Lessons learned and strategies for maintaining measles elimination Alberta s perspective

Transcription

1 Lessons learned and strategies for maintaining measles elimination Alberta s perspective Martin Lavoie, MD, FRCPC Deputy Chief Medical Officer of Health Government of Alberta

2 Disclosure Statement Martin Lavoie I have no affiliation (financial or otherwise) with a pharmaceutical, medical device or communications organization. 2

3 Plan of presentation 1. Simple arithmetic addition and subtraction 2. Alberta s immunization program 3. Recent outbreaks of Measles in Alberta 4. Lessons learned 5. What should we do next? 3

4 1. Simple arithmetic Simple additions are easy... You start with your typical childhood infections Then you consider a few others 4

5 1. Simple arithmetic And then you add +SARS And then you add +H5N1 And then you add +MERS-CoV And then you add +H7N9 And then you add +Chikungunya And then you add +Ebola = a whole lot of suffering and work! 5

6 1. Simple arithmetic Now let s try subtraction Let s subtract one - Smallpox But is it really gone? Let s try to subtract - Poliomyelitis Lots of sweat but we can t subtract just yet Let s try to subtract - Measles Subtractions are tough, aren t they? 6

7 2. Alberta s immunization Program Before the 70s everyone used to get Measles. It was expected. It had a very high incidence, significant morbidity and mortality. Measles: no specific treatment even today. In 1963, it became (vaccine) preventable! Killed vaccine used from 1966 to 1970 Live vaccine used since 1970 We added a second dose in 1996 A few second-dose and catch-up programs ( , ) 7

8 2. Alberta s immunization Program Why did we implement a program? To subtract one? It turns out, it is much easier to subtract millions first Then you subtract one! Direct protection, indirect protection, reduction in morbidity and mortality, elimination, eradication 8

9 Number of cases and incidence rate (per 1,000,000 population), by year, , and year of vaccine introduction - Canada. (source: PHAC) 9

10 2. Alberta s immunization Program Number of cases in AB since 1926 Thousands a year < s to 1,000 s <1970 s 100 s <1987 (but 1979!) Varied <100* until 2000 Almost exclusively travel-related now: 0 to 6 cases a year (Average 2.2) But 42 in 2013, 29 in 2014!! Killed vaccine Live vaccine Two doses 10

11 2. Alberta s immunization Program Contacts with parents multiple opportunities Prenatal education courses Resources to new mothers in hospitals Post partum home visit Well child appointments Other contacts Information shared by schools via school nurse Media campaigns for influenza or new programs Media coverage and messaging during outbreaks 11

12 2. Alberta s immunization Program 1 st dose at age % % % % % % % 2014 N/A 2 nd dose at age % % % % 12

13 2. Alberta s immunization Program 13

14 2. Alberta s immunization Program Immunization rates are decent and Measles is no longer endemic in north America We have been very successful at getting rid of Measles so all is good and we should be safe, right? 15

15 3. Alberta s Perspective Let s take a look at what has happened in Alberta in the last 16 months 16

16 3. Recent outbreaks of Measles South Zone May 2013 to January 2014 Perfect storm: - Unimmunized communities - do not support immunization in general (cultural and religious, alternate HCP, misinformation) - Fairly isolated from other Albertans - Ties with other non-immunizing communities in Alberta and outside of AB, including the Netherlands - Experience outbreaks of VPD s on a cyclical basis lack of herd immunity - Last outbreak of Measles in 1997 It s only a matter of time before the next outbreak Is a disaster about to happen? 17

17 3. Recent outbreaks of Measles South Zone May 2013 to January 2014 Luck vs. magic vs. amazing foresight and courage? Detection of risk of importation (not actual importation) from the Netherlands: strong trigger for planning and preparedness months before the first case occurred. 18

18 3. Recent outbreaks of Measles South Zone May 2013 to January 2014 Immunization: HCW and routine program Healthcare facility planning: Measles Assessment Centre Triage tools for physicians and hospital Negative pressure room capacity Community engagement: Communication with external stakeholders and public School administrators, church and community leaders, physicians, post secondary institutions 19

