Invasive and Respiratory Infectious Disease Updates

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Invasive and Respiratory Infectious Disease Updates

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Invasive and Respiratory Infectious Disease Updates

ELC Epidemiology WorkshopIRID/VPD Breakout SessionFebruary 25, 2016

Lesley Brannan, MPH

IRID Team Leader









IRID Diseases

NotifiableLegionellosisInvasive meningococcal infectionInvasive streptococcal diseasesInvasive Group A Streptococcus

(S. pyogenes)Invasive Group B Streptococcus (S. agalactiae)Invasive Streptococcus pneumoniaeNovel coronavirusNovel/variant influenza AInfluenza-associated pediatric mortalityAmebic meningitis/encephalitis, including Primary A

mebic Meningoencephalitis (PAM)



Respiratory syncytial virus (RSV)


Legionellosis Investigation Guidelines Updates

Basic epi: Note about incubation period for outbreaks, added severity info for disease types (p.155)Case Investigation checklist: clarified investigation forms to use for cases, updated web links, added recommendations for documentation to determine onset date, slight reordering of

section (p.157-158)Prevention and control: updated water birth guidelines (pp.159-161), added indications for Legionella testing (p.159), added and updated water maintenance bullet (p.159)Managing Special Situations: clearly defined sections for single cases vs. multiple cases; added water system maintenance guidance link; updated web links; added training video link for environmental assessment; updated ASHRAE standard; ask labs to retain Legionella isolates (p.161-169)Environmental Sampling and Testing: extensive changes (pp.173-177)Additional Resources: basically, new section (pp.177-178)


Legionellosis – New and Coming Soon-ish

CDC new resourcesLegionellosis investigation toolkits: http

:// CDC environmental investigation videos: On the horizonNear: Improved/expanded investigation formFar: NBS changes


Amebic Meningitis/Encephalitis (including PAM) – Guidance Updates

Case criteria – rewording of description only, to align with nationalEAIDB Investigation GuidelinesAdded transmission through organ transplantation (pp.13-14)Edited incubation period, illness duration (p.14)

Added ritual nasal rinsing, ablution to prevention section (p.18)Clarified that only waterborne outbreaks need to be reported in NORS (p.19)Lab section: Added required forms, added telediagnosis info (CDC), updated shipping and contact information (pp.19-22)


Need to investigate fully – Complete “Free-Living Ameba Case Report” form

Get detailed infoGet all medical recordsInterview family/surrogate for exposures

Determine whether organs/corneas were donatedMiltefosine updateSummer safety intern – PAM, CryptoPress release bulletsEducational material – pediatricians, camps, parks, etc.

Amebic Meningitis/Encephalitis

(GAE [

Balamuthia, Acanthamoeba


, PAM [

Naegleria fowleri

], & other)


Meningococcal Case Definition Updates

Case definition changeRemoved “clinically compatible” requirementMoved two formerly probable categories to suspectGNDC clarifying statement

2016 case definition (effective January 1, 2016):Confirmed: A case that is laboratory confirmed Probable: A case that has one of the following: N. meningitidis antigen detection by immunohistochemistry (IHC) on formalin-fixed tissue N. meningitidis antigen detection by latex agglutination of CSFSuspect: A case that has one of the following:

Clinical purpura fulminans in the absence of a positive blood culture

Gram-negative diplococci, not yet identified, isolated from a normally sterile site (e.g., blood or CSF



Meningococcal – More Updates

Investigation, Reporting, NBS:Case investigation, contact tracing, contact prophylaxis for C, P, and S casesEnter C, P, and

S cases in NBS and submit notificationsOnly C and P cases counted in official numbersMeningitis is not the only clinical presentation (p.210)Most common in TX: meningitis (48%)bacteremia/septicemia (34%)pneumonia (3%)


Invasive Meningococcal Infection – Investigation Guidelines and Form

EAIDB Investigation Guidelines updatesAdded clinical manifestations and occurrence in TX (p.210)Clarifications throughout for meningococcal disease vs. meningitisReporting and Data Entry Requirements: added instructions for suspect cases

(p.218)Added request for nonviable isolates and sterile sites specimens when isolates are not available (p.219)Updated Invasive Meningococcal Infection: Case Status Classification flowchart (p.222)On the horizonInvestigation form updates, including 3 new sexual contacts/history questions


Invasive Streptococcal Conditions(GAS, GBS, S. pneumoniae)

Case Criteria – minor changes to lab test wording or clinical description to align with nationalNBS Data Entry Guide: Ordered Test required in NBS lab report (Sept 2015)

Investigation form update: Added “Test Type” (July 2015)


Invasive Streps – Investigation Guidelines and NBS

EAIDB Investigation Guidelines: Emphasized need to collect enough information to meet case definition (pp. 323, 329, 333)EAIDB Investigation Guidelines flowcharts

Invasive Streptococcal Infection: Case Status Classification (p.386) – emphasized that alpha and beta hemolysis is not the same as the group (e.g., Streptococcus, alpha hemolytic ≠ Group A Strep)Sterile Site and Invasive Disease Determination (pp.383-384) – cord blood and respiratory specimens are not sterile sites, joint fluid might be a sterile siteNBS: If a lab report is not associated with the investigation, put enough information in the investigation comments so we can tell it meets case definition (i.e

., test type, test result, specimen source, and clinical syndrome [if necrotizing fasciitis or toxic shock syndrome with specimen from non-sterile site


We will reject 2016 cases if

there is no

lab information(i.e

., test type, test result, specimen source), or the provided lab data do not meet case definition.



