1. Epidemiology and Current Issues Annual Update Lambeth and Southwark Practice Nurses 4 May 2016 Nicki Banyard South London Health Protection Team

2. Outline Epidemiology of and impact of immunisation on Measles Rubella Meningococcal disease Rotavirus Pertussis 2Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016

3. Measles Measles Outbreak declared in London 20 April 2016 Since February, 64 confirmed cases across London 3Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016

4. Measles Cases in South London 1 January to 14 April 2016 Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 20164 Source: SLHPT HPZone. Figures provisional

5. Measles Cases in South London by borough 1 January to 14 April 2016 5Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016 Source: SLHPT HPZone. Figures provisional

6. Confirmed measles cases in South London by Age 1 January to 14 April 2016 6Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016 Source: SLHPT HPZone. Figures provisional

7. Proportion of confirmed measles cases in London hospitalised from February 2016 7Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016 Source: PHE Field Epidemiology Services London and South East April 2016

8. Measles Outbreak 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. 8Practice 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 20169

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 https://www.gov.uk/government/publications/viral-rash-in-pregnancy 10Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016

11. Meningococcal disease Source: PHE Green Book Immunisation against infectious 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 201611

12. Outline 12 Laboratory confirmed cases invasive meningococcal disease England and Wales Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016

13. Laboratory confirmed IMD by group and age (2010-2014) England and Wales 13Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016

14. Distribution of MenB cases by month of age England (2009/10-2013/4) 14

15. 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 15Practice 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 16Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016 AreaDose 1 coverage (%) Dose 2 coverage (%) London89.478.5 England94.084.8 Source: PHE Health Protection Report 26 February 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 17Practice 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 18Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016 AgePrimary/BoosterDose Two monthsPrimaryOne dose MenB Four monthsPrimaryOne dose MenB 12-13 monthsBoosterOne dose MenB

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 19Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016 Source: JCVI minutes June 2015

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 20Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016 AgeDose and Vaccine 12 -13 months oldOne dose – Hib/MenC vaccine Around 14 years old (ideally at same time as Td/IPV) One dose – MenACWY conjugate vaccine

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 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 201621

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

23. 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 201623

24. 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) 24Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016 Meningococcal ACWY programme

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 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 201625

26. Laboratory reports of rotavirus 2009/2010 to 2014/15 England and Wales Source: PHE HPR Vol 9 No. 30 28 August 2015 Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 201626

27. Rotavirus vaccine coverage in 25 week olds January 2016 BoroughUptake of one doseUptake of two doses Lambeth91.284.5 Lewisham89.682.8 Southwark91.886.3 London90.483.2 England93.888.6 27Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016 Source: PHE Sentinel Rotavirus Vaccine Coverage Monitoring Programme

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 28Practice 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 201629

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

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 32Practice 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 33Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016

34. Information Sources www.gov.uk/phe https://www.gov.uk/government/publications/the-complete-routine- immunisation-schedule https://www.gov.uk/government/collections/immunisation 34Practice Nurse Annual Immunisation Update Lambeth and Southwark 4 May 2016