Vaccine Preventable Disease Epidemiology

1
Vaccine Preventable Disease Epidemiology
Presenter Molly Crockett, MPH Epidemiologist/I
nfluenza Surveillance Coordinator Immunization
Program, MDPH
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Agenda

• Vaccine-preventable diseases in adults
• Measles
• Pertussis updates - US and MA
• Invasive pneumococcal disease
• Massachusetts influenza surveillance

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Recommended Vaccines for Adults

• Tdap/Td
• Influenza
• MMR
• Varicella (without history of disease or other
  evidence of immunity)
• Pneumococcal polysaccharide vaccine (PPV23)
• Zoster (shingles)
• Human papillomavirus (through age 26)
• Hepatitis A
• Meningococcal
• Hepatitis B

Recommended for individuals with particular risk
factors (e.g. medical, occupational or lifestyle
factors)
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VACCINE-PREVENTABLE DISEASES IN
MASSACHUSETTS REPORTED, CONFIRMED CASES,
2001-2010
Disease 2001 2002 2003 2004 2005 2006 2007 2008 2009 20101
Measles 3 0 0 2 0 19 1 2 2 3
Mumps 2 1 1 3 8 7 5 7 13 9
Rubella 0 0 1 0 1 2 1 1 1 0
Pertussis 539 602 1668 1713 1180 1199 1198 768 359 288
1 2010 data are not finalized
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Measles, 2011
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International

• April 2011 - WHO reported an increase in measles
  cases in 30 countries in Europe, with increased
  activity since 2007
• 6,500 cases in Jan-April 2011
• e.g., Austria, Germany, Ireland, Italy, the
  Netherlands, UK, Switzerland
• France - 4,937 cases January - March 2011 5090
  in 2010
• Bulgaria - Since 2009, 23,986 cases reported,
  including 24 deaths
• Attributed to increasing population of
  susceptible individuals that are unvaccinated or
  not vaccinated on schedule
• Spread to countries outside of Europe, including
  the US

Source WHO press release, 4/20/2011
(www.euro.who.int).
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United States

• January-February 2011 - 29 cases of measles 28
  import-associated, 16 of which were directly
  imported
• 13 of the imported cases were US residents, 7
  were in individuals between 6 and 23 months of
  age
• 692 measles cases reported in the US during
  2001-2010
• 604 (87) were import-associated and 159 were
  directly imported
• The large number of cases imported by US
  residents traveling overseas highlights the
  importance of ensuring that travelers are fully
  vaccinated against measles virus.

Source MMWR 2011 60(13)397-400
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Measles in Massachusetts, 1894-2011
Reported Cases
1963 Measles vaccine licensed
1967 1 dose measles vaccine added to school
requirements
1991 2 doses measles vacc required for 7th
grade, college
1995 2 doses measles vacc required at
kindergarten entry
Year
Source MDPH
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Measles in Massachusetts, 2011

• 17 confirmed cases as of 5/23/11 (compared with 3
  in all of 2010)
• 5 imported from overseas
• 2 cases from France, 1 from Spain, 1 from
  Nigeria, 1 from Dominican Republic
• 1 secondary case linked to imported case from
  France
• 7 cases with unknown source (no travel, no
  visitors or sick contacts)
• 1 secondary case linked to case with unknown
  source
• Age range 9 months-65 years
• 12 of 17 cases unvaccinated or with unknown
  vaccination status
• 7 cases with unknown or undocumented vaccination
  history
• 5 cases unvaccinated (1 underage, 1 missed
  appointment, 3 parental choice)
• 3 cases with 1 dose of MMR 2 cases with two
  doses of MMR
• In a highly vaccinated population, we expect to
  see some cases in vaccinated individuals

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Suspect Cases of MeaslesInitial Steps

• Call 617-983-6800 an epi will walk you
  through what to do
• Specimen collection and testing at the State Lab
• Control recommendations for patient, exposed
  staff
• Other steps
• Identify all close contacts among staff exposed
  to the suspect case.
• Assess all exposed individuals for acceptable
  evidence of immunity, as outlined in the table
  above.
• Vaccinate all susceptible individuals.
• Exclude all susceptible contacts from work from
  day 5 through day 21 after exposure. (If the case
  is confirmed, even those staff who were
  vaccinated after exposure should be excluded.)
• Surveillance for early identification of
  secondary cases.

