Operational Biosurveillance

Forecast Warning Sequence: 2012-2013 US Influenza Season

As the US national influenza season peaks out, it is important to review the importance of operational forecasting, "live" situational awareness, and proactive response in the local community setting.

Introduction

The Ascel Bio National Infectious Disease Forecast Center resides on the Western Slope of Colorado and issues monthly forecasts and "live" advisories covering approximately 100 infectious diseases.  The director of the center is a practicing pediatrician whose patients voluntarily sign up for access to the forecasts.  These forecasts are distrbuted electronically to local healthcare providers, school nurses, veterinarians, public health officials, pharmacists, EMS, and other members of the networked healthcare community.

The lay community is sharply polarized between those who vaccinate their children versus those who refuse the influenza vaccine only or the entire pediatric vaccination series (e.g., DTaP, HIB, IPV, Rota, etc).  This belief system does not fall squarely within one political bias or another such as liberal versus conservative.  However, the anti-vaccination belief system is firmly rooted in this rural community and is extremely difficult to counteract through clinical guidance.

Forecast Warning Sequence

The forecast warning sequence for the 2012-2013 influenza season has been previously described here.  This is the second time our team has successfully forecasted a vaccine drift season of influenza. 

 Forecasts were issued to the local community as such:

1. The community was pre-sensitized in the first week of September to the topic of influenza as a result of advisories issued by the Center regarding the local county agriculture fair (i.e. the concern of emerging A/H3N2 variant).
2. This was followed by the general forecast, which again emphasized concern for emerging A/H3N2 variant in late September.
3. In October, concern about a vaccine drift season of influenza was shared with patient families in the clinic, with emphasis on the need to vaccinate with the seasonal vaccine.  It was expressed the vaccine was expected to be well-matched to the drifted strains.  Limitations of vaccine efficacy overall were known to the clinician and expressed to patient families such as the vaccine is thought to prevent hospitalization, severe morbidity, and mortality.  This face to face dialog was maintained with every family that came to the clinic, regardless of chief complaint, throughout the season.
4. On October 25th, the November-December forecast was released to the community, which emphasized the same points described in bullet #3 above. 
5. On November 14th, an advisory was issued that described the first hospitalization of a combined RSV/influenza B patient. 
6. The December-January forecast was released on December 2nd, again emphasizing the need to vaccinate for influenza. 
7. Another advisory issued on December 12th with the second hospitalization of RSV/influenza B.
8. On January 7th, the January-February forecast was issued, again with emphasis on vaccination.

Results Thus Far

• All hospitalizations have been of children either incompletely or totally unvaccinated with this season's influenza.
• We have "converted" 4 families (each with between 1-3 children) who previously were staunch opponents to the influenza vaccine.
• Only 2 families (x2 children) refused influenza vaccination.  We estimate >99% compliance.
• The pediatric service has not been overwhelmed by influenza hospitalizations.  We have seen less than 5 children who presented at the outpatient level that were previously vaccinated.  None of these children had serious disease.

Preliminary Conclusions

• Development of trust with the receiver community was paramount to successful deployment of infectious disease forecasts.
• Issuance of operational forecasts coupled to updated "live" advisories drove compliance.
• Full transparency about vaccine efficacy directly relates to maintenance of trust with patient families.
• Issuance of operational forecasts coupled to updated "live" advisories that were trusted by the public ultimately resulted in mitigation of surge within a fragile pediatric healthcare infrastructure. 
• Prevention of hospitalization or transfer out of facility due to influenza is more cost-effective than lack of an aggressive vaccination education campaign facilitated by forecast and tactical warning.

 

 

 

Influenza A/H3N2 Variant: 50 Times The Fatality Rate of Pandemic H1N1

Current case counts for A/H3N2 variant is 289, with 15 hospitalizations and now finally we see our first fatality.  The hospitalization rate is 5.2%, which is more than 10 times the hospitalization rate of pandemic H1N1.  It is notable that we initially projected a "ballpark" estimate of more than 15,000 cases before we would see our first fatality, if the pediatric fatality rate was approximate to that of pandemic H1N1 (i.e. 0.006%- see below).  That is no longer the case.  Obviously, observation of fatal cases can occur at any time within a sample size of 15,000.

