FluWatch report: September 10 – September 23, 2017 (weeks 37 & 38)

Note: Influenza/ILI activity levels, as represented on this map, are assigned and reported by Provincial and Territorial Ministries of Health, based on laboratory confirmations, sentinel ILI rates and reported outbreaks. Please refer to detailed definitions at the end of the report. Maps from previous weeks, including any retrospective updates, are available in the mapping feature found in the Weekly Influenza Reports.

Figure 1 - Text Description

Figure 1 - Map of overall influenza/ILI activity level by province and territory, Canada

Influenza Surveillance Region	Activity Level
Newfoundland - Central	No Activity
Newfoundland - Eastern	No Activity
Grenfell Labrador	No Activity
Newfoundland - Western	No Activity
Prince Edward Island	No Data
Nova Scotia - Central (Zone 4)	No Activity
Nova Scotia - Western (Zone 1)	No Activity
Nova Scotia - Northern (Zone 2)	No Activity
Nova Scotia - Eastern (Zone 3)	No Activity
New Brunswick - Public Health Region 1	No Data
New Brunswick - Public Health Region 2	No Data
New Brunswick - Public Health Region 3	No Data
New Brunswick - Public Health Region 4	No Data
New Brunswick - Public Health Region 5	No Data
New Brunswick - Public Health Region 6	No Data
New Brunswick - Public Health Region 7	No Data
Nord-est Québec	No Activity
Québec et Chaudieres-Appalaches	No Activity
Centre-du-Québec	Sporadic
Montréal et Laval	Sporadic
Ouest-du-Québec	Sporadic
Montérégie	Sporadic
Ontario - Central East	Sporadic
Ontario - Central West	Sporadic
Ontario - Eastern	No Activity
Ontario - North East	No Activity
Ontario - North West	No Activity
Ontario - South West	No Activity
Ontario - Toronto	Sporadic
Manitoba - Interlake-Eastern	No Activity
Manitoba - Northern Regional	No Activity
Manitoba - Prairie Mountain	No Activity
Manitoba - South	No Activity
Manitoba - Winnipeg	No Activity
Saskatchewan - North	No Activity
Saskatchewan - Central	No Activity
Saskatchewan - South	Sporadic
Alberta - North Zone	Sporadic
Alberta - Edmonton	Sporadic
Alberta - Central Zone	No Activity
Alberta - Calgary	Sporadic
Alberta - South Zone	No Activity
British Columbia - Interior	No Activity
British Columbia - Fraser	Localized
British Columbia - Vancouver Coastal	Sporadic
British Columbia - Vancouver Island	Localized
British Columbia - Northern	No Activity
Yukon	No Activity
Northwest Territories - North	No Activity
Northwest Territories - South	No Activity
Nunavut - Baffin	No Activity
Nunavut - Kivalliq	No Activity
Nunavut - Kitimeot	No Activity

Laboratory Confirmed Influenza Detections

In weeks 37-38, the number of tests positive for influenza remained at interseasonal levels. The percentage of tests positive was low and remained at similar levels compared to the previous 2-week period (2.4% in week 38). The number and percentage of influenza A tests positive remains higher for this time of year than was observed during the previous seven seasons. Influenza B detections remain low and in keeping with previous seasons. For data on other respiratory virus detections, see the Respiratory Virus Detections in Canada Report.

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

Figure 2 - Text Description

Figure 2 - Number of positive influenza tests and percentage of tests positive, by type, subtype and report week, Canada, 2016-17

Report Week	A(Unsubtyped)	A(H3)	A(H1)pdm09	Influenza B
35	4	20	6	5
36	7	28	1	3
37	7	14	13	4
38	19	31	3	5
39	0	0	0	0
40	0	0	0	0
41	0	0	0	0
42	0	0	0	0
43	0	0	0	0
44	0	0	0	0
45	0	0	0	0
46	0	0	0	0
47	0	0	0	0
48	0	0	0	0
49	0	0	0	0
50	0	0	0	0
51	0	0	0	0
52	0	0	0	0
1	0	0	0	0
2	0	0	0	0
3	0	0	0	0
4	0	0	0	0
5	0	0	0	0
6	0	0	0	0
7	0	0	0	0
8	0	0	0	0
9	0	0	0	0
10	0	0	0	0
11	0	0	0	0
12	0	0	0	0
13	0	0	0	0
14	0	0	0	0
15	0	0	0	0
16	0	0	0	0
17	0	0	0	0
18	0	0	0	0
19	0	0	0	0
20	0	0	0	0
21	0	0	0	0
22	0	0	0	0
23	0	0	0	0
24	0	0	0	0
25	0	0	0	0
26	0	0	0	0
27	0	0	0	0
28	0	0	0	0
29	0	0	0	0
30	0	0	0	0
31	0	0	0	0
32	0	0	0	0
33	0	0	0	0
34	0	0	0	0

