1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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
Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016

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

12. 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

13. 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

14. Distribution of MenB cases by month of age
England (2009/ /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

15. Meningococcal B programme
Routine cohort:
Starting on the 1 September 2015 all infants born on or after the 1 July 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

16. 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

17. 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

18. 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

19. 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

20. 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
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

21. 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 deaths in infants, children, adolescents and young adults during 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

22. Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016

23. MenW immunisation - rationale
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 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

24. Meningococcal ACWY programme
Now
Routine at 13/14 years old
Catch up for 17/18 year olds (dob 01/09/ /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

25. 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 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 : ‘herd immunity’ impact was significant
PHE HPR Vol 9 No August 2015
Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016

26. 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 August 2015

27. 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

28. 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

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

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

31. 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

32. 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

33. 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

34. Information Sources
immunisation-schedule
Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016