A measles outbreak and the opportunity to protect a nation A joint presentation by Abertawe Bro Morgannwg University Health Board and Public Health Wales of NHS Wales

Confidence collapse in MMR Fall in uptake: – 11% in Wales – 19% in Swansea area Decade of action 2011: one in five 11 year olds not fully protected

How it started No measles notifications for 3 years November 2012, 2 nd week: Three notifications of suspected measles 26 November: Further notification 28 November: Outbreak declared case notifications per week until end of February 2013 Individual case management, school vaccination sessions in four schools

Summary 28 Nov July 2013 Biggest measles outbreak in Wales since introduction of MMR 1,202 cases notified, 37% laboratory confirmed 88 cases received hospital care 1 adult preventable death

Outbreak response Cases risk assessed and managed locally, apart from 4 weeks at height of outbreak Control escalated after two months to mobilise national support Further escalation to take up opportunity for national catch-up Warwick University modelling: outbreak shortened by 10 weeks

Initial response to the measles outbreak Child Health Service data validated Letters to all schools and vaccination in schools with measles circulating Action to encourage vaccination in primary care Letters to all families with susceptible children MMR catch-up encouraged by health visitors and midwives

March to July Emergency response arrangements established Followed the Health Board’s Pandemic Framework Multi-agency Command and Control meetings led to an integrated community response Experience shared across Wales

Integrated community response GP vaccination Outpatient drop-ins Occupational health Schools, colleges and university Prisons, homeless and long stay care

Results Over 31,500 unscheduled MMR vaccinations given in the Health Board Area (5,553 to those aged 10 – 18 years) – GPs (primary care)16,500 – Outpatient drop-in clinics8,674 – Occupational health clinics3,571 – Schools 1,749 – Prisons1,126 – Homeless82

What worked well Bank of immunisation staff drawn from the community Outpatient departments as mass vaccination venues Peer healthcare worker vaccinators on wards Child health data validation Refrigerated vans for the cold chain Multi-faceted media campaign

Surveillance is not diagnostics All notified measles cases in Wales tested in England Part of the WHO global measles enhanced surveillance scheme Confirmed cases determined by presence of measles IgM antibody Molecular testing is second-line

Three outbreaks not one

Surveillance challenges Identify the population at risk Evaluate effectiveness of MMR catch-up campaigns Provide timely and reliable data to monitor progress in campaigns National Community Child Health Database General Practice surveillance Data from Health Boards

1. Vulnerable population Epidemiological information for the Senior Response Team (SRT)

2. Monitoring progress Monitored and reported in real-time Slow start, rapid improvement

3. Evaluating campaigns National coverage of one or more MMR in year olds increased from 91.1% to 94.5% (in ABM 89.0% to 95.1%)

3. Evaluating campaigns Uptake of 1 MMR dose by 2 years Uptake of 2 MMR doses by 5 years

Working together with shared aims Coordinated multi-agency response was essential Communications essential in bringing support Provided clarification of roles and responsibilities Regular communications Trusted source of latest information

Understanding concerns Communications is about listening Important to understand, address and respond to parents’ concerns Telephone survey Social media

The online conversation Website – provided one online source of information Social media – important two way method of communication Vital tool to engage with wide range of stakeholders Self regulated Targeted

Use of social media Half a million Facebook contacts

Supportive media

Influencing policy Interest locally, regionally, nationally and internationally Boosted support on the ground Influenced Wales, England, Scotland and Northern Ireland to roll out catch-up campaigns

Lessons learned A measles outbreak was inevitable Multi-agency response was effective in controlling the outbreak Strength of timely diagnosis and the value of real time surveillance Importance of the media in raising awareness BUT over 30,000 teenagers in Wales still in need of 1 or 2 doses of MMR

Next steps Support for a policy of aggressive control of measles cases imported into or transmitted within Wales Assertive efforts should be made to target teenagers directly Prioritise the development and implementation of plans to proactively improve MMR rates

Next steps Action to ensure that all health care workers are protected against measles, mumps and rubella Further review looking at the issue of teenagers not being immunised with MMR Consider future strategy and protocols in dealing with measles cases in Wales

Acknowledgements Abertawe Bro Morgannwg University Health Board Molecular and Virology staff in Public Health Wales Microbiology Cardiff National Virus Reference Laboratory in Dublin Primary care NHS Wales Informatics Service City and County of Swansea Neath Port Talbot County Borough Council Bridgend County Borough Council Health Boards Welsh Ambulance Service Public Health Wales Third sector

Conclusions An outbreak was waiting to happen The outbreak response was effective Mass vaccination should be multi- faceted Rapid diagnosis was important Real time surveillance was important Multi-media response was important There is more work to do