1. The State of Communicable Diseases in Indiana
APIC Spring Conference
April 7, 2017
Joshua Clayton, PhD, MPH
Deputy State Epidemiologist

2. Topics Influenza Mumps Stats Explorer Seasonal
H7N9 North American Lineage
H7N9 Asian Lineage
Mumps
Stats Explorer

5. Virologic Surveillance
Positive Specimens (N=33,498)
Influenza A
28,647 (85.5%) H1
747 (2.6%) H3
27,552 (96.2%)
Subtype not performed
348 (1.2%)
Influenza B
4,851 (14.5%)
Yamagata lineage
2,387 (49.2%)
Victoria lineage
1,243 (25.6%)
Lineage not performed
1,221 (25.2%)

7. 2016-2017 Influenza Vaccine Components
Trivalent included:
A/California/7/2009 (H1N1)pdm09-like virus
A/Hong Kong/4801/2014 (H3N2)-like virus
B/Brisbane/60/2008-like virus
Quadrivalent also included:
B/Phuket/3073/2013-like virus

8. Antigenic Characterization
Influenza A
A(H1N1)pdm09: All 176 (100%) were characterized as the component of the vaccine
A(H3N2): 548 of 562 (97.5%) were characterized as the component of the vaccine
Influenza B
Victoria lineage: 172 of 187 (92%) were characterized as the component of the vaccine
Yamagata lineage: All 179 (100%) were characterized as the component of the vaccine

9. 2017-2018 Influenza Vaccine Components
Trivalent included:
A/Michigan/45/2015 (H1N1)pdm09-like virus
A/Hong Kong/4801/2014 (H3N2)-like virus
B/Brisbane/60/2008-like virus
Quadrivalent also included:
B/Phuket/3073/2013-like virus

10. Data through February 4, 2017

11. Vaccine Effectiveness Summary
Interim results for season (through February 4, 2017) indicate vaccine effectiveness of 48% against medically attended influenza
Interim estimate similar to previous seasons when vaccine was well matched to circulating influenza viruses
Significant protection against circulating influenza A(H3N2) and B viruses (predominantly B/Yamagata)

13. H7N9 North American Lineage
March 5, 2017 – Highly pathogenic avian influenza (HPAI) H7N9 detected in Tennessee
High mortality losses in a single barn
~80,000 birds depopulated (8 barns; 10,000 birds)
Surveillance zone (10 km) set for testing of all commercial and backyard poultry

14. H7N9 Human Infection Thought to occur rarely Generally mild
May include conjunctivitis
May include upper respiratory tract illness
May result in a wide spectrum of illness, including severe or fatal disease

15. H7N9 Worker Health Monitoring
Responders require monitoring if exposed to infected birds or contaminated environment
Continuously during activities
For 10 days after last exposure
Signs and symptoms of influenza prompt:
Visit a medical provider
Isolation patient pending results (home isolation allowed)
Collect and test respiratory specimen at State Lab, and
Consider treatment with antiviral medication

16. H7N9 Update (as of March 29) Infected poultry identified in 4 states
Alabama (LPAI)
Georgia (LPAI)
Kentucky (LPAI)
Tennessee (2 HPAI detections)
HPAI/LPAI designation based on molecular characteristics and ability to cause disease and mortality in chickens in a lab setting
Does not refer to disease causing ability in humans

17. Resources Specimen collection
Antiviral Treatment for Human Infection with Novel Influenza A Viruses

19. H7N9 Asian Lineage Virus is different than H7N9 North American Lineage
Human infections first reported in China in March 2013
1,364 human infections since 2013*
88% developed pneumonia
68% admitted to ICU
41% died
China is currently experiencing its 5th epidemic of H7N9
2 distinct lineages: Pearl River Delta lineage and Yangtze River Delta lineage
* As of April 5, 2017

21. Asian H7N9 Human Infections by Month

22. Asian H7N9 Human Infection
High fever
Cough
Severe pneumonia
Acute respiratory distress syndrome (ARDS)
Septic shock
Multi-organ failure
Death

24. Investigation of Asian H7N9 Increase
World Health Organization assessed surveillance and epi investigations
No changes in demographics of cases
Similar proportion of cases exposed to poultry
Similar number and size of cases in clusters
Case-fatality ratio similar to prior epidemics
No evidence of sustained person-to-person spread
CDC and Chinese CDC published a study
Human infections expanded to larger geographic area
Increase in proportion of persons becoming severely ill (e.g., pneumonia and ICU admission

25. Human Cases and Bird/Environment Detections

26. CDC Notice - Watch
Warning Level 3, Avoid Nonessential Travel
Alert Level 2, Practice Enhanced Precautions
Watch Level 1, Practice Usual Precautions
People traveling to China should avoid contact with:
Poultry (including poultry markets and farms)
Birds
Bird droppings
Avoid eating undercooked poultry
General care steps when visiting China:
Wash your hands often
Don’t touch your eyes, nose, or mouth
Cough or sneeze into a tissue or your sleeve
Avoid close contact with people who are sick
Talk to your doctor or nurse if you feel sick after returning

27. Clinical Considerations
Consider Asian H7N9 infection in persons with respiratory illness within 10 days of travel to China
Initiate airborne, droplet, and contact precautions
Notify ISDH ( or )
Obtain appropriate specimens (e.g., NP swab or nasal aspirate/wash or NP and OP swab in one VTM)
Consider treatment with antiviral medication

28. Resources Asian Lineage Avian Influenza A (H7N9) Virus
Infection Control Guidance
H7N9 Frequently Asked Questions
Specimen Collection

29. Hot Topics – Mumps virus
7 cases at Indiana University-Bloomington
4 cases at a business in Columbus

30. Mumps 2016 Provisional Data Male 158 (54%) Female 135 (46%) District
Count
Rate 1 6
0.7 2 9
1.4 3
0.3 4 42
11.4 5
116
6.6
0.8 7
1.1 8 97
26.1 10
1.6
Total
293
4.5
Male
158 (54%)
Female
135 (46%)

31. Stats Explorer

32. Questions? Josh Clayton, PhD, MPH Deputy State Epidemiologist
Indiana State Department of Health