2015 Communicable Disease

Summary and

Reporting Rule Revisions

APIC Spring Conference

April 8, 2016

Joshua Clayton, PhD, MPH

Deputy State Epidemiologist

2

2015 Statewide Data

3

District Count Rate*

1 5 0.6

2 20 3.1

3 12 1.7

4 5 1.4

5 46 2.6

6 15 2.3

7 4 1.4

8 8 2.2

9 9 2.0

10 11 2.3

Total 135 2.1

Shiga-toxin producing E. coli

181

121 117 135

0

50

100

150

200

2012 2013 2014 2015

Year

Male 63 (47%)

Female 71 (53%) 0

10

20

30

40

Age of Cases in Years

2015 Provisional Data

* Rate per 100,000 population

4

District Count Rate

1 0 –

2 2 0.3

3 1 0.1

4 0 –

5 4 0.2

6 1 0.2

7 0 –

8 1 0.3

9 0 –

10 0 –

Total 9 0.1

Hemolytic Uremic Syndrome

12

9 7

9

0

5

10

15

2012 2013 2014 2015

Year

Male 4 (44%)

Female 5 (56%) 0

5

10

Age of Cases in Years

2015 Provisional Data

5

District Count Rate

1 23 2.8

2 25 3.9

3 47 6.5

4 23 6.3

5 109 6.2

6 125 19.5

7 3 1.1

8 3 0.8

9 6 1.3

10 14 2.9

Total 278 4.2

Shigella

161 117

1362

278

0

500

1000

1500

2012 2013 2014 2015

Year

Male 127 (46%)

Female 150 (54%) 0

25

50

75

Age of Cases in Years

2015 Provisional Data

6

District Count Rate

1 373 45.6

2 163 25.1

3 284 39.2

4 149 40.6

5 867 49.6

6 493 76.8

7 273 97.0

8 234 63.0

9 410 90.0

10 309 63.4

Total 3,555 54.3

Hepatitis C, Acute & Chronic

4528 4623 5475

3558

0

2000

4000

6000

2012 2013 2014 2015

Year

Male 2052 (58%)

Female 1500 (42%) 0

250

500

750

1000

Age of Cases in Years

2015 Provisional Data

7

District Count Rate

1 8 1.0

2 8 1.2

3 10 1.4

4 9 2.5

5 33 1.9

6 19 3.0

7 2 0.7

8 8 2.2

9 13 2.9

10 8 1.6

Total 118 1.8

Hepatitis C, Acute

112

139 122 118

0

50

100

150

2012 2013 2014 2015

Year

Male 65 (55%)

Female 53 (45%) 0

10

20

30

40

50

Age of Cases in Years

2015 Provisional Data

8

District Count Rate

1 1 0.1

2 0 –

3 1 0.1

4 0 –

5 0 –

6 2 0.3

7 1 0.4

8 0 –

9 1 0.2

10 0 –

Total 6 0.09

Meningococcal disease

8

15

4

9

0

5

10

15

20

2012 2013 2014 2015

Year

Male 2 (33%)

Female 4 (67%) 0

1

2

3

Age of Cases in Years

2015 Provisional Data

9

District Count Rate

1 1 0.1

2 1 0.2

3 1 0.1

4 0 –

5 1 0.06

6 0 –

7 1 0.4

8 0 –

9 1 0.2

10 0 –

Total 6 0.09

Mumps

4 4

24

6

0

10

20

30

2012 2013 2014 2015

Year

Male 2 (33%)

Female 4 (67%) 0

1

2

3

4

Age of Cases in Years

2015 Provisional Data

10

Hot Topics – Mumps virus

• 24 cases at Butler University

• 17 cases at Indiana University-Bloomington

• 4 cases at IUPUI

• 5 cases at Purdue University

11

Hot Topics (2) – Zika virus

• United States

– 346 Travel-associated cases in U.S.

• 32 pregnant women

• 7 sexual transmission

• 1 Guillian-Barre syndrome

– No locally acquired vector-borne cases

• Indiana

– 6 Travel-associated cases

– No sexual transmission

– No Guillian-Barre syndrome

12

Zika Virus: Transmission Routes

• Recently detected in

the Americas

– A. albopictus and

A. aegypti mosquito

• 3 patterns of spread

– Direct bites by infected

mosquito

– Trans-placental

– Sexual

13

Zika Virus Infection

• Most people do not have symptoms

• Signs and symptoms are non-specific

– Rash

– Fever

– Joint pain

– Headache

– Reddish eyes

14

Zika Virus Prevention

• Pregnant women

– Follow CDC’s travel guidance

– Do not travel to areas with Zika virus

– Use a condom or refrain from sex

• Everyone

– Prevent mosquito bites

• Use insect repellant

• Cover your skin

15

Major Outbreak Responses

(2015)

16

Meningococcal Disease Mass

Prophylaxis (Allen Co. )

• 1 identified case in a school staff member (Dec. 2015)

• Case was a person employed at an elementary school who had

intermittent close contact with many students.