CDC's estimates for cases, hospitalizations, and fatalities for the 2009 H1N1 pandemic are as follows:

Total cases (all ages): 61 milllion

Total hospitalizations (all ages): 274,000 (0.4%)

Total fatalities (all ages): 12,470 (0.02%)

Total pediatric cases: 20 million

Total pediatric hospitalizations (all ages): 87,000 (0.4%)

Total pediatric fatalities (all ages): 1,280 (0.006%)

Current CDC estimates for influenza A/H3N2 variant are as follows, which were posted 4 days ago:

289 cases since July 2012

15 hospitalizations (5.1%)

1 fatality (CFR 0.3%)

Therefore, current statistics place influenza A/H3N2 variant at more than 12x and a fatality rate 50x that of pandemic H1N1.

The question is, "how accurate are these stats?"  We of course only know what we clinically recognize and test for.  After years of monitoring influenza, one is reminded of the tremendous uncertainty associated with the ever-elusive denominator. 

This has now become the "Super Bowl" of emergency public health.  If HHS is able to recognize this agent going "hot" fast enough (i.e. recognition of sustained human-human transmission) to execute production of vaccine ahead of a wave of transmission, then public health will claim a major and significant victory.  There is no guarantee this will happen, of course. 

Influenza A/H3N2 variant is top infectious agent that should be on any operational biosurveillance analyst's radar.

 

 

 

Influenza A/H3N2 Variant: Ten Times the Hospitalization Rate of Pandemic H1N1

CDC has now released updated statistics for influenza A/H3N2 variant.  This is an emerging strain of type A/H3N2, which is a triple-reassortant strain that includes genetic sequences from pandemic H1N1.  Transmission has been predominantly swine-human, however there have been three instances of human-human transmission.  It remains unclear whether this virus will supercede current globally circulating influenza A/H3N2.  

Current case counts for A/H3N2 variant is 276, with 13 hospitalizations.  The hospitalization rate is 4.7%.  There have been no fatalities, however the case count is insufficient statistically to "draw out" this observation.  We will need to see an estimate of more than 15,000 cases before we see our first fatality, if the pediatric fatality rate is approximate to that of pandemic H1N1 (i.e. 0.006%- see below).

CDC's estimates for cases, hospitalizations, and fatalities for the 2009 H1N1 pandemic are as follows:

Total cases (all ages): 61 milllion

Total hospitalizations (all ages): 274,000 (0.4%)

Total fatalities (all ages): 12,470 (0.02%)

Total pediatric cases: 20 million

Total pediatric hospitalizations (all ages): 87,000 (0.4%)

Total pediatric fatalities (all ages): 1,280 (0.006%)

Bottom line:

Current hospitalization rate for A/H3N2 variant is more than 10 times that of pandemic H1N1 if considering all ages.  But A/H3N2 variant affects predominantly children.  Therefore, the current pediatric hospitalization rate is 10 times that of pandemic H1N1.  It should be emphasized the current case count for A/H3N2 variant is based on recognized cases and likely reflects a degree of underreporting.

Vigilance and submission of samples for testing is strongly recommended for the pediatric population this fall.

Influenza A/H3N2 Variant: SO WHAT?

[Having engaged in several spirited conversations on various other online forums, I thought the below further explanation might shed more light on the basis of the concern stated in the prior post. -JW]

 

The issue with the current circulation of A/H3N2 variant is:

 

The influenza A/H3N2 variant is a triple-reassortant virus. Federally funded and peer reviewed studies have suggested this agent is capable of triggering a "pandemic", however the probable outcome is the emergence of another "wave" of vigorous, socially disruptive transmission. This is predicated on lack of an available vaccine. That said, HHS/CDC considered the virus concerning enough to advance seed stock to the vaccine manufacturers for mass production.

 

There is no apparent herd immunity in the pediatric population. The parameters at the ag fairs indicate a high degree of efficiency in swine-human transmission. Human to human transmission this summer has yet to be identified, however last summer this was suspected as several of the cases had no history of exposure to swine.

 

The driving concern from a virulence perspective is NOT case fatality rate but the potential for abrupt and explosive transmission at a national / global level, producing a situation of infrastructure inundation. The law of numbers predicts greater numbers of patients hospitalized and recognition of the first fatality. The currently recognized case count precludes any firm conclusions about the clinical profile of this agent.