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MDPH Measles Recommendations - Healthcare
Settings

• Ensure staff are immune Maintain documentation of
  staff immunity in case of exposure.
• Have a high index of suspicion Carefully assess
  all patients presenting with febrile rash illness
  and report such suspect cases to your local board
  of health and MDPH (617-983-6800).
• Educate staff to recognize potential cases
  quickly and isolate them immediately
• Institute control measures promptly This is
  essential to prevent spread of disease and to
  limit disruption at your facility due to
  vaccination activities, exclusion of staff, etc.
• Vaccination within 72 hours of exposure may
  prevent disease.

MDPH should be contacted at 617-983-6800 or
888-658-2850 as soon as there is suspicion of a
case of measles - 24 hours/day, 7 days/week
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Evidence of Measles Mumps Immunity

• Born in the US before January 1, 1957
• Two doses of measles or mumps-containing vaccine,
  given gt12 months of age and at least 4 weeks
  apart
• Serologic proof of immunity
• Note Physician-diagnosed disease is not
  acceptable for any group

Exception healthcare workers, where year of
birth does not constitute acceptable proof of
immunity (see next slide)
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2-Dose MMR Recommendations -Healthcare Workers
New!

• All healthcare workers without laboratory
  evidence of immunity should have 2 doses of MMR
  vaccine, regardless of year of birth.
• Documentation of 2 doses or serologic proof of
  immunity will be required in an outbreak.

It is important to ensure all who work in
healthcare settings are protected prior to an
exposure, as vaccination of susceptible workers
after exposure will no longer be acceptable in
most settings -- and such individuals will be
excluded from work.
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MDPH Recommendations

• Review the immunization status of all staff now!
• Review the immunization status of all patients.
• Those with exemptions Re-evaluate the status of
  those with medical or religious exemptions and
  offer vaccine, if indicated or appropriate.
• Travelers
• Everyone 12 months of age should have 2 doses
  of MMR at least 28 days apart.
• Children 6 to 11 months of age should receive 1
  dose of MMR. Since the immune response to doses
  given before 12 months of age is variable, these
  children must receive a normal 2-dose series
  starting at age 12 months.
• Those that may have received killed vaccine
  Adults who may have had a dose in the 1960s
  (when the ineffective killed vaccine was
  available) should be considered for
  revaccination.

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Pertussis in the Era of Tdap
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Pertussis in the United States

• Pertussis (whooping cough) incidence varies
  annually and tends to peak every 3-5 years
• Last national peak was 2005 with more than 25,000
  cases reported
• Several states reported increased cases of
  pertussis in 2010 as compared to the previous year

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Pertussis in Massachusetts 1904 2010
1985 - 2010
2005 Tdap licensed for 10 y/o
1949 Pertussis vaccine introduced
1967 Pertussis vaccine added to school
requirements
1996 Acellular pertussis vaccine licensed
2005 Tdap licensed for 10 y/o
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Pertussis Incidence by Age Group (MA), 2000-2010
May/June 05 Tdap licensure for 10 y/o Oct 05
Tdap provided for 11-12 y/o by MDPH
Population estimates based on 2000 census
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Percent of Pertussis cases by age group (MA),
2000-2010
May/June 05 Tdap licensure for 10 y/o
Oct 05 Tdap provided for 11-12 y/o by MDPH
Population estimates based on 2000 census
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Tdap Uptake in Massachusetts

• According to 2009 NIS-Teen, MA was one of four
  states with gt60 coverage for all 3 routinely
  recommended adolescent vaccines (Tdap, MCV, HPV
  for females)
• 62.7 of 13-17 year olds in MA received 1 dose of
  Tdap
• National average 55.6
• California (site of large 2010 outbreak) 53.1
• Our annual school immunization surveys show that
  at least 78 of 7th grade children (11-12 yr
  olds) in MA received a dose of Tdap in 2009.
• Starting in the fall of 2011, Tdap will be
  required for students entering 7th grade and
  post-secondary institutions (replacing the
  requirement for Td)

