Sentinel Provider Surveillance: Influenza-like illness activity 
Week 20 Activity (representing geographic distribution): Local
Week 20 ILI Activity (representing intensity of ILI activity): 1 (Minimal)
Provider offices across the US report the amount of influenza-like illness (ILI) they see in their patients each week during regular flu season.  These outpatient providers’ offices, which include doctors' offices, school health services, and community health centers, are called 'sentinel sites.’  Here we present Massachusetts sentinel site data.  Please note that the data do not represent only confirmed influenza cases, but also those just with ILI, which may be caused by other viruses. ILI is defined as fever above 100.01 in addition to either cough or sore throat.  ILI is a marker of influenza and is used throughout the regular influenza season to monitor influenza since most people are not tested for influenza.  Figure 1 shows that ILI activity is low and is consistent with activity levels normally seen at this time of year.  For more information, see CDC’s influenza surveillance website at www.cdc.gov/flu/weekly/fluactivitysurv.htm.

Figure 1: Percentage of ILI visits reported by sentinel provider sites

*Influenza-like illness (ILI, defined by fever >100F and cough and/or sore throat), as reported by Massachusetts sentinel surveillance sites.

Table 1 below shows a geographical distribution of reported ILI in Massachusetts.  Table 1 shows that sentinel sites in most regions of the state are reporting little to no ILI activity, while some sites in the Boston and Southeast regions are reporting slightly elevated ILI levels.

Table 1: Percent ILI reported weekly by Massachusetts sentinel sites

 	Regional Baseline % ILI*	2012-2013	2011-2012	
		% ILI	Report. Sites	Total enroll.	% ILI	Report. Sites	Total enroll.	
Boston	0.66	0.68	4	5	0.53	3	7	
Central	0.96	0.33	6	11	0.22	8	11	
Inner Metro Boston	0.93	0.73	7	13	0.77	11	12	
Northeast	0.84	0.54	6	11	0.80	7	12	
Outer Metro Boston	2.56	2.13	3	4	2.23	2	4	
Southeast	0.56	0.81	2	3	0.00	2	3	
West	1.51	0.00	3	7	0.46	5	8	
*Regional baseline % ILI is calculated weekly using reporting providers’ baseline % ILI estimates.

Influenza-Associated Hospitalizations
In 2010, MDPH began to request voluntary reporting of all laboratory-confirmed influenza hospitalizations from hospitals in Massachusetts.  Up to 50 hospitals from across the state report these data to MDPH on a weekly basis during flu season.  The graph below shows the number of laboratory-confirmed hospitalizations per 1,000 licensed beds represented by reporting hospitals for the current season and two previous seasons.

Figure 2: Massachusetts laboratory-confirmed influenza hospitalizations

Laboratory testing for influenza
Laboratories in Massachusetts report all positive influenza tests to MDPH, including viral culture, polymerase chain reaction (PCR) and rapid influenza diagnostic tests.  Because the majority of cases are not tested, the number of 'confirmed' cases does not reflect the overall incidence of influenza; however, this information is essential to track the types of influenza circulating in Massachusetts and can be a useful indicator of the presence and distribution of influenza in the state.  Figure 3 illustrates the number of laboratory confirmed cases in Massachusetts by week, shown along with Massachusetts ILI. Table 2 reflects the number of laboratory-confirmed influenza cases by region and influenza type.

Figure 3: Laboratory-confirmed Influenza Cases and Influenza-like Illness
Massachusetts, September 30, 2012 – May 18, 2013

*Influenza cases confirmed via viral culture, PCR or rapid test by specimen collection date.
**Influenza-like illness (ILI, defined as fever>100F and cough and/or sore throat), as reported by Massachusetts sentinel surveillance sites by CDC week date.

Table 2: Laboratory-confirmed Influenza by Region – 2012-2013 and 2011-2012 Influenza Seasons

 	2012-2013	2011-2012	
	A	B	Untyped	A	B	Untyped	
Region	Week	YTD	Week	YTD	Week	YTD	Week	YTD	Week	YTD	Week	YTD	
Boston	1	1652	1	274	0	32	0	39	1	47	0	0	
Central	0	2637	0	1022	0	130	4	70	2	32	0	8	
Inner Metro Boston	1	3390	3	815	1	177	5	197	4	82	0	4	
Northeast	0	3979	1	1354	1	914	7	130	5	57	0	26	
Outer Metro Boston	0	2606	0	771	0	264	18	135	1	71	0	1	
Southeast	2	3765	4	902	0	583	14	178	11	240	4	138	
Unknown	2	962	0	187	0	22	1	22	0	6	0	0	
West	0	1521	0	585	0	92	5	160	1	28	0	8	
Total	6	20,512	9	5,910	2	2,214	54	931	25	563	4	185	

Testing at the Hinton State Laboratory Institute
The William A. Hinton State Laboratory Institute performs confirmatory testing, typing and subtyping of influenza using PCR and viral culture.  Figure 4 summarizes the testing conducted at the HSLI since MMWR week 40 or the week ending October 6, 2012. To date the HSLI has confirmed 170 cases of seasonal A/H3N2 influenza, 10 cases of 2009 A/H1N1 influenza and 63 cases of influenza B for the 2012-2013 season.

At the start of the 2012-2013 season, the first 10 early season isolates and thereafter 5 every two weeks will be sent by Hinton State Laboratory Institute (HSLI) for National Routine Surveillance including antigenic characterization by hemagglutination inhibition (HI), genetic analysis (sequencing) and sensitivity to FDA-approved drugs for identification of resistance.  HSLI will perform pyrosequencing of 5 or more samples every two weeks to detect the point mutation (H275Y) in the N1 NA gene target of influenza A (2009) viruses to assess trends in oseltamivir-resistance.  This information will be reported locally and captured nationally in FluView.  Specimens will also be evaluated at commercial laboratories. There were three specimens from MA during the 2009-2010 season with this mutation conferring oseltamivir-resistance and none during the 2010-2011 and 2011-2012 seasons and none for the 2012-2013 season to date.  Nineteen influenza A/H3N2 specimens, two A/H1N1 and 15 influenza B specimens have been characterized for the 2012-2013 season to date; three influenza B specimens, all 19 A/H3N2 specimens and both influenza A/H1N1 specimens were consistent with strains in the 2012-2013 seasonal influenza vaccine; 12 influenza B specimens were not consistent with the strain included in the vaccine.

Figure 4: Influenza positive tests reported to CDC by HSLI, September 30, 2012 – May 18, 2013

Table 3: Weekly Summary of HSLI Influenza Surveillance Test Results

2012-2013 Season: Influenza Surveillance
William A. Hinton State Laboratory Institute	
MMWR Week:
(Specimen Collected)	2009 H1N1	Seasonal A/H1N1	Seasonal A/H3N2	Influenza B	No. Flu Pos (%)	Unsat	Total Tested	Total
Rec’d	
17 (04/21 - 04/27/13)	0	0	0	3	3(60%)	0	5	5	
18 (04/28 - 05/04/13)	0	0	0	3	3(100%)	0	3	3	
19  (05/05 - 05/11/13)	1	0	0	1	2(67%)	0	3	3	
20  (05/12 - 05/18/13)	0	0	0	0	0(0%)	0	0	0	
Prior 4 wk Total	1	0	0	7	8(73%)	0	11	11	
Cumulative Season total	10	0	170	63	243(69%)	18	353	371	
All data are subject to change as test results become finalized. 2012-2013 influenza season began MMWR 40 (09/30 - 10/06/2012).