 

Comparisons to H5N1 highlight a typical human bias in focusing on the most severe clinical outcomes versus disease capable of generating acute, broad-scale disruption to medical infrastructure writ large. As stated in the original content, this situation therefore represents a serious risk. High morbidity disruptor agents are extremely difficult to surveil due to human bias in reporting mortality over morbidity- hence the reason why CDC in pushing diagnostic kits out to the state labs. Another indicator of the seriousness with which professionals in this domain are treating the issue.

 

The name of the game when it comes to medical infrastructure (and community) resilience is whether or not an infectious disease event is "routine". Unexpected explosive transmission of an agent like this is likely to generate infrastructure inundation according to this scheme: outpatient > inpatient > ICU level care > excession of capacity & capability.

 

The mitigation challenge is to determine how quickly an agent will evolve towards a profile of human-human transmission versus how fast we will recognize what is happening versus how fast vaccine can be put into production versus how quickly it can be distributed. As it stands, if A/H3N2 variant takes off, we have no vaccine at our disposal.  HHS/CDC is certainly aware of this challenge, as indicated by their recent public statements.

 

The CURRENT profile of A/H3N2 variant is one of a mild infection but apparently very efficient at transmitting between swine and humans. Swine are considered "mixing vessels" for influenza viruses, which is the reason why this particular virus has genetic sequences from human strains of pandemic H1N1. Therefore, the forward evolutionary path of A/H3N2 variant is one of the following:

 

1. Nothing. The virus remains stable with the same clinical profile.

2. Further reassortment with circulating seasonal influenza strains to produce another variant able to transmit efficiently human-human... with an undefined clinical profile

3. Further molecular adaptation to humans, to produce another variant able to transmit efficiently human-human... with an undefined clinical profile.

4. A combination of #2 and #3 above.

5. Evolutionary competition forces A/H3N2 variant out of circulation.

 

The key question, not answered above, was how did pandemic H1N1 emerge in the first place? If one goes back to CDC advisories on swine influenza in the years preceding the 2009 pandemic, one notices the possible footprints of a virus that seemed at that time to be "not a big deal". Yet then we had an unexpected pandemic. On the other hand, H5N1 has failed for years to evolve to a point of efficient human-human transmission. Again, this shows the unpredictability of influenza virus molecular evolution... and how little we truly understand this pathogen.

 

Rapid Emergence of Influenza A/H3N2 Variant: Now What?

Most people are reassured by reports of influenza A/H3N2 producing a mild infection, yet ignore the five-fold increase in cases now observed in states hosting agricultural fairs.  The case count now stands at 158 (that have been detected and recognized).  Most infectious disease specialists would say, "Big deal, most of the infections are mild."  The typical hospitalization rate for influenza is low, and the case fatality rate very low. 

But that isn't the primary concern with influenza.  It is community penetrance: the efficiency and pervasiveness of transmission that becomes the problem.  It is the reason why we consider influenza to be a top infectious agent disruptor due to the sheer volume of case counts and impact on the medical infrastructure at all levels of care.  It is the law of numbers that is the problem. It is the rapid evolution of co-existence with the host (i.e. habituation) that is the key issue.  For this biodefense professional and practicing pediatrician, I care about the case count "tsunami" effect more than a highly localized, relatively low case count but high case fatality rate crisis exemplified by the recent Ebola outbreak in Uganda.

We currently live in a situation of economic austerity, where both physicians and public health have been severely impacted by changed in healthcare.  Recent reports have suggest a full 1/3 of physicians are actively looking to retire within the next 10 years. 

Further, pediatric healthcare is not a prioritized subset of our healthcare infrastructure.  We spend far more money as Americans keeping the dying alive for an extra couple of weeks than we do taking care of our children.  Hence, the pediatric infrastructure is vulnerable to sudden surge in patient volume and complexity. 

Therefore, the emergence of a new strain of influenza that predominantly effects children is a serious problem from the perspective of this practicing pediatrician.  The persistent lack of education in the public about vaccination is another serious issue.  That said, we have noted in the past that those who refuse vaccination for their child often change their mind if community heresay produces report of children in the hospital- especially if that child winds up on a ventilator or dies.  Unfortunately, herd immunity comes at a cost, where the current social attitude is to effectively use the children of our community as a canary in a coal mine- one of them has to go down to convince the not-insignificant subset of vaccine refusers to vaccine and contribute to protective herd immunity.

