Current Issues Template Training Slides February 2017

Current Issues Template Training Slides February 2017
Vaccine Preventable Disease Programme: Promoting immunisation in Wales

Template slide set: Vaccine Preventable Disease Programme
Notes to trainers The purpose of this template is that slides can be added/removed to suit local delivery Local trainers should update, amend and check prior to use Its good practice to critically appraise sources of information prior to using them in the training session Material contained in this document may be reproduced without prior permission provided it is done so accurately and is not used in a misleading context. Acknowledgement to Public Health Wales NHS Trust to be stated. All photos unless otherwise highlighted © Leah Millinship-please acknowledge source if used Websites and sources of further information are included in slides or notes sections Further information is available from: Vaccine Preventable Disease Programme (VPDP) website: NHS Direct Wales: Public Health England: Template slide set: Vaccine Preventable Disease Programme

Learning objectives At the end of this session, you should be able to: List key points for responding to queries raised by clients about vaccination and changes to the vaccine schedule Identify reliable information on new issues (Green Book, Public Health England, WHO, Public Health Wales, VPDP) Critically evaluate vaccine research, allegations and media reporting of vaccine issues To be aware of planned programme changes Template slide set: Vaccine Preventable Disease Programme

Cold chain – vaccine wastage
Template slide set: Vaccine Preventable Disease Programme

Vaccine wastage costs thousands This is particularly important for Fluenz® Tetra which has a very short shelf-life. Reporting vaccine wastage incidents via your health boards DATIX system and through the incident reporting pages on ImmForm is recommended – see ImmForm help sheet fridge failures and stock incidents . There are several ways to avoid cold chain incidents from the ordering stage right through to administration. Having vaccine storage and handling protocol is an essential element for GP practices and immunisation clinics to prevent vaccine wastage. Public Health Wales have provided template documents to help services develop cold chain protocols and conduct regular audits. At a time when we all have to be more much careful with our budgets it is particularly important that we are vigilant around the use of valuable resources. Between October 2015 and September 2016, 78 vaccine wastage incidents of centrally procured vaccines were reported through the ImmForm website in Wales with an NHS list price of approximately £129,000. The pie-chart shows the reasons given for these incidents. Template slide set: Vaccine Preventable Disease Programme

Vaccine Wastage Over a third of incidents involved the vaccine fridge: Fridge door left open Fridge switched off accidentally Fridge failing Best practice: Ensure fridge is secured with a locked door The fridge should have its own dedicated power supply The fridge should be properly maintained and serviced Avoid stockpiling vaccines Template slide set: Vaccine Preventable Disease Programme

Temperature monitoring
Observe the four Rs Read: daily reading of the thermometer’s maximum, minimum and current temperatures at the same time every day during the working week and during transit Record: Recording temperatures in a standard way, on a standard form, signing each entry Reset: resetting the thermometer after each reading, the thermometers should also be reset when temperatures have stabilized after periods of high activity React: the person making the recording should take action if the temperature falls outside +2˚C to + 8˚C and document/report this action Important that staff using the thermometer are familiar with it and trained to use it. Template slide set: Vaccine Preventable Disease Programme

Vaccine wastage - resources
Stickers available - Hard copies of this poster may be ordered from Template slide set: Vaccine Preventable Disease Programme

Immunisation against meningococcal B disease

MenB vaccine All children born from 1 May 2015 are eligible for vaccination There is no catch up for children born before this date Routine schedule is doses at 2, 4 and 12 months Children born May-July 2015 may have received a different schedule: 1 dose at 4 months or 2 doses at 3 and 4 months Date of birth groups: May 2015:dose at 4 months, booster at 12 months June 2015:3 and 4 months, booster at 12 months *July2015:2 and 4 months, booster at 12 months * Children born on or after 1st July 2015 who received < than 2 doses in first year of life should be offered 2 doses of MenB vaccine 2 months apart up to 2nd birthday Template slide set: Vaccine Preventable Disease Programme

The PHE algorithm - July 2016 offers the following guidance on incomplete MenB vaccine status in children up to 2 years. Only children born on or after 1/5/15 should be offered MenB. Children born on or after 1/7/15 who received less than 2 doses of MenB in the first year of life should receive two doses of MenB at least two months apart before their second birthday. Template slide set: Vaccine Preventable Disease Programme

MenB vaccine Source: Oxford Vaccine Group Template slide set: Vaccine Preventable Disease Programme

