0 Other:

Comments: For Use by the Ohio Department of Health Laboratory Only Date Received Date Reported

Fee Due MI

Exemption ODH LAB ID

ODH Form HEA 2530 (Revised 12/2018) HAN Archive - 00443 | Health Alert Network (HAN)

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Emergency Preparedness and Response

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Distributed via the CDC Health Alert Network June 10, 2021, 1:30 PM ET CDCHAN-00443

Summary The Centers for Disease Control and Prevention (CDC) is issuing this health advisory to notify clinicians and caregivers about increased interseasonal respiratory syncytial virus (RSV) activity across parts of the Southern United States. Due to this increased activity, CDC encourages broader testing for RSV among patients presenting with acute respiratory illness who test negative for SARS-CoV-2, the virus that causes COVID-19. RSV can be associated with severe disease in young children and older adults. This health advisory also serves as a reminder to healthcare personnel, childcare providers, and staff of long-term care facilities to avoid reporting to work while acutely ill – even if they test negative for SARS-CoV-2.

Background RSV is an RNA virus of the genus Orthopneumovirus, family Pneumoviridae, primarily spread via respiratory droplets when a person coughs or sneezes, and through direct contact with a contaminated surface. RSV is the most common cause of bronchiolitis and pneumonia in children under one year of age in the United States. Infants, young children, and older adults with chronic medical conditions are at risk of severe disease from RSV infection. Each year in the United States, RSV leads to on average approximately 58,000 hospitalizations1 with 100-500 deaths among children younger than 5 years old2 and 177,000 https://emergency.cdc.gov/han/2021/han00443.asp[6/10/2021 3:51:55 PM] HAN Archive - 00443 | Health Alert Network (HAN)

hospitalizations with 14,000 deaths among adults aged 65 years or older.3

In the United States, RSV infections occur primarily during the fall and winter cold and flu season. In April 2020, RSV activity decreased rapidly, likely due to the adoption of public health measures to reduce the spread of COVID-19.4 Compared with previous years, RSV activity remained relatively low from May 2020 to March 2021. However, since late March, CDC has observed an increase in RSV detections reported to the National Respiratory and Enteric Virus Surveillance System (NREVSS), a nationwide passive, laboratory- based surveillance network. CDC noted increases in laboratory detections and in the percentages of positive detections for both antigen and PCR testing in parts of HHS Region 4 (Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee) and Region 6 (Arkansas, Louisiana, New Mexico, Oklahoma, and Texas). Due to limited testing outside of the typical RSV season, data are limited in some jurisdictions and may be incomplete for the most recent weeks. Since this elevated interseasonal activity is a deviation in the typical circulation patterns for RSV, at this time it is not possible to anticipate the likely spread, peak, or duration of activity with any certainty. Health officials also identified increased interseasonal RSV circulation in parts of Australia during late 2020 and in South Africa in early 2021. Still, RSV did not reach seasonal peak levels in most regions or result in widespread circulation.5-7

Due to reduced circulation of RSV during the winter months of 2020–2021, older infants and toddlers might now be at increased risk of severe RSV-associated illness since they have likely not had typical levels of exposure to RSV during the past 15 months. In infants younger than six months, RSV infection may result in symptoms of irritability, poor feeding, lethargy, and/or apnea with or without fever. In older infants and young children, rhinorrhea and decreased appetite may appear one to three days before cough, often followed by sneezing, fever, and sometimes wheezing. Symptoms in adults are typically consistent with upper respiratory tract infections, including rhinorrhea, pharyngitis, cough, headache, fatigue, and fever. There is no specific treatment for RSV infection other than symptom management.

