You Asked: Haemophilus and AFM Rachel Wiseman, MPH VPD Epidemiologist

Haemophilus Influenzae: What’s New for 2016

What is an H. flu serotype? The H. flu bacteria is typically encapsulated. There are six types of capsules (a through f). Some H. flu bacteria do not have a capsule at all. Those are referred to as non-typeable. Of course, if no one looks for a capsule, then the H. flu is considered untyped.

Overview of Changes Changed the Texas Administrative Code to make all Haemophilus Influenzae (H. flu) reportable. Consistent with national standards Allows for better understanding of the epidemiology of H. flu in Texas and how vaccine impacts that Reduces potential for missed cases Texas Administrative Code also updated to mandate submission of H. flu isolates to DSHS Lab on children under 5 years of age only DSHS will still accept (sterile site) isolates on H. flu patients of all ages.

New Case Definition All invasive Haemophilus influenzae disease is now reportable, regardless of serotype. H. flu type b is still reportable. Types a, c, d, e, and f are also now reportable. Non-typeable H. flu is reportable. Untyped H. flu is reportable. Non-invasive Haemophilus influenzae is still NOT reportable.

Probable Case Status Still the Same Meningitis with detection of H. flu type b antigen in CSF. Per CDC, this test is unreliable in urine or serum, so only CSF can be used for case classification This test only applies to type b. I’m not sure why.

Updated Documents Updated H. flu case track Updated case criteria guide Updated case investigation guidelines DEG was updated Sept 2015 NBS was already designed for all H. flu, no changes made

Follow up of H. flu Cases Our primary interest is still H. flu, type b—especially in children under 5 This is because only type b is vaccine preventable AND Only children under 5 are vaccinated against H. flu, type b

Prioritization Children under 5 with H. flu, type b ~1% of reports Children under 5 with non-b H. flu ~12% of reports Anyone 5 or older with H. flu, type b Anyone 5 or older with non-b H. flu

H. Flu Cases under 5 Determine case definition is met Ensure isolate has been sent to DSHS If H. Flu type b, determine need for contact PEP Obtain complete vaccination history Complete all questions on case track Enter everything into NBS

H. Flu Cases over 5 If type b If NOT type b Confirm case definition Obtain vaccination history Determine need for contact PEP Enter what you have into NBS If NOT type b Just confirm case definition, serogroup and enter into NBS

Control Measure Concerns Type b, ANY AGE Determine if children under 5 have been exposed Prophylaxis may be required depending on age and vaccine and immunologic status of contacts NOT Type b, ANY AGE Recommend good hand hygiene

Questions?

Acute Flaccid Myelitis: What? Why? How?

What is Acute Flaccid Myelitis (AFM)? Rapid onset of limb(s) weakness and distinct abnormalities of the spinal cord gray matter Mostly caused by West Nile, polio, and flaviviruses AFM is a subset of acute flaccid paralaysis (AFP) Surveillance for AFP is the worldwide gold standard for polio surveillance. The US does not do AFP surveillance. Global expected AFP incidence: 1/100,000 children <15 years old

AFM Epidemiology Basically unknown Aug 2014-Feb 2015, 111 cases reported in 34 states in patients <22 No fatalities 62% had not fully recovered, 37% had not improved Possibly EVD-68 related, but no pathogens isolated in CSF on any patient 12 cases had respiratory specimens positive for viruses besides EVD-68 CDC estimates <20 cases of AFM per year in a state (all ages)

National AFM Surveillance Plan CDC has requested states to surveil for AFM CSTE made a case definition, but decided not to make AFM nationally notifiable CDC made an investigation form CDC has agreed to do testing CDC published a clinical reminder for clinicians to continue vigilance for AFM CDC has a neurologist to help, because AFM is hard Some states have started the process to make AFM notifiable in their states

Texas’s AFM Surveillance Plan Texas published CSTE’s case definition in the 2016 Epi Case Criteria Guide Texas adapted the CDC’s investigation form and put it on the IDCU site Texas sent out a health advisory requesting clinicians to report Texas wrote an AFM chapter for the EAID Guidelines Texas has begun the work to include AFM in NBS Texas plans to send a letter to neurologists asking them to report Texas has opened up discussion about making AFM a reportable condition

Investigation Plan Read the AFM chapter in the Guidelines Give the neurologist the AFM investigation form and ask them to complete it and return it Request a copy of the MRI results Ask what (viral/bacterial) testing has been done and what the results are Ask the provider to collect specimens (stool, CSF, NP swab, see Guidelines) Report to Rachel who will facilitate testing with CDC

Investigation Plan, Part 2 No public health intervention needed UNLESS: If pathogen is identified, follow up (PEP, treatment) may be warranted If reportable pathogen is identified, follow up and further investigation and data entry will be needed If cluster or outbreak detected (regardless of pathogen), alerts to medical community (and possibly other entities) may be needed

The Point Baseline data Ensure US can detect polio Difficult to determine significance of 2014 outbreak with no baseline data Ensure US can detect polio Random fact: Guillain-Barre is not AFM, but it is AFP Important if Zika becomes established AND if Zika does cause Guillain-Barre Guillain-Barre is not reportable as AFM, but the underlying condition may be reportable it and of itself

Questions?