MenB success! Public Health England - cohort study
In September, 2015, the UK became the first country to introduce the multicomponent, protein-based meningococcal vaccine Bexsero® into a national, publicly funded infant immunisation programme The current 2 dose infant schedule was found to be 83% effective against all cases of MenB in vaccine eligible infants. In the first ten months of the programme, there has already been a 50% reduction in MenB cases in those who were eligible for the vaccination. This is good news and reflects the hard work, dedication and effectiveness of those who deliver immunisation services to the public in Wales – congratulations to all who have contributed to this successful programme The study can be viewed in full here: Template slide set: Vaccine Preventable Disease Programme

Immunisation against meningococcal W disease

The Men W story so far... February JCVI advised that a new vaccine programme against meningococcal group W (MenW) disease is to be offered to year olds This was due to a report from PHE that highlighted a continuing rise in cases of MenW disease since 2009 The increase in MenW cases caused by emergence of a particularly virulent strain of MenW Cases increased rapidly from around 10 cases in 2009/10 to around 60 in 2013/14 Study in 2010 highlighted asymptomatic carriage of MenW was widespread across UK Template slide set: Vaccine Preventable Disease Programme

The Men W story so far... In 2013 a new MenW strain with higher case fatality rate than original UK strain 12% compared to 8% Evidence of atypical presentation in all ages, with cases in yr olds in 2015/16 showing high levels of gastrointestinal symptoms In 2015/16 MenW cases in the 2015 school leavers’ who were eligible for vaccine was significantly lower. No cases in vaccinated adolescents Cases of MenW disease has continued to increase across England and Wales with 215 cases during epidemiological year 2015/16 W strain is presenting in all age groups including older groups with atypical symptoms such as gastrointestinal and also arthralgia. It is important to achieve high vaccine uptake not only to provide direct protection for the teenage groups targeted with the MenACWY programme but it is also expected to provide indirect protection to the wider population in the coming years Template slide set: Vaccine Preventable Disease Programme

MenW cases in Wales The current outbreak of MenW disease continues in the UK; it is a particularly virulent strain with a high case fatality. There were 11 cases of confirmed disease in 2015 in Wales, the same as the total number of cases from 2010 to 2014, and unvaccinated individuals remain at risk. Template slide set: Vaccine Preventable Disease Programme

Immunisation uptake figures for teenagers and young adults born from 01/09/1996 to 31/08/1999, vaccinated as part of the general practice-based catch-up campaign can be accessed, by year of birth, using online interactive reports available from the MenACWY programme page on the VPDP website. Uptake figures are calculated using data provided by general practices, through Audit+. Initially from August 2015 Young people born 01/09/1996 to 31/08/1997 (aged 19 years during the academic year) were offered vaccination through general practice, in addition to any new starters at university under the age of 25. From April 2016 the general practice catch-up campaign was extended to include those born 01/09/1997 to 31/08/1999 (17 and 18 years (School Years 12 and 13) during the academic year). The update data source is immunisations given and read-coded in general practice and reported through Audit + the figures presented as correct as of 10th January 2017. Template slide set: Vaccine Preventable Disease Programme

Uptake of MenACWY vaccine (%) in teenagers and young adults born 01/09/1996 to 31/08/1999, by health board of residence and age group; Wales Data as at 03/01/2016 show uptake of MenACWY vaccine in teenagers and young adults in each annual cohort born 01/09/1996 to 31/08/1999 is 37.3%, 33.3% and 21.3% respectively. This is compared to 78.3% and 77.9% uptake in the year 9 and year 11 age groups which are mainly vaccinated through school based programmes. General practices should invite all eligible adolescents for vaccination on a call and recall basis. Young people within the routine and catch up cohorts who may have missed their vaccination remain eligible up to the age of 25 and should therefore be offered the vaccine on request or opportunistically. University students remain eligible to receive the vaccine whilst in their first year at university. Further information and resources to support the MenACWY programme are available from the MenACWY Programme page of the VPDP website. Template slide set: Vaccine Preventable Disease Programme

This new webpage targeted at young people is bilingual and hosts an eligibility checker and information on the MenACWY programme and includes patient stories and links to further information. The website was launched in January 2017 as part of a renewed social media comms campaign in response to poor uptake in the primary care cohorts.