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Updated Tdap Recommendations

• In October 2010, ACIP expanded Tdap
  recommendations to include
• Use of Tdap regardless of interval since last Td
• Use of Tdap in adults aged 65 years
• Use of Tdap in under-vaccinated children aged
  7-10 years
• Study in patients receiving Tdap lt2 years after a
  dose of Td found no severe adverse events
• When indicated, chance of increased risk of local
  site reactions is outweighed by the benefit of
  protection against pertussis

Off-label recommendation. See MMWR 201160(No. 1)
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ACIP Recommendations for Tdap Adults - Routine

• No minimal interval following last dose of Td
• Single dose of Tdap (either brand) to replace a
  single dose of Td for those aged 19-64 years
• No booster doses at this time
• Single dose of Tdap (either brand) to replace a
  single dose of Td for those 65 who expect to
  have contact with an infant under 1
• Tdap may also be given in place of a single
  booster of Tdap for other adults aged 65 years
  and older.
• Special emphasis on adults with close contact
  with infants (cocoon strategy)
• Parents
• Grandparents
• Childcare providers
• Healthcare workers

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Pertussis Transmission to Infants

• Infants lt12 months of age are at greatest risk
  for death and complications from pertussis
• 2000-2006 infants lt3 months old accounted for
  83 of US pertussis deaths risk of death highest
  among youngest infants
• Over 60 infants lt12 months with pertussis
  hospitalized
• Household contacts responsible for majority of
  transmission to infants
• 2007 study household contacts responsible for
  76-83 of infant cases with known source 55 of
  source cases were parents, 16 siblings
• 2010 Dutch study of hospitalized infants with
  known source case, 38 of transmissions were
  attributed to mother, 17 to father, 41 to
  sibling
• Infant pertussis rates have declined in
  Massachusetts simultaneous with decreases in
  adolescent pertussis incidence

De Greeff et al Clin Inf Dis 2010 Wendelboe et
al Pediatr Infect Dis J. 2007
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Tdap for Healthcare Personnel (HCP)

• April 2011 - ACIP released provisional updated
  recommendations for use of Tdap in HCP
• Tdap is recommended for all healthcare workers,
  regardless of age, as soon as is feasible if they
  have not already received Tdap
• Tdap should be given regardless of the interval
  since the last dose of Td
• Tdap is currently licensed for only a single
  dose HCP should continue to receive Td every 10
  years following Tdap
• Hospitals and ambulatory care facilities should
  provide Tdap, use approaches to maximize
  vaccination rates (e.g., education, convenient
  access, offering vaccine free of charge)

ACIP Provisional Recommendations, April 2011
(http//www.cdc.gov/vaccines/recs/provisional/down
loads/use-of-Tdap-in-hcp.pdf)
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Influenza Surveillance in MA
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Percentage of ILI Visits Reported by MA Sentinel
Sites, 2010-2011 and Two Previous Seasons
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Influenza Hospitalization/Death Surveillance

• Data requested by CDC starting in September 2009
• Purpose To monitor severity of influenza, with
  each state having its own baseline
• Weekly reporting of laboratory-confirmed flu
  hospitalizations and deaths by age group
• All acute care hospitals asked to participate on
  a voluntary basis for 2010-2011 season
• Average of 50 MA hospitals reported weekly during
  the 2010-2011 season

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Influenza-Related Hospitalizations and Outpatient
ILI, Massachusetts, 2010-2011
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Influenza Reporting

• Suspected novel influenza cases (e.g., avian)
• All deaths related to influenza in children under
  18
• All deaths and ICU admissions related to
  influenza in pregnant women
• Unusually severe cases of Influenza
• Any confirmed cases of influenza with
  encephalopathy
• Clusters of Influenza-like illness (ILI) in
  children, pregnant women, or adults
• Laboratory confirmed case(s) or clusters of ILI
  in LTCF or in high risk institutions
• Cases of antiviral treatment failure, begun
  within 48 hours of symptom onset
• Cases of antiviral prophylaxis failure, begun
  with 48 hours of exposure