But we get ahead of ourselves.  The key questions to ask now are the following:

1. What are the policy triggers to execute release into production of the seed strains already sent to the vaccine manufacturers?
2. What is the current time delta for vaccine production?  Two months?  Four months?  Six?
3. How quickly is HHS able to distribute the produced vaccine nationwide?

CDC should be commended for pushing laboratory testing capacity out to the states.  It is clear this has helped to boost the gain on signature recognition.  Based on the experience with the 2009 H1N1 influenza pandemic, the first wave of impact observed weeks before many communities saw distribution of vaccine.  In the case of A/H3N2v, we have been provided more warning time.  It will now be interesting to see if we as a nation are able to proactively execute on that increased warning opportunity.

 

 

Increase in Influenza A H3N2v Virus Infections in Three U.S. States

CDC HEALTH ADVISORY - Increase in Influenza A H3N2v Virus Infections in Three U.S. States
 
This is an official  CDC HEALTH ADVISORY
 
Distributed via the CDC Health Alert Network.  August 3, 2012, 11:00 ET CDCHAN-00325-ADV-N
 
Increase in Influenza A H3N2v Virus Infections in Three U.S. States

Summary and Background
 
Multiple infections with variant* influenza A (H3N2v) viruses have been identified in 3 states in recent weeks. From July 12 through August 3, 2012, 16 cases of H3N2v were reported and confirmed by CDC. This virus was first detected in humans in July 2011. It has also been isolated in U.S. swine in many U.S. states. Since July 12, 2011, there have been 29 cases of H3N2v virus infection, including the 16 cases occurring in the last three weeks.  All 29 cases were infected with H3N2v viruses that contain the matrix (M) gene from the influenza A (H1N1)pdm09 virus. This M gene may confer increased transmissibility to and among humans, compared to other variant influenza viruses. All cases have been laboratory-confirmed at CDC. Each of the 16 cases identified since July 12, 2012, reported contact with swine prior to illness onset; in 15 cases, contact occurred while attending or exhibiting swine at an agricultural fair. While the viruses identified in these cases are genetically nearly identical, separate swine exposure events in each state were associated with human infections. There is no indication that the cases in different states are epidemiologically related.
 
Clinical characteristics of the 16 H3N2v recent cases have been generally consistent with signs and symptoms of seasonal influenza, and have included fever, cough, pharyngitis, myalgia, and headache. No hospitalizations or deaths have occurred among the 16 confirmed cases since July 2012. Public health and agriculture officials are investigating the extent of disease among humans and swine, and additional cases are likely to be identified as the investigation continues.
 
Novel influenza A virus infection has been a nationally notifiable condition in the United States since 2007. Since that time, human infection with animal-origin influenza viruses has been rare, with ≤6 cases reported each year, until 2011 when 14 cases were identified. While most of the cases are thought to have been infected as a result of close contact with swine, limited human-to-human transmission of this virus was identified in some cases in 2011. Therefore, enhanced influenza surveillance is indicated, especially in regions and states with confirmed H3N2v cases.
 
Interim Recommendations for the Public
 
·   Persons who are at high risk for influenza complications (e.g., underlying chronic medical conditions such as asthma, diabetes, heart disease, or neurological conditions, or who are pregnant or younger than 5 years, older than 65 years of age or have weakened immune systems) should consider avoiding exposure to pigs and swine barns this summer, especially if ill pigs have been identified.
·   Persons engaging in activities that may involve swine contact, such as attending agricultural events or exhibiting swine, should wash their hands frequently with soap and running water before and after exposure to animals; avoid eating or drinking in animal areas; and avoid close contact with animals that look or act ill.
·   Patients who experience influenza-like symptoms following direct or close contact with pigs and who seek medical care should inform their health care provider about the exposure.
·   Patients with influenza-like illness who are at high risk for influenza complications (e.g., underlying chronic medical conditions such as asthma, diabetes, heart disease, or neurological conditions, or who are pregnant or younger than 5 years, older than 65 years of age or have weakened immune systems) should see their health care provider promptly to determine if treatment with antiviral medications is warranted.
·   Influenza viruses have not been shown to be transmissible to people through eating properly handled and prepared pork or other products derived from pigs. For more information about the proper handling and preparation of pork, visit the USDA website fact sheet “Fresh Pork from Farm to Table.”
 