Pertussis Template slide set: Vaccine Preventable Disease Programme

Pertussis resources The pregnancy – how to help protect you and your baby includes information on pertussis Template slide set: Vaccine Preventable Disease Programme

Reduction in confirmed cases of pertussis in the 0-9 yr olds, slight reduction in age group. For older adults pertussis is still a significant issue and confirmed cases have increased in 2016 from 2015. Template slide set: Vaccine Preventable Disease Programme

Current issues for pertussis
Green book pertussis chapter 24 updated April 2016 – recommending maternal pertussis immunisation should take place from week 16 of pregnancy (JCVI, 2016) Welsh Health Circular WHC (2016) 020 advising on earlier timing of vaccination published June 2016 Change is based on a Swiss study, which shows that maternal immunisation against pertussis in the second trimester significantly increased neonatal antibodies Offering the pertussis vaccine from 16 weeks of gestation will not only improve antibody levels, but will also provide more opportunity for pregnant women to be vaccinated JCVI advise healthcare workers with close contact to infants under three months should receive a pertussis containing vaccine. Currently considering priority cohort for recommendation JCVI minutes Nov 2016 Change in updated GB chapter: Immunisation after week 38 is unlikely to provide passive protection to the infant but would potentially protect the mother from pertussis infection and thereby reduce the risk of exposure to her infant. For women who have not received the vaccine in pregnancy, pertussis-containing vaccine can be offered in the two months following birth i.e. up until their child receives their first dose of pertussis-containing vaccine. Template slide set: Vaccine Preventable Disease Programme

If a woman reaches 38 weeks of pregnancy and has still not received a pertussis containing vaccine, should vaccine be offered? Yes, although immunisation after week 38 of pregnancy may not provide passive protection to the infant, it would potentially protect the mother from pertussis infection and thereby reduce the risk of her becoming a source of infection to her infant. Template slide set: Vaccine Preventable Disease Programme

If a woman did not receive pertussis vaccine in pregnancy, can she still be offered pertussis vaccine after delivery? Yes. For women who did not receive their vaccine in pregnancy, pertussis-containing vaccine can be offered in the two months following birth i.e. up until their child receives their first dose of pertussis containing vaccine. This will protect the woman and may prevent her from becoming a source of infection for the infant but will not provide direct protection for the infant. Template slide set: Vaccine Preventable Disease Programme

Stopping rubella screening in Wales
The Welsh Health Circular WHC (2016) 038: announced that antenatal screening for rubella susceptibility for pregnant women in Wales would be discontinued on 3 October 2016 The evidence has proved that screening for rubella susceptibility during pregnancy does not meet the UK National Screening Committee criteria for a screening programme. The best way to protect pregnant women from rubella infection is to ensure they have two measles, mumps and rubella (MMR) vaccinations before they are pregnant Template slide set: Vaccine Preventable Disease Programme

Stopping rubella screening in Wales
All healthcare professionals should make every contact count and take advantage of existing opportunities to check vaccination status and administer or arrange MMR vaccination (two doses if needed) for: all children and young adults who have not been vaccinated new entrants to the UK at General Practice registration consultation postnatal women through health visiting assessments and six week maternal checks women accessing preconception, fertility or miscarriage and termination services Template slide set: Vaccine Preventable Disease Programme

Measles – MMR vaccine Template slide set: Vaccine Preventable Disease Programme

This report for Health Boards is intended to provide information for monitoring coverage of MMR vaccination in school-aged children and teenagers. The report documents coverage of one and two doses of MMR vaccination in children from five to 16 years of age in Wales during the 2015/16 academic year. It also highlights the potential for future outbreaks of measles and mumps where MMR coverage is low and reminds about existing opportunities and national recommendations for catching children up with their MMR schedule. The report is available here.

Key points in report 21,000 children aged 5 – 16 years in 2015 – 16 recorded as not having any MMR vaccine 18,000 recorded as having only received one dose of MMR vaccine Which means 39,000 children aged between 5-16 years of age in had incomplete immunisation records for MMR vaccine All European countries had a long-standing commitment to eliminate measles and rubella from the region by 2015, some progress has been made, with 34 of 53 countries having interrupted transmission of either or both diseases by The UK is working towards elimination by Whilst progress has been made in preschool ages, uptakes in older children are sub optimal. Every opportunity should be used to bring children of any age who have not received two doses of MMR vaccine up to date. Template slide set: Vaccine Preventable Disease Programme

Coverage of at least one MMR dose (MMR1) and two MMR doses (MMR2) in children reaching their 5th to 16th birthdays between 01/09/2015 and 31/08/2016, by health board. Coverage of at least one MMR dose varied by health board. Coverage ranged from 96.6% in Cwm Taf UHB to 91.4% in Powys THB. Coverage exceeded 95% in Abertawe Bro Morgannwg UHB, Aneurin Bevan UHB and Cwm Taf UHB. Coverage of two doses of MMR did not exceed 95% in any of the health board areas and ranged from 92.5% in Cwm Taf UHB to 85.7% in Powys THB. Source: Public Health Wales Template slide set: Vaccine Preventable Disease Programme