Recommendations

1. Clinicians and caregivers should be aware of the typical clinical presentation of RSV for different age groups. 2. Clinicians should consider testing patients with a negative SARS-CoV-2 test and acute respiratory illness or the age-specific symptoms presented above for non-SARS-CoV-2 respiratory pathogens, such as RSV. Real-time reverse transcription-polymerase chain reaction (rRT-PCR) is the preferred method for testing for respiratory viruses. 3. Clinicians should report laboratory-confirmed RSV cases and suspected clusters of severe respiratory illness to local and state health departments according to their routine reporting requirements. 4. Healthcare personnel, childcare providers, and staff of long-term care facilities should avoid reporting to work while acutely ill – even if they test negative for SARS-CoV-2. 5. Clinicians can review weekly updates to the NREVSS website and refer to surveillance data collected

https://emergency.cdc.gov/han/2021/han00443.asp[6/10/2021 3:51:55 PM] HAN Archive - 00443 | Health Alert Network (HAN)

by local hospitals and health departments for information on RSV circulation trends in their area.

For More Information

CDC – RSV Information for Healthcare Providers CDC – RSV National Trends – NREVSS CDC – RSV Trends and Surveillance CDC – RSV Symptoms and Care

References 1Rha B, Curns AT, Lively JY, Campbell AP, Englund JA, Boom JA, Azimi PH, Weinberg GA, Staat MA, Selvarangan R, Halasa NB, McNeal MM, Klein EJ, Harrison CJ, Williams JV, Szilagyi PG, Singer MN, Sahni LC, Figueroa-Downing D, McDaniel D, Prill MM, Whitaker BL, Stewart LS, Schuster JE, Pahud BA, Weddle G, Avadhanula V, Munoz FM, Piedra PA, Payne DC, Langley G, Gerber SI. Respiratory Syncytial Virus- Associated Hospitalizations Among Young Children: 2015-2016. Pediatrics. 2020 Jul;146(1):e20193611. doi: 10.1542/peds.2019-3611. Epub 2020 Jun 16. PMID: 32546583. 

2Thompson WW, Shay DK, Weintraub E, Brammer L, Cox N, Anderson LJ, Fukuda K. Mortality associated with influenza and respiratory syncytial virus in the United States. JAMA. 2003 Jan 8;289(2):179-86. doi: 10.1001/jama.289.2.179. PMID: 12517228. 

3Falsey AR, Hennessey PA, Formica MA, Cox C, Walsh EE. Respiratory syncytial virus infection in elderly and high-risk adults. N Engl J Med. 2005 Apr 28;352(17):1749-59. doi: 10.1056/NEJMoa043951. PMID: 15858184. 

4Haddadin Z, Schuster JE, Spieker AJ, Rahman H, Blozinski A, Stewart L, Campbell AP, Lively JY, Michaels MG, Williams JV, Boom JA, Sahni LC, Staat M, McNeal M, Selvarangan R, Harrison CJ, Weinberg GA, Szilagyi PG, Englund JA, Klein EJ, Curns AT, Rha B, Langley GE, Hall AJ, Patel MM, Halasa NB. Acute Respiratory Illnesses in Children in the SARS-CoV-2 Pandemic: Prospective Multicenter Study. Pediatrics. 2021 May 13:e2021051462. doi: 10.1542/peds.2021-051462. Epub ahead of print. PMID: 33986150. 

5Foley DA, Yeoh DK, Minney-Smith CA, Martin AC, Mace AO, Sikazwe CT, Le H, Levy A, Moore HC, Blyth CC. The Interseasonal Resurgence of Respiratory Syncytial Virus in Australian Children Following the Reduction of Coronavirus Disease 2019-Related Public Health Measures. Clin Infect Dis. 2021 Feb 17:ciaa1906. doi: 10.1093/cid/ciaa1906. Epub ahead of print. PMID: 33594407; PMCID: PMC7929151  .

6Virus Watch  , Week Ending 30 May 2021. Government of Western Australia, Department of Health. Accessed 6/7/2021.

7Weekly Respiratory Pathogens Surveillance Report  , South Africa, Week 21, 2021. National Institute for Communicable Diseases, Division of the National Health Laboratory Service. Accessed 6/7/21.

https://emergency.cdc.gov/han/2021/han00443.asp[6/10/2021 3:51:55 PM] HAN Archive - 00443 | Health Alert Network (HAN)

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