Update: Influenza Activity — United States, September 30, 2018–February 2, 2019

In the United States, influenza activity remained elevated through early February. Influenza A(H1N1)pdm09 viruses have predominated nationwide, but influenza A(H3N2) viruses have predominated in the southeastern United States. Influenza A(H3N2) viruses have accounted for an increasing proportion of reported influenza viruses in several regions. The number of influenza B viruses reported has been low; influenza B/Yamagata viruses were more commonly reported from September through late December, and influenza B/Victoria viruses have been reported more frequently since late December. ILI activity and the percentage of respiratory specimens testing positive for influenza in clinical laboratories have been increasing since mid-January. This season, the percentage of outpatient ILI visits has reached 4.3% at the beginning of February. The peak ILI activity for the past two A(H1N1)pdm09-predominant seasons was 3.6% during the 2015–16 season and 4.6% during the 2013–14 season. Influenza-associated hospitalization rates and P&I-attributed mortality have been relatively low this season and are consistent with what has been observed during previous seasons when influenza A(H1N1)pdm09 viruses predominated (4,5). During most seasons, including this season, adults aged ≥65 years have the highest hospitalization rates, followed by children aged <5 years. Severity indicators demonstrate that, as of February 2, 2019, the severity of influenza activity has been low; however preliminary cumulative in-season prevalence estimates indicate that influenza has caused 155,000–186,000 hospitalizations and 9,600–15,900 deaths. Current influenza forecasts^†††† predict that elevated influenza activity in parts of the United States will continue for several more weeks.

Most of the influenza viruses characterized during this time are antigenically similar to the cell culture-propagated reference viruses representing the 2018–19 Northern Hemisphere influenza vaccine viruses. However, genetic diversity among currently circulating influenza A(H1N1)pdm09 viruses belonging to clade 6B.1 viruses has increased, suggesting ongoing evolution of these viruses. Increased circulation and testing of 3C.3a viruses has contributed to a recent increasing proportion of A(H3N2) viruses that are antigenically distinct from the reference virus representing the A(H3N2) vaccine component. The majority of influenza viruses collected since October 1, 2018, and tested (>99%) displayed susceptibility to oseltamivir and peramivir, and all tested viruses displayed susceptibility to zanamivir.

The 2018–19 season is the first season that CDC has reported preliminary estimates of the prevalence of influenza in the United States during the season, and prevalence estimates will be updated each week over the remainder of the season. CDC estimates that since the 2010–11 season, during an influenza season, influenza virus infection has caused 9.3 million–49 million symptomatic illnesses, 4.3 million–23 million medical visits, 140,000–960,000 hospitalizations, and 12,000-79,000 deaths^§§§§.

Health care providers should continue to offer and encourage vaccination to all unvaccinated persons aged ≥6 months as long as influenza viruses are circulating (3). Interim estimates of vaccine effectiveness based on data collected during November 23, 2018–February 2, 2019, indicate that, overall, the influenza vaccine has been 47% (95% confidence interval = 34%–57%) effective in preventing medically attended acute respiratory virus infection across all age groups and specifically was 46% (30%–58%) effective in preventing medical visits associated with influenza A(H1N1)pdm09 (6). Annual influenza vaccination is the first and best defense against influenza infection. Depending on the vaccine formulation (trivalent or quadrivalent), influenza vaccines can protect against three or four different influenza viruses. With vaccine effectiveness in the range of 30%–60%, influenza vaccination prevents millions of infections and medical visits and tens of thousands of influenza-associated hospitalizations each year in the United States.^¶¶¶¶ During the 2017–18 season, vaccination averted an estimated 7.1 million illnesses, 3.7 million medical visits, 109,000 influenza-associated hospitalizations, and 8,000 influenza-associated deaths (7). In addition, influenza vaccination has been found to reduce deaths, intensive care unit admissions and length of stay, and overall duration of hospitalization among hospitalized influenza patients (8).

Influenza antiviral medications are an important adjunct to vaccination in the treatment and prevention of influenza. Treatment as soon as possible with influenza antiviral medications is recommended for patients with confirmed or suspected influenza who have severe, complicated, or progressive illness; who require hospitalization; or who are at high risk for influenza complications. Providers should not rely on less sensitive assays such as rapid antigen detection influenza diagnostic tests to inform treatment decisions (9). Four influenza antiviral drugs are approved by the Food and Drug Administration (FDA) for treatment of acute uncomplicated influenza within 2 days of illness onset and are recommended for use in the United States during the 2018–19 season: oseltamivir, zanamivir, peramivir, and baloxavir, which was approved by the FDA on October 24, 2018 (10).