Interim Recommendations for Health Care Providers
 
·   Clinicians who suspect influenza in persons with recent exposure to swine should obtain a nasopharyngeal swab or aspirate from the patient, place the swab or aspirate in viral transport medium, and contact their state or local health department to arrange transport and request a timely diagnosis at a state public health laboratory.
·   Reverse-transcription polymerase chain reaction (RT-PCR) testing for influenza should be considered for patients with influenza-like illness prior to the start of the traditional influenza season in October.
·   RT-PCR testing for influenza should be considered throughout the year for patients with influenza-like illness reporting recent swine exposure and for those who can be epidemiologically linked to confirmed cases of variant influenza.
·   Commercially available rapid influenza diagnostic tests (RIDTs) may not detect H3N2v virus in respiratory specimens. Therefore, a negative rapid influenza diagnostic test result does not exclude infection with H3N2v or any influenza virus. In addition, a positive test result for influenza A cannot confirm H3N2v virus infection because these tests cannot distinguish between influenza A virus subtypes (they do not differentiate between human influenza A viruses and H3N2v virus). Therefore, respiratory specimens should be collected and sent for RT-PCR testing at a state public health laboratory.
·   Clinicians should consider antiviral treatment with oral oseltamivir or inhaled zanamivir in patients with suspected or confirmed H3N2v virus infection. Antiviral treatment is most effective when started as soon as possible after influenza illness onset.
 
 
For more information:
 
·   “Interim Guidance on Case Definitions to be Used for Investigations of Influenza A (H3N2) Variant Virus Cases” for state and local health departments is   available at http://www.cdc.gov/flu/swineflu/case-definitions.htm.
·   “Prevention Strategies for Seasonal and Influenza A(H3N2)v in Health Care Settings” is available at http://www.cdc.gov/flu/swineflu/prevention-strategies.htm.
·   “Interim Guidance on Specimen Collection, Processing and Testing for Patients with Suspected Influenza A (H3N2) Variant Virus Infection” for public health professionals is  available at http://www.cdc.gov/flu/swineflu/h3n2v-testing.htm, and
·   “Interim Guidance for Influenza Surveillance: Additional Specimen Collection for Detection of Influenza A (H3N2) Variant Infections” for state and local health departments is available at  http://www.cdc.gov/flu/swineflu/h3n2v-surveillance.htm.
·   Compendium of Measures to Prevent Disease Associated with Animals in Public Settings, 2011 is available at http://nasphv.org/documentsCompendiumAnimals.html

 
*Influenza viruses that circulate in swine are called swine influenza viruses when isolated from swine, but are called variant viruses when isolated from humans.
 
The Centers for Disease Control and Prevention (CDC) protects people's health and safety by preventing and controlling diseases and injuries; enhances health decisions by providing credible information on critical health issues; and promotes healthy living through strong partnerships with local, national, and international organizations.

ADVISORY (Updated): Influenza in Previously Vaccinated Patients (Pacific NW and Colorado, USA)

Per our prior Advisory, we have report of another metropolitan hospital in the Pacific NW seeing influenza in previously vaccinated children. 

Here in western Colorado, we saw the death of an elderly woman who had a prior medical history of chronic pulmonary disease.  Both she and her husband were vaccinated for influenza, but the husband was the first to be infected, then the wife who later succumbed.

A notable phenomenon given we forecasted this outcome months ago for our hospital, prior to the advent of influenza season.

Several comments from readers indicate a healthy debate related to a chicken-egg problem: is what we are seeing true vaccine drift or simply a poor vaccine match in the first place?  A tricky question to answer...

ADVISORY: Influenza in Previously Vaccinated Children (Pacific NW, USA)

We have report of a significant bump in influenza-positive pediatric patients presenting to a major metropolitan hospital in the Pacific NW, USA over the last 2-3 weeks.  Of note, many of these patients were previously vaccinated for influenza at the start of the school year (~September). 

 

Differential diagnosis (in order of probability):

1. Waning immunity as the predominant type A influenza circulating is H3N2 in the Pacific NW.  Waning immunity over the course of a routine influenza season is an expected phenomenon.  Our team forecasted a moderate vaccine drift probability for A/H3N2 this season several months ago.

2.  Waning immunity as there are still significant levels of circulating A/H1N1 (2009) in the Pacific NW.  We believe this is highly unlikely and forecasted very low probabilities of vaccine drift for A/H1N1.