To date this season, 166 laboratory-confirmed influenza detections have been reported, of which 90% have been influenza A. Influenza A(H3N2) has been the most common subtype detected this season, representing 79% of subtyped influenza A detections. Detections from BC and AB represent 66% of the cases reported in this 2-week period, with a further 25% from Ontario. For more detailed weekly and cumulative influenza data, see the text descriptions for Figures 2 and 3 or the Respiratory Virus Detections in Canada Report.

Figure 3 - Text Description

Figure 3 - Cumulative numbers of positive influenza specimens by type/subtype and province/territory, Canada, 2016-17

Reporting provincesTable Figure 3 - Footnote 1	Week (September 10, 2017 to September 23)					Cumulative (August 27, 2017 to September 23, 2017)
	Influenza A				B	Influenza A				B	A & B Total
	A Total	A (H1)pdm09	A (H3)	ATable Figure 3 - Footnote UnS	B Total	A Total	A (H1)pdm09	A (H3)	ATable Figure 3 - Footnote UnS	B Total
BC	26	1	20	5	3	53	2	40	11	4	57
AB	20	2	11	7	5	44	8	29	7	9	53
SK	0	0	0	0	0	0	0	0	0	0	0
MB	0	0	0	0	0	0	0	0	0	0	0
ON	27	13	10	4	1	39	13	18	8	3	42
QC	8	0	0	8	0	9	0	0	9	0	9
NB	0	0	0	0	0	1	0	0	1	0	1
NS	0	0	0	0	0	0	0	0	0	0	0
PE	0	0	0	0	0	0	0	0	0	0	0
NL	0	0	0	0	0	0	0	0	0	0	0
YT	0	0	0	0	0	3	0	2	1	0	3
NT	0	0	0	0	0	0	0	0	0	0	0
NU	0	0	0	0	0	0	0	0	0	1	1
Canada	81	16	41	24	9	149	23	89	37	17	166
PercentageTable Figure 3 - Footnote 2	90%	20%	51%	30%	10%	90%	15%	60%	25%	10%	100%
Table Figure 3 - Footnote 1 Specimens from NT, YT, and NU are sent to reference laboratories in other provinces. Return to Table Figure 3 - Footnote 1 referrer Table Figure 3 - Footnote 2 Percentage of tests positive for sub-types of influenza A are a percentage of all influenza A detections. Return to Table Figure 3 - Footnote 2 referrer Table Figure 3 - Footnote UnS Unsubtyped: The specimen was typed as influenza A, but no result for subtyping was available. Return to first Table Figure 3 - Footnote UnS referrer Discrepancies in values in Figures 2 and 3 may be attributable to differing data sources. Cumulative data includes updates to previous weeks.

To date this season, detailed information on age and type/subtype has been received for more than 49 laboratory-confirmed influenza cases (Table 1). Based on the limited data to date, among influenza cases with reported age and type/subtype information, the majority of cases have been reported in adults aged 45-64 years of age (28%) and 65 years and older (43%).

Table 1 - Cumulative numbers of positive influenza specimens by type, subtype and age-group reported through case-based laboratory reporting, Canada, 2017-18, weeks 35 to 38

Age groups (years)	Cumulative (August 27, 2017 to September 23, 2017)
	Influenza A				B	Influenza A and B
	A Total	A(H1) pdm09	A(H3)	A (UnS)Footnote 1	Total	#	%
0-4	6	<5	<5	0	<5	>6	7%
5-19	<5	<5	0	0	<5	5	4%
20-44	21	<5	14	<5	<5	>21	18%
45-64	31	9	11	11	<5	>33	28%
65+	49	<5	40	7	<5	>49	43%
Total	>107	21	>65	21	11	>118	100%
Tableau 1 - Note 1 UnS: unsubtyped: The specimen was typed as influenza A, but no result for subtyping was available; Return to Table 1 - Note 1 Tableau 1 - Note x Supressed to prevent residual disclosure Return to Table 1 - Note x

Syndromic/Influenza-like Illness Surveillance

Healthcare Professionals Sentinel Syndromic Surveillance

In week 38, 1.2% of visits to healthcare professionals were due to influenza-like illness, which follows the expected gradual increase for this time of year. The proportion of visits for ILI remains low, although it is higher than observed over the past five years.

