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

2. Haemophilus Influenzae:
What’s New for 2016

3. 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.

4. 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.

5. 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.

6. 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.

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. Questions?

14. Acute Flaccid Myelitis:
What? Why? How?

15. 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

16. 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)

17. 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

18. 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

19. 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

20. 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

21. 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

22. Questions?