Nicki Banyard South London Health Protection Team Epidemiology and Current Issues Annual Update Lambeth and Southwark Practice Nurses 12th October 2016 Nicki Banyard South London Health Protection Team

Outline Epidemiology of and impact of immunisation on Measles Rubella Meningococcal disease Rotavirus Pertussis Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016

Measles Outbreak declared in London 20 April 2016 Since February, 64 confirmed cases across London Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016

Measles Cases in South London 1 January to 14 April 2016 Source: SLHPT HPZone. Figures provisional Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016

Measles Cases in South London by borough 1 January to 14 April 2016 Source: SLHPT HPZone. Figures provisional Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016

Confirmed measles cases in South London by Age 1 January to 14 April 2016 Source: SLHPT HPZone. Figures provisional Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016

Proportion of confirmed measles cases in London hospitalised from February 2016 Source: PHE Field Epidemiology Services London and South East April 2016 Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016

Measles Outbreak What can you do? Most confirmed cases unimmunised. Others partially immunised. A number of cases seriously ill and requiring ICU admission A number of family clusters What can you do? Take any opportunity to check MMR status of patients, particularly children of ALL ages, and young adults Check your practice procedures for patients attending with rash illness, or who are known contacts of measles cases. Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016

Rubella Antenatal rubella screening in UK stopped on 1 April 2016 because High rates of MMR vaccination Rubella infection levels in UK are so low as to be defined as eliminated by WHO Rubella infection in pregnancy is very rare Screening test used can potentially give inaccurate results Being fully immunised with MMR vaccine before becoming pregnant is more effective in protecting women against rubella in pregnancy Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016

Rubella However………… Rubella is still widespread in many parts of the world, such as Africa and Asia In the past two years three cases of congenital rubella and one case of rubella in pregnancy in UK All in women who had migrated to UK and so not included in UK immunisation programme In three of the cases, infection likely acquired abroad Take opportunities to check rubella status in women who may have missed out on rubella/MMR vaccination Appropriate management of rash in pregnancy is vital. See HPA guidance https://www.gov.uk/government/publications/viral-rash-in-pregnancy Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016

Meningococcal disease Cases of invasive meningococcal disease by epidemiological year. E&W 1998-2013. PHE Meningococcal Reference Unit Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016 Source: PHE Green Book Immunisation against infectious disease

Laboratory confirmed cases invasive meningococcal disease England and Wales Outline The graph shows laboratory confirmed IMD cases by capsular group. Although cases of IMD have decreased over time, the graph shows that capsular group B, W and Y now account for the majority of cases in the UK. Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016

Laboratory confirmed IMD by group and age (2010-2014) England and Wales The graph shows laboratory confirmed cases of IMD by capsular group and age. Significantly, capsular group B account for the majority of cases across all age groups. The graph shows the highest incidence of IMD in infants aged less than 12 months, noting a steady decline until the second peak in the adolescent population. Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016

Distribution of MenB cases by month of age England (2009/10-2013/4) The graph shows the distribution of confirmed Men B cases by age (months). It details a gradual increase in Men B cases from birth with the highest risk of disease at around 5 months before gradually declining. Immunising infants before 5 months of age (i.e. 2 and 4 months) ensures optimal protection against Men B disease. Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016

Meningococcal B programme Routine cohort: Starting on the 1 September 2015 all infants born on or after the 1 July 2015 will be eligible for the meningococcal B vaccine at 2, 4 and 12 months Catch-up cohort: A catch-up programme from 1 September 2015 for infants born from 1 May to 30 June 2015 The aim of the routine infant meningococcal B immunisation programme is to reduce the burden and severity of invasive meningococcal disease caused by Neisseria Meningitidis capsular B in the UK by protecting those at increased risk of disease. Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016

MenB MenB vaccine introduced in September 2015 Preliminary vaccine coverage evaluated at six months old in January 2016 Area Dose 1 coverage (%) Dose 2 coverage (%) London 89.4 78.5 England 94.0 84.8 Source: PHE Health Protection Report 26 February 2016 Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016

MenB programme – early data Since 1 September 2015, 15 lab confirmed cases of meningococcal disease in infants aged 3 months or over and eligible for menB vaccine: 8 MenB, 5 MenW and 2 MenY Of the 8 MenB cases, 3 had one dose MenB No cases seen in infants who had received two doses of MenB vaccine Number of yellow card reports received as expected and no concerns identified Source: JCVI minutes 3 February 2016 Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016

MenB vaccine schedule MenB vaccine schedule is 2+1 ie two primaries followed by a booster Age Primary/Booster Dose Two months Primary One dose MenB Four months 12-13 months Booster Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016

MenC schedule change From 1 July 2016 menC vaccine will be removed from infant programme Almost no cases of invasive MenC disease in infants or young children in UK Most invasive MenC disease is seen in over 25s with travel outside UK or coming to UK from abroad MenB vaccine likely to give some protection against MenC MenC (or MenACWY) vaccination of adolescents should provide good herd protection to infants, although may not be fully realised until completion of MenACWY catch up in 2017 With current level of herd protection, very small risk that removal of infant MenC dose could increase risk of exposure to MenC amongst infants Netherlands and Switzerland had good control of MenC disease in infancy through herd protection and not through use of MenC vaccines in infancy Source: JCVI minutes June 2015 Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016