The shaded area represents the maximum and minimum percentage of visits for ILI reported by week from seasons 2012-13 to 2016-17

Figure 4 - Text Description

Figure 4 - Percentage of visits for ILI reported by sentinels by report week, Canada, 2016-17

Report week	2017-18	Average	Min	Max
35	1.0%	0.8%	0.5%	1.2%
36	1.2%	0.8%	0.7%	1.0%
37	1.3%	0.9%	0.7%	1.0%
38	1.2%	1.1%	1.0%	1.4%
39	0.0%	1.1%	0.9%	1.4%
40	0.0%	1.3%	0.9%	1.6%
41	0.0%	1.4%	0.9%	2.4%
42	0.0%	1.4%	1.0%	1.9%
43	0.0%	1.3%	1.0%	1.5%
44	0.0%	1.3%	0.9%	1.6%
45	0.0%	1.3%	1.2%	1.5%
46	0.0%	1.6%	1.0%	2.0%
47	0.0%	1.5%	1.1%	1.9%
48	0.0%	1.6%	0.8%	2.1%
49	0.0%	1.5%	1.0%	2.5%
50	0.0%	2.3%	1.3%	3.7%
51	0.0%	2.5%	1.6%	4.1%
52	0.0%	4.5%	1.7%	7.1%
1	0.0%	3.7%	1.7%	5.2%
2	0.0%	3.0%	1.1%	4.5%
3	0.0%	2.5%	1.3%	3.6%
4	0.0%	2.4%	1.7%	3.5%
5	0.0%	2.7%	2.0%	4.4%
6	0.0%	2.7%	2.1%	3.3%
7	0.0%	2.4%	1.7%	3.0%
8	0.0%	2.3%	1.9%	2.7%
9	0.0%	2.2%	1.8%	2.7%
10	0.0%	2.1%	1.8%	2.7%
11	0.0%	2.1%	1.7%	2.7%
12	0.0%	1.8%	1.1%	2.7%
13	0.0%	1.7%	1.2%	2.6%
14	0.0%	1.8%	1.3%	2.4%
15	0.0%	1.6%	0.9%	1.9%
16	0.0%	1.5%	1.0%	1.9%
17	0.0%	1.5%	0.9%	2.2%
18	0.0%	1.2%	0.8%	1.6%
19	0.0%	1.3%	1.0%	1.7%
20	0.0%	1.2%	0.9%	1.4%
21	0.0%	0.9%	0.3%	1.3%
22	0.0%	0.8%	0.6%	1.0%
23	0.0%	0.9%	0.6%	1.2%
24	0.0%	0.7%	0.4%	1.0%
25	0.0%	1.2%	0.5%	1.6%
26	0.0%	0.8%	0.4%	1.4%
27	0.0%	0.8%	0.4%	1.5%
28	0.0%	1.0%	0.6%	1.9%
29	0.0%	0.8%	0.5%	1.1%
30	0.0%	0.5%	0.3%	0.7%
31	0.0%	0.9%	0.3%	1.4%
32	0.0%	1.0%	0.6%	1.6%
33	0.0%	1.2%	0.4%	2.1%
34	0.0%	0.7%	0.5%	0.9%

Participatory Syndromic Surveillance

FluWatchers is a participatory ILI surveillance system that relies on weekly voluntary submissions of syndromic information from the Canadians across Canada.

The 2017-18 FluWatchers reporting season will begin October 1^st, 2017 (week 40).

Influenza Outbreak Surveillance

In weeks 37-38, two new laboratory-confirmed influenza outbreaks were reported, both in long-term care facilities.

Figure 6 - Text Description

Figure 6 - Cumulative numbers of pediatric hospitalizations (≤16 years of age) with influenza by type and age-group reported by the IMPACT network, Canada, 2016-17

Report week	Hospitals	Long Term Care Facilities	Other
35	0	0	0
36	0	1	0
37	0	0	0
38	0	2	0
39	0	0	0
40	0	0	0
41	0	0	0
42	0	0	0
43	0	0	0
44	0	0	0
45	0	0	0
46	0	0	0
47	0	0	0
48	0	0	0
49	0	0	0
50	0	0	0
51	0	0	0
52	0	0	0
1	0	0	0
2	0	0	0
3	0	0	0
4	0	0	0
5	0	0	0
6	0	0	0
7	0	0	0
8	0	0	0
9	0	0	0
10	0	0	0
11	0	0	0
12	0	0	0
13	0	0	0
14	0	0	0
15	0	0	0
16	0	0	0
17	0	0	0
18	0	0	0
19	0	0	0
20	0	0	0
21	0	0	0
22	0	0	0
23	0	0	0
24	0	0	0
25	0	0	0
26	0	0	0
27	0	0	0
28	0	0	0
29	0	0	0
30	0	0	0
31	0	0	0
32	0	0	0
33	0	0	0
34	0	0	0

Severe Outcomes Influenza Surveillance

Provincial/Territorial Influenza Hospitalizations and Deaths

To date this season, seven influenza-associated hospitalizations have been reported by participating provinces and territories^{Footnote 1} six of which were associated with influenza A, and all cases were adults 45 years of age or older.

