Disease Trends and Events in Idaho * Christine Hahn, MD 10/23/2015

Syphilis outbreak, Treasure Valley

Ebola preparations

Assessment Hospitals  prepared to receive and isolate a Person under Investigation for Ebola Virus Disease (EVD)  decision on which hospitals to designate will be made between state and local health authorities and the hospital administration  prepared to transport patients with confirmed EVD to an Ebola treatment center, informed by discussions among public health authorities and referring and accepting physicians on a case-by-case basis  should be able to provide up to 96 hours of evaluation and care until the diagnosis is either confirmed or ruled out and discharge or transfer is completed Source:

Idaho: progress to date  Dec 11, 2014– survey sent to all Idaho acute care hospitals  Sent to CEO, COO and CNO level staff, asked for the survey to be completed by December 26  12 hospitals indicated interest initially; now 7  CDC site visit August 3-5

CDC Team

Results and Next Steps  Visits were very productive and well received  Both hospitals are considered assessment hospitals for planning purposes, although a few gaps remain (eg, laboratory protocols)  Additional hospitals are being contacted to determine interest in visit by Idaho team

Tularemia  gram negative coccobacillus, Francisella tularensis, causes infection  naturally found in animals, especially rodents, rabbits, and hares  transmitted by multiple routes to humans: –tick bite –deer fly bite (“deer fly fever”) –skinning infected rabbits (“rabbit fever”), muskrats, prairie dogs and other rodents –handling sick cats, pet hamster –eating under-cooked meat of infected animals –inhaling dust or aerosols during farming or landscaping activities, especially when machinery (e.g. tractors or mowers) runs over infected animals or carcasses –drinking contaminated water (rare in US)  risk to laboratorians

Idaho tularemia 2015  9/2015, Valley County: –77-yr old male –Patient reported possible yellow jacket sting on lower leg but did not see it –MRSA suspected in leg ulcer –3 laboratorians received prophylaxis  10/17/2015, Twin Falls County: –79-yr old male –Finger wound that appeared infected –Patient reported gardening, possible puncture by thorn

Tularemia … a long recognized hazard to laboratorians Source: Public Health Reports, Feb 24, 1922

Tularemia exposure to laboratorians  Lab personnel should be informed if tularemia is suspected clinically  BSL-2 practices recommended for handling clinical materials  BSL-3 practices recommended for manipulations of positive cultures  Francisella tularensis is a Select Agent; notify public health of suspected isolations even before confirmed if possible

Highly Pathogenic Avian Influenza outbreaks in the United States  Designation of highly pathogenic avian influenza (HPAI) is based on molecular characteristics of the virus and the ability of the virus to cause disease and mortality in chickens in a laboratory setting.  Between 1997 and 2014, the U.S. experienced one incident of HPAI in poultry. –2004: H5N2 in Texas An outbreak of HPAI (H5N2) virus was reported in a flock of 7,000 chickens in south-central Texas. At that time, this was the first outbreak of HPAI in the United States in 20 years. No transmission to humans was reported.

Highly Pathogenic Avian Influenza (HPAI) 2015

Idaho Summer Preparedness Summit 2015 Kris Carter, DVM, MPVM Career Epidemiology Field Officer IDHW DPH

Initial notice May 19: Idaho Dept. of Fish and Game (IDFG) wildlife veterinarian informs IDHW DPH State Public Health Veterinarian about several ground squirrel mortality events – earliest report May 12 – several locations in Snake River Birds of Prey National Conservation Area south of Boise – IDFG sent specimens to CDC for testing for plague

Source: EID 2015: Jan; 21 (1): 16-22

Epidemiology of Plague in Western US: Source: USGS Circular 1372

Confirmation May 20 — CDC reports carcasses are presumptive positive for Yersinia pestis by direct fluorescent antibody (DFA) test on tissue May 22 — CDC confirmed Yersinia pestis by bacterial culture Source: CDC Public Health Image Library

Informing the Public: Posting

Informing the Public: Websites

Vaccine news 2015

HPV news 2015

Idaho and U.S.-- HPV

HPV – dose reduction coming?