Measles – MMR vaccine In children reaching their 5th to 16th birthdays between 01/09/2015 and 31/08/2016, coverage of two doses of MMR did not reach 95% in any health board area, Wales average 90.6% Two doses of MMR vaccine are recommended to fully protect individuals from measles, mumps and rubella Levels of population protection against measles of 95% or higher are advised to eliminate transmission of measles Between July and September 2016 there were 20 confirmed cases of measles in Wales, eight of which were in school aged children There is potential for further outbreaks of measles if MMR coverage remains low Confirmed cases were linked to festivals in the summer months. Template slide set: Vaccine Preventable Disease Programme

Strategies for improving uptake
In October 2005 Welsh Health Circular (2005) 081 gave the following policy guidance concerning routine follow-up of missing immunisations in school-aged children: School nurses need to identify those children at primary and secondary school entry whose parents have previously consented, but two doses of MMR have not been received. They need to write to these parents recommending MMR and advising how to obtain it Health visitor or school nurse to follow up quarterly list from CHD of all children reaching 18 months and 4½ years of age who have not received one or two doses of MMR for action Health visitors or school nurses need to ensure the accuracy of data by checking the list against other records, and then contact the parents of children who have missed MMR to offer discussion or immunisation. This list should then be amended and returned within 3 months to the CHD Opportunity of giving MMR in Yr 9 vaccination sessions must be used to offer MMR to those who have not received two doses - unless consent for this vaccine has previously been withdrawn Template slide set: Vaccine Preventable Disease Programme

Strategies for improving uptake
Following the strategy of making every contact count (MECC) every opportunity should be used to bring children of any age who have not received two doses of MMR vaccine up to date Highlighting it on the GP database to flag up at appointments Appropriate signposting Template slide set: Vaccine Preventable Disease Programme

Influenza – Season 2016/17 Influenza circulating in Wales, outbreaks have been reported in residential/care homes and hospitals Currently dominant type of flu circulating in Wales this season is influenza A(H3) which generally causes illness in older adults Laboratory testing shows that this season’s flu vaccine appears to be a good match to the circulating strains of flu More information can be viewed here Childhood flu vaccination programme page: Template slide set: Vaccine Preventable Disease Programme

Introduction of a HPV vaccination programme for men who have sex with men From 1 April 2017, a new targeted human papillomavirus (HPV) immunisation programme will be offered to men who have sex with men (MSM) and those at similar risk of HPV infection Vaccination with Gardasil® will be offered through sexual health and HIV clinics in Wales Welsh Health Circular published on the 13th January outlines the detail of this new programme Training resources, including an e-learning package, to support the HPV programme will be made available soon. Template slide set: Vaccine Preventable Disease Programme

Introduction of a HPV vaccination programme for men who have sex with men Eligibility WHC (2017) 03 : All MSM up to and including 45 years of age Assessment of potential benefit of HPV vaccine to other groups: Some MSM over 45 years Transgender men and women HIV positive men who are not MSM HIV positive women and sex workers Sexual health services visiting prisons should offer HPV vaccine to MSM up to and including 45 years of age in the prison setting and other high risk individuals based on clinical judgment HPV vaccination for adolescent boys: JCVI has reviewed the evidence and there is currently insufficient evidence on the cost effectiveness of introducing a universal programme to offer the HPV vaccine to adolescent boys. Template slide set: Vaccine Preventable Disease Programme