Immunization Grant Requirements (meningococcal, S. pneumoniae)

You have 30 days from time of report to HD until case is finished (investigated, reported in NBS, etc.)Obtain vaccination statusSources: patient/parent/surrogate, PCP, hospital/reporting facility, ImmTrac, employer, school/daycare

Children: a record existsAdults: try your bestGet serogroup – send in those isolates to DSHS Austin Lab!Required for Neisseria meningitidisVoluntary for S. pneumoniae (isolates from sterile sites, kids <5yo)Patient outcomeFollow patient until discharge


Novel Coronavirus/MERS

EAIDB Investigation Guidelines changesUpdated PUI definition – fever note; removed Republic of Korea (p.244)For anyone tested for MERS-CoV, PUI form must be completed and submitted to DSHS within 48 hours of testing (p.245)

Prevention and Control Measures: specific recommendations provided throughout section (pp.247-262)New: Air and Ground Medical Transport section (p.256) – REPLACE w/handoutLaboratory Procedures: attempted to clarify when serum should be collected for rRT-PCR testing at a state or local PHL (more common) vs. PCR testing at CDC (less common) (pp.266-267)


Novel Coronavirus/MERSPUI Criteria Updates from CDC

Deleted reference to the Republic of Korea More than two incubation periods have passed since the last MERS case was reported from the Republic of Korea.

Revised the MERS Patient Under Investigation (PUI) Short Form.Added footnote to PUI Guidance clarifying that fever may not be present in some patients, such as those who are very young, elderly, immunosuppressed, or taking certain medications. Clinical judgement should be used to guide testing of patients in such situations.Revised document title to “Interim Patient Under Investigation (PUI) Guidance and Case Definitions for MERS” from “Case Definitions” to highlight the current clinical features and epidemiologic risks that guide testing and decisions

for a patient under investigation, rather than using a more absolute case definition



Novel/Variant Influenza

EAIDB Investigation Guidelines: changed Case Under Investigation definition and footnotes for “Novel Influenza A Viruses with the Potential to Cause Severe Disease in Humans” (p.140)


Influenza-associated Pediatric Mortality Updates

Get flu vaccine history (often missing)EAIDB is routinely receiving vital stats dataIf pediatric influenza deaths are found you will be asked to investigate



Vital statistics – pneumonia & influenza deathsAdded to weekly flu report

On the horizonAdding influenza-associated deaths (all ages) as notifiable conditionPossibly Jan 1, 2017?2017-2018 season?



Influenza Surveillance Workshop (influenza, MERS/novel coronavirus, respiratory viruses) – Summer 2016Any influenza, influenza-like illness, or respiratory virus (non-VPD) questions? Contact us at



US Outpatient Influenza-like Illness Surveillance Network (ILINet)Voluntary nationwide network of outpatient providers who report weekly on number of patients seen with influenza-like illness (ILI) by age group, and total patients seen for any reasonCan calculate % ILIILI definition: fever ≥ 100°F plus cough and/or sore throat

CDC recruitment target: 1 provider per 250,000 populationProviders urgently needed in Regions 1 (Lubbock, Potter, Hale) and 4 (Smith, Gregg, Bowie)Provider participation takes about 20 minutes/weekContact Robert Russin to enroll providersOnly non-lab flu surveillance system to “detect” the start of the 2009 pandemicTo log in to the online system to see data from Texas, contact Robert Russin



National Respiratory and Enteric Virus Surveillance System (NREVSS) – CDC online systemWeekly data (# total tests, # tests positive) voluntarily entered by hospital laboratoriesViral data captured (any/all of the following): influenza, parainfluenza, RSV, human metapneumovirus, rhinovirus, enterovirus, adenovirus (respiratory and enteric), seasonal coronaviruses, rotavirus

Labs urgently needed in Regions 2, 4, 9, 10, 1 (or anywhere there is an interested lab)Contact Johnathan to enroll new labs


Respiratory Syncytial Virus (RSV)

Trends in RSV lab detections inform Texas Medicaid office on approval dates for palivizumab (Ig monoclonal Ab) Monthly injections recommended for children with certain risk factors for RSV – see 2015 Red Book for list or

DSHS Austin makes weekly graphs of RSV test data from NREVSSTesting trendsPCR testing is becoming more common but no season threshold existsAntigen testing is becoming less commonStay tuned for changes to graphs, etc.

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