33 Influenza Vaccine Recommendations, Routine annual influenza vaccination is recommended for all persons age 6 months and older who do not have a contraindication Routine annual influenza vaccination is recommended for all persons age 6 months and older who do not have a contraindication Special effort should be made to vaccinate Special effort should be made to vaccinate -infants and young children and their contacts -persons age 65 years and older and their contacts -persons with underlying medical conditions (including pregnancy) and their contacts -healthcare providers Routine annual influenza vaccination is recommended for all persons age 6 months and older who do not have a contraindication Routine annual influenza vaccination is recommended for all persons age 6 months and older who do not have a contraindication Special effort should be made to vaccinate Special effort should be made to vaccinate -infants and young children and their contacts -persons age 65 years and older and their contacts -persons with underlying medical conditions (including pregnancy) and their contacts -healthcare providers MMWR 2015;64:818-25

34 What’s New for Influenza H3N2 and B virus strains changed H3N2 and B virus strains changed New vaccines (Flublok age now 18+ years, Fluzone Intradermal now quadrivalent) New vaccines (Flublok age now 18+ years, Fluzone Intradermal now quadrivalent) Removal of preference for LAIV for children 2 through 8 years of age Removal of preference for LAIV for children 2 through 8 years of age H3N2 and B virus strains changed H3N2 and B virus strains changed New vaccines (Flublok age now 18+ years, Fluzone Intradermal now quadrivalent) New vaccines (Flublok age now 18+ years, Fluzone Intradermal now quadrivalent) Removal of preference for LAIV for children 2 through 8 years of age Removal of preference for LAIV for children 2 through 8 years of age MMWR 2015;64:818-25

35 Fluzone High-Dose Available since December 2009 Available since December 2009 Trivalent formulation only Trivalent formulation only Contains 4 X amount of influenza antigen than regular Fluzone Contains 4 X amount of influenza antigen than regular Fluzone Approved only for persons 65 years and older Approved only for persons 65 years and older Produces higher antibody levels Produces higher antibody levels Local reactions more frequent than with standard dose vaccine Local reactions more frequent than with standard dose vaccine Available since December 2009 Available since December 2009 Trivalent formulation only Trivalent formulation only Contains 4 X amount of influenza antigen than regular Fluzone Contains 4 X amount of influenza antigen than regular Fluzone Approved only for persons 65 years and older Approved only for persons 65 years and older Produces higher antibody levels Produces higher antibody levels Local reactions more frequent than with standard dose vaccine Local reactions more frequent than with standard dose vaccine MMWR 2011;60:

36 Fluzone High Dose Clinical Trial Multi-center randomized clinical trial Multi-center randomized clinical trial 32,000 persons 65 years or older 32,000 persons 65 years or older Compared to standard Fluzone Compared to standard Fluzone -24.2% reduction in laboratory- confirmed influenza -effective against both influenza A and B -reduction in risk of pneumonia and hospitalization Multi-center randomized clinical trial Multi-center randomized clinical trial 32,000 persons 65 years or older 32,000 persons 65 years or older Compared to standard Fluzone Compared to standard Fluzone -24.2% reduction in laboratory- confirmed influenza -effective against both influenza A and B -reduction in risk of pneumonia and hospitalization N Engl J Med 2014;371:635-45

37 Adult Immunization Coverage Rates Source: National Health Interview Surveys : Healthy People 2020 target

38 Pneumococcal Conjugate Vaccine (PCV13) and Adults FDA approved PCV13 for use among adults 50 years of age and older in December 2011 FDA approved PCV13 for use among adults 50 years of age and older in December 2011 Immunogenicity of PCV13 was found to be non- inferior to PPSV23 Immunogenicity of PCV13 was found to be non- inferior to PPSV23 ACIP recommended 1 dose of PCV13 for adults at high risk of invasive pneumococcal disease* in October 2012 ACIP recommended 1 dose of PCV13 for adults at high risk of invasive pneumococcal disease* in October 2012 FDA approved PCV13 for use among adults 50 years of age and older in December 2011 FDA approved PCV13 for use among adults 50 years of age and older in December 2011 Immunogenicity of PCV13 was found to be non- inferior to PPSV23 Immunogenicity of PCV13 was found to be non- inferior to PPSV23 ACIP recommended 1 dose of PCV13 for adults at high risk of invasive pneumococcal disease* in October 2012 ACIP recommended 1 dose of PCV13 for adults at high risk of invasive pneumococcal disease* in October 2012 *immunocompromised, functional or anatomic asplenia, cochlear implant, CSF leak