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Outbreaks of influenza in institutions

• Facilities should contact an MDPH epidemiologist
  at 617-983-6800
• MDPH can recommend control measures, including
  guidance on use of antivirals for treatment and
  prophylaxis
• The state lab can provide respiratory testing for
  patients, including
• Influenza A and B
• Parainfluenza
• Adenovirus
• RSV

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Invasive Pneumococcal Disease (IPD)
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Invasive Pneumococcal Disease

• Streptococcus pneumoniae bacteria in a normally
  sterile site (blood, CSF, pleural or synovial
  fluid, etc.)
• Leading cause of pneumonia and meningitis in the
  US
• Estimated 43,500 cases and 5,000 deaths in 2009
• Approximately 84 of IPD cases and nearly all
  deaths occurred in adults
• Disproportionally affects the very young and the
  elderly

Source MMWR 59(34)1102-1106, 2010
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Pneumococcal Vaccines

• Conjugate vaccine used routinely in children
• 7-valent conjugate vaccine (PCV7) introduced in
  2000
• 13-valent vaccine licensed in 2010
• 4 dose series
• 23-valent polysaccharide vaccine approved for all
  ages
• Routine use in adults 65
• Used in high-risk children and younger adults

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PPV23 Recommendations

• One dose for all adults 65
• Recommended for younger adults and children with
  high-risk conditions
• e.g., chronic heart, lung, immune disorders
• ACIP added smoking and asthma to the list of high
  risk conditions for adults in 2010
• Single booster recommended for
• Adults 65 who received a first dose lt65 years
  and at least 5 years previously
• Very high risk children and younger adults
• Immunocompromised due to asplenia, disease or
  medication
• Renal failure, nephrotic syndrome
• Post-transplant

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Reduction in IPD after PCV7 introduction
Source MMWR 200554893-897
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Reduction in Adult IPD

• Significant reduction of vaccine-type cases in
  all age groups following introduction of PCV7
• In 2003, PCV7 prevented twice as many cases
  through indirect effects on transmission (herd
  immunity) than through direct effects on
  vaccinated children
• Indirect effects likely attributable to reduction
  in nasopharyngeal carriage of vaccine strains of
  S. pneumoniae in vaccinated children ? decreased
  transmission (MMWR 200554893-897)
• By 2007, overall incidence rate of IPD among all
  ages decreased by 45 compared with 1998-1999
  before PCV7 was introduced
• Decreases of 40, 18, and 37 among persons aged
  18-49, 50-64, and 65 years, respectively
• Decreases resulted from overall reductions of
  87-92 in cases of infection with serotypes
  covered in PCV (MMWR 2010591102-1106)

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Pneumococcal Vaccination Rates, MA Adults
Source MA BRFSS
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The Future of Adult IPD

• Introduction of PCV13 2010 is expected to ?
  greater reductions in IPD across all age groups
• 2008 - PCV13 serotypes accounted for 44 of IPD
  cases in adults 65
• PPV23 serotypes responsible for 66 of IPD cases
  in same age group
• Research into the use of pneumococcal conjugate
  vaccine in adults is ongoing
• It is important to continue routine vaccination
  with PPV23 it is the best tool we have for
  directly reducing invasive pneumococcal disease
  in high-risk adults.

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Questions?
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Measles in Massachusetts, 2011
Case Age Rash Onset Vaccination Status Import -Related?
Case 1 9 mo. 1/21/2011 Unvaccinated (Underage) Dominican Republic
Case 2 15 mo. 2/3/2011 Unvaccinated (Missed Appt) Nigeria
Case 3 24 2/10/2011 Unknown France
Case 4 30 2/23/2011 2 Doses Contact of Case 3
Case 5 43 2/25/2011 Unknown Unknown
Case 6 34 4/30/2011 Unknown France
Case 7 16 mo. 5/1/2011 Unvaccinated (Missed Appt) Unknown
Case 8 27 5/4/2011 Unknown Unknown
Case 9 65 5/5/2011 Unknown Spain
Case 10 64 5/5/2011 Unknown Unknown
Case 11 43 5/6/2011 2 Doses (?) Unknown
Source MDPH