3.  Possible emergence of other type A influenza viruses such as A/H3N2-variant.  While we believe this is unlikely, we cannot exclude it.  One of the key indicators we have been monitoring is the appearance of influenza in patients who were previously vaccinated.

A Gap in Situational Awareness: A/H3N2v in the United States

The last public update from CDC regarding the status of A/H3N2v in the United States was January 6, referring to information end-dated (and originally posted) on December 23rd (exactly one month ago).  This update did not reflect test results for the Marin County suspect case.  The January 6th MMWR Editorial Note stated:

Human infections with the influenza viruses currently circulating among swine are rare. Since 2005, only 35 cases have been reported in the United States, but the frequency with which they have been detected increased in 2011. When different influenza viruses simultaneously infect a single host (e.g., a human or swine), exchange of genetic material can occur, resulting in a new influenza virus. Depending on the antigenic distance between the new virus and recently circulating seasonal viruses, little or no immunity might exist in the human population.

Despite this apparent concern, situational awareness has been scant, with substantial time deltas between detection and warning noted.  The latest Flu Weekly provides no information on A/H3N2v antigenic characterization.  There is no indication of "samples received for testing" versus "samples actually tested".  Therefore the lab processing backlog is in question.

Put another way:

 

"What is the status of A/H3N2v in the United States???"

 

 

 

 

Social Media, Public Health Accountability, and The Positive Outcome

If one examines every CDC Flu Weekly report since the 1997-1998 season, one notices stretches of editorial errors and careless data transcription in the early years.  It is almost as if those filling out the reports intuitively knew most people didn't bother to read the deeper complexity of the information- specifically that describing antigenic testing and compatibility with vaccine strains.

After SARS, H5N1 emergence in Asia, and the 2009 H1N1 influenza pandemic, many more are paying attention to the information.   Here in Operational Biosurveillance and elsewhere people noticed the emergence of A/H3N2v being reported and viewed it as an opportunity to tell CDC "here's your chance to make right".  Indeed that appears to be happening, with seed stock being moved to the vaccine manufacturers and very quickly thereafter movement to clinical trials.  These are good measures of progress for an agency we've grown quite frustrated with over the years. 

We are pleased to finally see guidance for clinicians trying to make the difficult decision in the context of an economic recession whether to test for influenza in their patients (i.e. children):

Currently, while there are  low levels of circulating seasonal influenza viruses, CDC recommends increasing collection of specimens from patients with influenza-like illness (ILI) , and having these specimens sent to the state or local laboratory for prioritization for rRT-PCR testing. States should specifically consider increasing collection of specimens from patients presenting with ILI in the following high priority areas:

1. ILI outbreaks, particularly among children in child-care and school settings, since these have been the settings associated with human-to-human influenza A(H3N2)v virus transmission.
2. Unusual or severe presentations of ILI, especially among children.
3. Medically attended ILI and ARI in children under 18 years of age

Our only nit-pick with the recommendations (albeit an important one) is to suggest that pediatricians should at least test medically attended ILI and ARI in children under 18 years of age who were vaccinated for this season's influenza.  This is a loose call at this point given the low number of cases identified so far, however it may overcome social reluctance to test.

We have pinged several physician and pediatric social networks to raise this issue to their attention- that testing children with influenza-like illness may enable quicker decision-making for response.  That we have an opportunity to shorten the time delta to having a vaccine if we need it for our patients.  However we still see "pandemic fatigue" and desensitization to anything related to the word "pandemic".  And yes, with all the talk of healthcare spending cuts physicians do appear to hesitate to test for fear of denial of coverage by insurance.  In our patient population, we hesitate to test because our patients are at poverty level already, without insurance, without Medicaid, and may be paying in cash.  Often these are our sickest patients and the very ones we should test. 

But this entire phenomenon of holding public health accountable for faster reporting of A/H3N2v, transparency in the decision process to move vaccine through trials just in case, and enhanced media visibility to, let's face it, a bare few cases that would have escaped notice just a few short years ago.  Technology does make us more vulnerable because we don't have as much ignorance to be blissful about.  But social media holds us nevertheless responsible for this information and the actions implied by that information.  One only needs to see the hashtag "H3N2" on Twitter to see the wave of social sensitization. 

Here we are hopeful that the convergence of better laboratory diagnostics, risk communication, transparency in response operations, and the accountability provided by social media brings positive change in public health.  And positive change improves our nation's resilience in the face of infectious disease crises.