39 Pneumococcal Vaccines for Persons Age 65 Years and Older One lifetime dose of PCV13 for adults One lifetime dose of PCV13 for adults PCV13 and PPSV23 should NOT be administered at the same visit PCV13 and PPSV23 should NOT be administered at the same visit Administer PCV13 before PPSV23, whenever possible Administer PCV13 before PPSV23, whenever possible PCV13 should be administered to those who have already received PPSV23 PCV13 should be administered to those who have already received PPSV23 One lifetime dose of PCV13 for adults One lifetime dose of PCV13 for adults PCV13 and PPSV23 should NOT be administered at the same visit PCV13 and PPSV23 should NOT be administered at the same visit Administer PCV13 before PPSV23, whenever possible Administer PCV13 before PPSV23, whenever possible PCV13 should be administered to those who have already received PPSV23 PCV13 should be administered to those who have already received PPSV23 MMWR 2014;63(No. 37):822-5

Pneumococcal vaccination for seniors Source:

42 Meningococcal Incidence in Adolescents and Young Adults by Serogroup, 2009–2013 Source: NNDSS data supplemented with additional serogroup data from ABCs and state health departments

43 Groups at Increased Risk for Meningococcal B Disease High-risk medical conditions: High-risk medical conditions: -persistent complement component deficiencies -functional or anatomic asplenia Certain microbiologists Certain microbiologists Populations at risk during an outbreak Populations at risk during an outbreak NOT at increased risk: international travelers, first year college students NOT at increased risk: international travelers, first year college students High-risk medical conditions: High-risk medical conditions: -persistent complement component deficiencies -functional or anatomic asplenia Certain microbiologists Certain microbiologists Populations at risk during an outbreak Populations at risk during an outbreak NOT at increased risk: international travelers, first year college students NOT at increased risk: international travelers, first year college students CDC unpublished data

44 ACIP Recommendations for Meningococcal B Vaccine of High Risk Persons Certain persons 10 years of age or older* who are at increased risk for meningococcal disease should receive MenB vaccine Certain persons 10 years of age or older* who are at increased risk for meningococcal disease should receive MenB vaccine -persistent complement component deficiency -anatomic or functional asplenia -risk in a serogroup B meningococcal disease outbreak -certain microbiologists MenB vaccines are included in VFC MenB vaccines are included in VFC NOT routinely recommended for college students or international travelers NOT routinely recommended for college students or international travelers Certain persons 10 years of age or older* who are at increased risk for meningococcal disease should receive MenB vaccine Certain persons 10 years of age or older* who are at increased risk for meningococcal disease should receive MenB vaccine -persistent complement component deficiency -anatomic or functional asplenia -risk in a serogroup B meningococcal disease outbreak -certain microbiologists MenB vaccines are included in VFC MenB vaccines are included in VFC NOT routinely recommended for college students or international travelers NOT routinely recommended for college students or international travelers *off-label for persons 26 years and older. MMWR 2015;64:608-12

 “A MenB vaccine series may be administered to adolescents and young adults aged 16–23 years to provide short-term protection against most strains of serogroup B meningococcal disease. The preferred age for MenB vaccination is 16–18 years.”  Bexsero® (MenB-4C, 2 doses) and Trumenba® (MenB-FHbp, 3 doses) are both licensed. The two MenB vaccines are not interchangeable; the same vaccine product must be used for all doses.  MenB-FHbp or MenB-4C may be administered concomitantly with other vaccines indicated for this age, but at a different anatomic site, if feasible.

 7698 participants received the vaccine; 7713 participants got placebo  Mean follow-up of 3.2 years  Herpes zoster in 6 participants in the vaccine group; 210 participants in the placebo group  Overall vaccine efficacy against herpes zoster was 97.2% (95% confidence interval [CI], 93.7 to 99.0; P<0.001). Source:

News from ACIP this week  Influenza activity very low right now; over the summer, H3N2 predominated  Supply: million doses of flu vaccine expected to be available; last million were distributed. So far, million have been distributed, similarly to last year.  Fluzone and FluZone High Dose distribution complete, other than prefilled syringes but expected to be complete by November  FluMist distribution ongoing but delayed

News from ACIP this week  Early data showing impact of HPV vaccination  Early results of CDC Ebola vaccine trial

This week  Investigations by local public health district epidemiologists at PHD3 and PHD4 of 4 campylobacter cases and 4 STEC cases, including two hospitalized patients  Raw milk consumption linked to illnesses

Thank You!