Pediatric Influenza Hospitalizations and Deaths

To date this season, less than five laboratory-confirmed influenza-associated pediatric (≤16 years of age) hospitalizations were reported from the Immunization Monitoring Program Active (IMPACT) network.

Influenza Strain Characterizations

During the 2017-18 influenza season, the National Microbiology Laboratory (NML) has characterized five influenza viruses [2 A(H3N2) were characterized genetically and 3 influenza B were characterized antigenically] that were received from Canadian laboratories.

Antigenic Characterization

Table 2 - Influenza antigenic strain characterizations, Canada, 2017-18

Strain Characterization Results	Count	Description
Influenza A (H3N2)
A/Hong Kong/4801/2014-like	0	Viruses antigenically similar to  A/Hong Kong/4801/2014, the A(H3N2) component of the 2017-18 Northern Hemisphere's trivalent and quadrivalent vaccine.
Influenza A (H1N1)
A/Michigan/45/2015-like	0	Viruses antigenically similar to A/Michigan/45/2015, the A(H1N1) component of the 2017-18 Northern Hemisphere's trivalent and quadrivalent influenza vaccine.
Influenza B
B/Brisbane/60/2008-like (Victoria lineage)	0	Viruses antigenically similar to B/Brisbane/60/2008, the influenza B component of the 2017-18 Northern Hemisphere’s trivalent and quadrivalent influenza vaccine.
B/Phuket/3073/2013-like (Yamagata lineage)	3	Viruses antigenically similar to B/Phuket/3073/2013, the additional influenza B component of the 2017-18 Northern Hemisphere quadrivalent influenza vaccine.

Genetic Characterization of A(H3N2) viruses

During the 2017-18 season, two A(H3N2) viruses did not grow to sufficient titers for antigenic characterization by HI assay. Therefore, genetic characterization was performed to determine to which genetic group they belong. Both A(H3N2) viruses belonged to the same genetic group as the vaccine strain, A/Hong Kong/4801/2014 (group 3C.2a).

Antiviral Resistance

During the 2017-18 season, the National Microbiology Laboratory (NML) has tested five influenza viruses for resistance to oseltamivir and zanamivir, and all viruses were sensitive. (Table 3)

Table 3 - Antiviral resistance by influenza virus type and subtype, Canada, 2017-18

Virus type and subtype	Oseltamivir		Zanamivir
	# tested	# resistant (%)	# tested	# resistant (%)
A (H3N2)	2	0 (0%)	2	0 (0%)
A (H1N1)	0	0 (%)	0	0 (%)
B	3	0 (0%)	3	0 (0%)
TOTAL	5	0 (0%)	5	0 (0%)
Note: Since the 2009 pandemic, all circulating influenza A viruses have been resistant to amantadine, and it is therefore not currently recommended for use in the treatment of influenza. During the 2017-18 season, the subset of influenza A viruses that were tested for resistance to amantadine were resistant.

Provincial and International Influenza Reports

FluWatch definitions for the 2017-2018 season

The FluWatch report is compiled from a number of data sources. Surveillance information contained in this report is a reflection of the surveillance data available to FluWatch at the time of production. Delays in reporting of data may cause data to change retrospectively

Influenza/Influenza-like Illness (ILI) Activity
Influenza/ILI activity levels, as represented on the map, are assigned and reported by Provincial and Territorial Ministries of Health, based on laboratory confirmations, primary care consultations for ILI and reported outbreaks. ILI data may be reported through sentinel physicians, emergency room visits or health line telephone calls, and the detemination of an increase is based on the assessment of the provincial/territorial epidemiologist. Maps from previous weeks, including any retrospective updates, are available in the mapping feature found in the Weekly Influenza Reports.