MenC schedule change (2) From 1 July 2016 Infants should no longer have MenC vaccine with second primaries (around 12 weeks) Hib/MenC vaccine dose at 12 months remains unchanged MenACWY vaccine dose given at around 14 years remains unchanged Revised routine schedule for MenC-containing vaccinations from 1 July 2016 Age Dose and Vaccine 12 -13 months old One dose – Hib/MenC vaccine Around 14 years old (ideally at same time as Td/IPV) One dose – MenACWY conjugate vaccine Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016

Rise in Meningococcal Group W cases Historically, MenW cases accounted for 1-2% of invasive meningococcal disease But, since 2009, year on year increase in MenW cases and the increase seem to be accelerating During June 2013 to July 2014 accounted for 15% Increase nearly all of a particular strain of MenW belonging to clonal complex 11 (MenW:cc11) previously associated with large men C outbreak in late 1990s. The MenW:cc11 strain initially identified in adults, but now being seen in all ages For the first time since outbreak associated with Hajj in 2000-2002 deaths in infants, children, adolescents and young adults during 2012-2014 During 2013 and 2014, 24 of 193 MenW cases died No other European country has yet reported an increase in MenW Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016

Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016

MenW immunisation - rationale 2015 - JCVI reviewed data and concluded that cases seen to date likely to be the start of a much larger outbreak The committee concluded the outbreak is a public health emergency and urgent action required Distribution of cases: large number in under 1s, peaking at 7 months, with smaller peak in adolescence JCVI advised a vaccination programme for teenagers aged 14-18 with conjugate MenACWY vaccine as soon as possible Aim is to generate herd immunity for rest of the population including infants Based on evidence that adolescents in this age range most likely to carry meningococcal bacteria and spread to other in population and vaccination has significant impact on acquisition of carriage in adolescents No changes to infant programme at this time in addition to Men B introduction Bexsero vaccine likely to protect against MenW cc11 strain as well as MenB Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016

Meningococcal ACWY programme Now Routine at 13/14 years old Catch up for 17/18 year olds (dob 01/09/1997-31/08/1998) who are leaving school this summer (Year 13) And for freshers under 25 years old and starting university/further education in Autumn 2016 Opportunistic catch-up for those school leavers in summer 2105 who have not yet received vaccine (remain eligible up to 25 years old) Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016

Rotavirus vaccine Rotavirus infection common. Previously nearly every child would have at least one rotavirus infection by age 5 Rotavirus vaccine introduced in July 2013 with aim of preventing infection in young infants where illness more severe Two doses between 6 and 24 weeks old During 2014-15 season, 63% fall in number of laboratory reports of rotavirus compared to average in previous ten seasons Tens of thousands of cases prevented Seasonal peak in confirmed cases in all ages eliminated in 2013-14: ‘herd immunity’ impact was significant PHE HPR Vol 9 No. 30 28 August 2015 Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016

Laboratory reports of rotavirus 2009/2010 to 2014/15 England and Wales Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016 Source: PHE HPR Vol 9 No. 30 28 August 2015

Rotavirus vaccine coverage in 25 week olds January 2016 Borough Uptake of one dose Uptake of two doses Lambeth 91.2 84.5 Lewisham 89.6 82.8 Southwark 91.8 86.3 London 90.4 83.2 England 93.8 88.6 Source: PHE Sentinel Rotavirus Vaccine Coverage Monitoring Programme Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016

Pertussis Prenatal programme Introduced in October 2012 as temporary programme – in response to national outbreak Aim to protect babies before active vaccination, based on theoretical protection from passively transferred maternal antibodies Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016

Source: PHE HPR Vol 9 No. 18 22 May 2015 Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016

Laboratory confirmed cases of pertussis, England (1998-2013) Source: Green Book Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016

Impact and Vaccine effectiveness Maternal pertussis immunisation programme very effective in protecting infants too young to be vaccinated During first year of programme, average coverage 64% Vaccine effectiveness around 90% where vaccine at least one week before delivery Infant pertussis disease returned to levels similar to those pre-2012, but disease in other age groups remains higher Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016

Pertussis deaths 14 deaths were reported for infants with pertussis confirmed in 2012 Following introduction of the pertussis vaccination in pregnancy: 10 babies died up to October 2014 All cases too young to be protected by infant vaccination Nine born to unvaccinated mothers Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016

Prenatal vaccination schedule Vaccine should be offered to women in every pregnancy Now offer between weeks 16 and 32 of pregnancy Immunisation can still be offered after 32 weeks, but may not offer as high a level of passive protection, although may directly protect mother Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016

Information Sources www.gov.uk/phe https://www.gov.uk/government/publications/the-complete-routine- immunisation-schedule https://www.gov.uk/government/collections/immunisation Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016