CONSENT Montgomery replaces Bolam Bolam - adequate information provided to a patient would be assessed by reference to a responsible body of medical opinion The previously accepted model of the doctor-patient relationship no longer reflects reality. Patients are not incapable of understanding medical matters, or wholly dependent on information from the doctors Montgomery - Montgomery principle outlines a move from medical paternalism i.e. ‘doctors knows best’ to one of ‘self – determination’. The patient is no longer a passive recipient of medical treatment, but a partner in the provision of that treatment Bolam was a measure of a reasonable doctor where as Montgomery is now focused on the measure of a reasonable patient The facts of Montgomery Nadine Montgomery gave birth to her son, Sam, on 1 October As a result of an occlusion of the umbilical cord caused by shoulder dystocia, Sam's brain was starved of oxygen for some 12 minutes. Consequently, he was born with a dyskinetic form of cerebral palsy. He also suffered an avulsion of the brachial plexus, rendering his arm useless. His mother subsequently sought damages from Lanarkshire Health Board. Mrs Montgomery was five feet tall, and was also diabetic, which often results in a larger foetus with weight concentrated around the shoulders. The Lord Ordinary (the judge in the Outer House of Scotland’s Court of Session, where the case was initially heard), was presented with expert evidence that where a diabetic woman gives birth via vaginal delivery, there is a 9%-10% risk that dystocia will occur. The treating obstetrician hadn't warned Mrs Montgomery of the risk of shoulder dystocia, or offered her a caesarean section as an alternative. It was her view that if women were advised of the risk of shoulder dystocia they would opt for a caesarean. As far as she was concerned, this was not in the maternal interest. Template slide set: Vaccine Preventable Disease Programme

BCG vaccination with Intervax
BCG prioritisation During this period of constrained BCG vaccine supply, the Welsh Government endorses the World Health Organisation’s statement on prioritisation of BCG vaccine to neonates and infants of recognised high-risk groups for tuberculosis (TB) and to tuberculin-negative children under 6 years of age. Intervax is unlicensed in the UK therefore it cannot be administered via a PGD, a PSD or individual prescription would be required. Template slide set: Vaccine Preventable Disease Programme

Green Book chapter updates
Japanese encephalitis: Chapter 20 has been updated regarding reinforcing immunisation Immunisation of individuals with underlying medical conditions: Chapter 7 includes clarification on immunisation of asplenics and the addition of morbid obesity as a risk group. It also includes changes to reflect the routine immunisation schedule Meningococcal: Chapter 22 corrected table 22.3 on recommendations for the use of quadrivalent meningococcal ACWY vaccines for travel The primary immunisation schedule for JE remains a 2 dose course, and adults at continuous risk of acquiring JE, e.g. laboratory personnel and long-term travellers who expect to reside in JE endemic areas for appreciable periods of time, should receive a booster dose 12 – 24 months after this primary immunisation course. There are no data currently regarding recommendations for boosting in infants and children below 18 years. Template slide set: Vaccine Preventable Disease Programme

Resources Template slide set: Vaccine Preventable Disease Programme

Routine Childhood Immunisation Schedule Wales May 2016
The childhood immunisation schedule has been designed to provide early protection against infections that pose more of a health risk for the very young. Recommendations for the age at which vaccines should be administered are informed by the age specific risk of disease, risk of disease complications and the ability to respond to the vaccine. The schedule should be followed as closely as possible. This resource is available to download in English and Welsh. Template slide set: Vaccine Preventable Disease Programme

The complete routine schedule May 2016
The complete routine schedule, revised in May 2016, is a two sided chart available to download in English it includes all the recent vaccine changes, reflecting the timing change for pertussis vaccine in pregnancy from 16 weeks and removal of MenC at 3 months from 1st July It also features immunisations for those in ‘at risk’ groups. Template slide set: Vaccine Preventable Disease Programme

Useful resources Template slide set: Vaccine Preventable Disease Programme

Leaflets Copies of the Welsh Government immunisation information leaflets are available by ing or telephoning Leaflets are available on the NHS Direct Wales website Link to NHS Direct Wales: Template slide set: Vaccine Preventable Disease Programme

New leaflets The pregnancy – how to help protect you and your baby includes information on pertussis, influenza, rubella and the MMR vaccine and new rash in pregnancy guidance. Hep B and BCG are also discussed. Template slide set: Vaccine Preventable Disease Programme

Shingles vaccination resources
Link to shingles vaccine eligibility checker: Link to WHC (2015) 19 Changes to Shingles Vaccination Programme : Template slide set: Vaccine Preventable Disease Programme

Screening tool for contraindications for shingles vaccine
A tool to help clinicians screen individuals for contraindications to the live attenuated shingles vaccine has been produced by Health Protection Scotland The screening tool is designed to help identify patients who may be contra-indicated for shingles vaccine. Link to screening tool Link to screening tool: Template slide set: Vaccine Preventable Disease Programme

Acknowledgements PHW–VPDP intranet site Public Health England VPDP team members NHS Education Scotland Other references included in slides Material contained in this document may be reproduced without prior permission provided it is done so accurately and is not used in a misleading context. Acknowledgement to Public Health Wales NHS Trust to be stated. © 2017 Public Health Wales NHS Trust. Template slide set: Vaccine Preventable Disease Programme

Current Issues Template Training Slides February 2017

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