Influenza/ILI activity level

1 = No activity: no laboratory-confirmed influenza detections in the reporting week, however, sporadically occurring ILI may be reported

2 = Sporadic: sporadically occurring ILI and lab confirmed influenza detection(s) with no outbreaks detected within the influenza surveillance region ^{Footnote †}

3 = Localized:

1. evidence of increased ILI^{Footnote *} and
2. lab confirmed influenza detection(s) together with
3. outbreaks in schools, hospitals, residential institutions and/or other types of facilities occurring in less than 50% of the influenza surveillance region^{Footnote †}

4 = Widespread:

1. evidence of increased ILI^{Footnote *} and
2. lab confirmed influenza detection(s) together with
3. outbreaks in schools, hospitals, residential institutions and/or other types of facilities occurring in greater than or equal to 50% of the influenza surveillance region^{Footnote †}

Laboratory-Confirmed Influenza Detections
Provincial, regional and some hospital laboratories report the weekly number of tests and detections of influenza and other respiratory viruses. Provincial public health laboratories submit demographic information for cases of influenza. This case-level data represents a subset of influenza detections reported through aggregate reporting. Specimens from NT, YT, and NU are sent to reference laboratories in the provinces for testing.

Syndromic/Influenza-like Illness Surveillance
FluWatch maintains a network of primary care practitioners who report the weekly proportion of ILI cases seen in their practice. Independent sentinel networks in BC, AB, and SK compile their data for reporting to FluWatch. Not all sentinel physicians report every week.

Definition of Influenza-like-illness (ILI): Acute onset of respiratory illness with fever and cough and with one or more of the following - sore throat, arthralgia, myalgia, or prostration which is likely due to influenza. In children under 5 years of age, gastrointestinal symptoms may also be present. In patients under 5 or 65 years and older, fever may not be prominent.

Influenza Outbreak Surveillance
Outbreaks of influenza or ILI are reported from all provinces and territories, according to the definitions below. However, reporting of outbreaks of influenza/ILI from different types of facilities differs between jurisdictions. All provinces and territories with the exception of NU report influenza outbreaks in long-term care facilities. All provinces and territories with the exception of NU and QC report outbreaks in hospitals.

Outbreak definitions:
Schools: Greater than 10% absenteeism (or absenteeism that is higher (e.g. >5-10%) than expected level as determined by school or public health authority) which is likely due to ILI.
Hospitals and residential institutions: two or more cases of ILI within a seven-day period, including at least one laboratory-confirmed case of influenza. Residential institutions include but are not limited to long-term care facilities (LTCF) and prisons.
Workplace: Greater than 10% absenteeism on any day which is most likely due to ILI.
Other settings: two or more cases of ILI within a seven-day period, including at least one laboratory-confirmed case of influenza; i.e. closed communities.

Serious Outcome Influenza Surveillance
Provincial/Territorial Influenza Hospitalizations and Deaths
Influenza-associated hospitalizations and deaths are reported by 8 Provincial and Territorial Ministries of Health (excluding BC, NU, ON and QC). The hospitalization or death does not have to be attributable to influenza, a positive laboratory test is sufficient for reporting. Only hospitalizations that require intensive medical care are reported by SK.
Due to changes in participating provinces and territories, comparisons to previous years should be done with caution.
Pediatric Influenza Hospitalizations and Deaths
The Immunization Monitoring Program Active (IMPACT) network reports the weekly number of hospitalizations with influenza among children admitted to one of the 12 participating paediatric hospitals in 8 provinces. These represent a subset of all influenza-associated pediatric hospitalizations in Canada.

Influenza Strain Characterizations and Antiviral Resistance
Provincial public health laboratories send a subset of influenza virus isolates to the National Microbiology Laboratory for strain characterization and antiviral resistance. These represent a subset of all influenza detections in Canada and the proportion of isolates of each type and subtype is not necessarily representative of circulating viruses.
Antigenic strain characterization data reflect the results of hemagglutination inhibition (HI) testing compared to the reference influenza strains recommended by WHO. Genetic strain characterization data are based on analysis of the sequence of the viral hemagglutinin (HA) gene.

Antiviral resistance testing is conducted by phenotypic and genotypic methods on influenza virus isolates submitted to the National Microbiology Laboratory. All isolates are tested for oseltamivir and zanamivir and a subset are tested for resistance to amantadine.

Abbreviations: Newfoundland/Labrador (NL), Prince Edward Island (PE), New Brunswick (NB), Nova Scotia (NS), Quebec (QC), Ontario (ON), Manitoba (MB), Saskatchewan (SK), Alberta (AB), British Columbia (BC), Yukon (YT), Northwest Territories (NT), Nunavut (NU).

This report is available on the Government of Canada Influenza webpage.
Ce rapport est disponible dans les deux langues officielles.

We would like to thank all the Fluwatch surveillance partners who are participating in this year's influenza surveillance program.