• The Local Health Department worked with the Hospital pharmacy

and school to provide prophylaxis

• Mass prophylaxis clinic was held at the school

• Approximately 500 students and staff received antibiotic post-

exposure prophylaxis

– Each of the 300+ students had to be weighed to determine appropriate dose of

suspension medication.

17

Shigella Outbreak 2014 (Central IN)

• Shigellosis transmission among daycare and school

attendees

• 854 S. sonnei cases from 9 counties were identified

• 749 of 854 cases (88%) were treated with antibiotics

regardless of severity.

• Indiana daycare/school exclusion policy encouraged

antibiotic treatment.

• CD Rule was revised to decrease antibiotic treatment

requirements and decrease antibiocitc resistance

emergence.

18

The CD Rule

19

CD Rule

• 410 IAC 1-2.3 repealed

• 410 IAC 1-2.5 enacted December 25, 2015

• 410 IAC 1-2.5-75: Reporting requirements for

physicians and hospital administrators

• 410 IAC 1-2.5-76: Laboratories; reporting requirements

• 410 IAC 1-2.5-77: Disease intervention measures;

responsibility to investigate and implement

20

Overview of the CD Rule

• Definitions

• Reporting requirements for physicians,

hospitals, and laboratories

• Disease intervention measures (general and

disease specific)

– Responsibilities

– Timeliness

• References

21

What’s New to the CD Rule?

22

Reportable Diseases

• Newly reportable:

– Carbapenemase-producing Carbapenem-resistant

Enterobacteriaceae (CP-CRE)

– Chikungunya virus disease

– Cysticercosis (Taenia solium)

– Varicella-zoster virus

23

Carbapenemase-Producing

Carbapenem-Resistant

Enterobacteriaceae

• Epidemiology – Can cause infections associated with high mortality rates (up to 50%)

due to resistant to carbapenem antibiotics and contain enzymes (carbapenemases) that

make carbapenems ineffective.

• Transmission – person to person via hands of HCPs or contact with infected stool,

wounds, or contaminated environmental surfaces (e.g. medical equipment)

• Incubation – not well defined

• Control Measures – The facility should initiate Contact Precautions; additional

precautions should be added if any other transmissible condition is present. AND…

– Can consider screening patients to determine if they are epidemiologically linked

– Can consider chlorhexidine gluconate bathing

• Laboratory Testing – Bacterial culture with antibiotic resistance susceptibility

testing.

24

Chikungunya virus disease

• Epidemiology

– Travel to Caribbean, Central/South America, other tropical and

subtropical areas

• Transmission

– Aedes aegypti and Aedes albopictus mosquitoes

• Incubation: 3–7 days

• Control measures

– Traveler education

– Mosquito bite prevention

• Laboratory testing: PCR, IgM/IgG serology

25

Taenia solium and

cysticercosis

• Epidemiology

– Underdeveloped areas with poor sanitation and pork consumption

– US: Latin American immigrants

• Transmission

– Ingestion of undercooked pork from a pig that has ingested human feces

(taeniasis)

– Ingestion of human feces (cysticercosis)

• Control measures:

– Cook meat to temperature

– Basic sanitation

• Laboratory testing: fecal microscopy, tissue biopsy

26

Varicella Zoster Virus (VZV) (newly LAB reportable)

• Epidemiology

– Varicella occurs worldwide. Humans are the only source of infection.

• Transmission

– Person-to-person transmission occurs via airborne route from infected

respiratory tract secretions or by direct contact with or inhalation of

aerosols from vesicular fluid of skin lesions.

• Incubation

– usually 14 to 16 days

• Control Measures

– school or child care setting exclusion until the rash has crusted.

• Laboratory Testing

– PCR or IgG Serology

27

Latent Tuberculosis Infection (LTBI)

(Cases and Suspects still reportable) • Epidemiology

– Prevalence increases with age. Estimated that 1/3 of the human population is

infected (worldwide)

• Transmission

– TB is spread only by those with active TB disease, who expel tubercle bacilli via

aerosolized, droplet or airborne route through coughing, singing, or sneezing.

– People with Latent TB infections (LTBI) cannot infect others

• Incubation

– Latent TB: 2-10 weeks from infection to primary lesion or positive TST/IGRA

• Control Measures

– Prompt diagnoses and treatment of active TB disease

– Treatment of LTBI before progression to active disease

– Screening of high-risk population, including HIV positive and homeless individuals

• Laboratory Testing

– Test for infection only, further evaluation need for distinction between TB/LTBI

– Tuberculin Skin Test (TST) using a purified protein derivate (PPD)

– Interferon Gamma Release Assay (IGRA) of blood

28

Reportable Diseases

• Scientific name change:

– Anaplasma phagocytophilum (formerly Ehrlichia

phagocytophilum)

• To be removed from the reportable list:

– Streptococcus Group B Invasive Disease

29

Isolate Reportable Changes

• Newly required:

– Carbapenemase-producing Carbapenem-resistant

Enterobacteriaceae (CP-CRE)

– Shigella species

– Vibrio cholerae

– Vibrio species (other than toxigenic Vibrio

cholerae)

• No longer required:

– Nocardia

30

Isolate Reportable Changes

• Require specimen submission for organisms

detected by a culture-independent diagnostic

test (CIDT):

– Shiga toxin-producing E. coli (STEC)

– Salmonella species

– Shigella species

– Vibrio cholera

– Vibrio species (other than toxigenic Vibrio

cholerae)

31

Timeliness Changes

• Laboratory: reporting timeliness now match

those for disease reporting

• Now reportable within 24 hours:

– Invasive Haemophilus influenzae (previously

immediately reportable)

– Mumps (previously reportable within 72 hours)

– Pertussis (previously immediately reportable)

32

Disease Specific Control

Measures

33

Animal Bites

• ANY rabies vector species (including bats,

skunks, raccoons, foxes, and other wild

carnivores) must be euthanized and tested

for rabies after a human bite, even if the

animal is being kept as a pet and/or permitted

by the Indiana DNR.

• Authorization to make exceptions to this

section is granted to the local health officer

and/or State Veterinarian.

34

Animal Bites (cont.)

• Language permitting euthanasia and rabies

testing of “stray or unwanted” biting animals

has been removed. These animals must now

be quarantined for 10 days after a bite.

• Unhealthy or terminally injured animals may

still be euthanized and tested.

35

Arboviral Diseases

• Dengue, chikungunya, EEE, SLE, WEE, West

Nile virus, California serogroup viruses, and

Powassan virus

• All will remain reportable, but will now be

listed separately on the reportable disease

list, as well as under the general term

“arboviral disease”.

• Note: formerly “Encephalitis, arboviral”

36

Food Employee Exclusions

• Specific to Hepatitis A, Shiga toxin-producing

E. coli (STEC), Salmonellosis, Shigellosis,

and Typhoid Fever.

• Aligned with the Retail Food Establishment

Sanitation Requirements (410 IAC 7-24)

proposed revisions.

37

Food Employee Exclusions

• Some examples of the alignment between the

CD Rule and the Food Code…

– “Ready-to-eat” was defined and the its use was

expanded to be included in Hepatitis A

– In regards to Shigella, the rule now clarifies when

to restrict and re-instate food employees

38

Influenza-associated Death

• Definition has been expanded to include

“listed anywhere on the death certificate as

primary, secondary, or contributory cause of

death” as a means by which an influenza

diagnosis has been detected.

• Investigations by the local health officer shall

now include an epidemiologic investigation.

39

Influenza-associated Death

(cont.)

What the rule says:

• A report is not necessary if the diagnosis of influenza is

neither confirmed by laboratory testing nor listed on the

death certificate as primary, secondary, or contributory

cause of death on the death certificate.

What the rule means:

• Influenza-associated death is only reportable if

laboratory confirmed or listed on the death certificate

as a primary, secondary, or contributory cause of

death.

40

Measles School Exclusions

• Anyone who gets a first or second dose of MMR as

part of an outbreak control program can return

immediately to school as long as all persons without

documented proof of immunity have been excluded

and that vaccination occurred within 72 hours of

exposure.

• Previous rule did not address case contacts who

received vaccination as part of an outbreak response

41

Measles and Mumps Health

Care Facility Exclusions

• All exposed employees without proof of immunity

must be excluded from day 5-21 (for measles) and

day 9-25 (for mumps) after exposure, regardless of

vaccination or if IG was given after exposure.

• This was a clarification added to the rule, as the

previous version of the rule did not directly address

this

42

Shigella Exclusion

• Daycare & pre-school attendees will be able to return to

school after 48 hours if they…

– Are asymptomatic

– Received antibiotic treatment

– Submit 1 negative stool sample

• Healthcare workers, and daycare workers will be able

to return to work after 24 hours if they…

– Are asymptomatic;

– Submit 1 negative stool sample

43

Varicella

• Laboratory testing requirements for “break-through”

and hospitalized cases have been added.

– PCR

– Culture

– IgG paired serology

• Outbreak control measures added

– Defines an outbreak

– Provides guidance on exclusions and timelines

– Provides guidance on contact tracing

44

Link to the New CD Rule

410 Indiana Administrative Code (Full):

www.in.gov/legislative/iac/T04100/A00010.PDF

Or

Visit the ISDH website:

www.in.gov/isdh/25366.htm

45

Recorded Webinar

A pre-recorded Communicable Disease Reporting

Rule webinar is available at:

https://videocenter.isdh.in.gov/videos/video/2011/

46

2015

Reportable

Disease

List

47

Questions?

Josh Clayton, PhD, MPH

Deputy State Epidemiologist

Indiana State Department of Health

317-233-7009

jclayton1@isdh.in.gov