19 3. Recent outbreaks of Measles South Zone May 2013 to January 2014 First case: Lab confirmed October 18, 2013 travel to Netherlands, unimmunized. Outbreak was declared at that time. Immediate engagement (school and church leaders) and broad communication Immediate EOC activation, use of portable isolation containment system, Mobile Measles Assessment Teams, Measles hotline 20

20 3. Recent outbreaks of Measles South Zone May 2013 to January 2014 Special measures: mass immunization clinics, outbreak dose (6 to 12 months of age), immunization of staff and students in medical clinics and schools Rest of Alberta: action plan with prioritization of highest risk communities (with cases, linked communities or low ICR, others) and risk groups within each (HCW, infants and children) 21

21 3. Recent outbreaks of Measles South Zone May 2013 to January 2014 Outbreak: October 18 th, 2013 January 6, confirmed cases, 1 probable All were genotype D8 (MVs/Taunton/GBR/27.12) Age range <1 24 years (median = 13; mean = 12) Total of 12 families All but 2 cases epidemiologically linked 100% unimmunized 1 hospitalization; 6 complications; no deaths Exposures at church, school, household and community Located in 5 communities surrounding Lethbridge; 22

22 3. Recent outbreaks of Measles South Zone Rash onset - October 16 to November 25, 2013 Index case 23

23 3. Recent outbreaks of Measles South Zone May 2013 to January 2014 Quarantine orders only provided upon request No mandatory immunization Respect for individuals and communities Cultural awareness and competency Measles Planning phase enabled external partners to develop business continuity plans and take accountability for their respective organizations/communities. Community leaders took ownership of prevention strategies if you do not immunize, you quarantine and isolate. 24

24 3. Recent outbreaks of Measles South Zone May 2013 to January 2014 Lessons learned: Risk of massive outbreak was known locally with risk of provincial spread Knowing your community and its characteristics pays Imminent danger can motivate action Outbreak prevention and mitigation are possible Strong, organized, efficient response, full engagement of key stakeholders can alter the course Significant gaps exist: immunization rates, herd immunity, capacity to respond When it occurs: intense drain on resources, no guarantees of success, morbidity and mortality are real possibilities It only takes one case in the wrong place at the wrong time When a few choose to not get immunized, we are all in danger Being respectful of values and supportive go a very long way 25

25 3. Recent outbreaks of Measles South Zone May 2013 to January 2014 Lessons learned: Risk of massive outbreak was known locally with risk of provincial spread Knowing your community and its characteristics pays Imminent danger can motivate action Outbreak prevention and mitigation are possible Strong, organized, efficient response, full engagement of key stakeholders can alter the course Significant gaps exist: immunization rates, herd immunity, capacity to respond When it occurs: intense drain on resources, no guarantees of success, morbidity and mortality are real possibilities It only takes one case in the wrong place at the wrong time When a few choose to not get immunized, we are all in danger Being respectful of values and supportive go a very long way 26

26 3. Recent outbreaks of Measles in Alberta Rash onset - January 14 to May 26,

27 3. Recent outbreaks of Measles in Alberta January to June 2014 Lessons learned: We are regularly importing Measles from other countries With fairly high immunization rates and good herd immunity, and some luck, most cases usually do not transmit to many other persons Measles is significantly under-reported: mild disease, not seeking medical attention It s Measles: desperate measures for desperate times. Isolation, quarantine, immunization campaign, education, media presence, support, etc. Huge commitment of time, effort and resources is required to keep things under control Immunization rates are far from meeting our target of 98%, and while on average fairly good, it varies significantly from area to area, from community to community, from school to school, from family to family. Getting these rates higher is proving very challenging. They are slowly going down. 28

28 3. Recent outbreaks of Measles in Alberta January to June 2014 Lessons learned (continued): International travel is the source of most of our cases, until it starts spreading locally. We will continue to be vulnerable as long as other countries experience significant endemic circulation Travel health is not a publicly funded service, so generally not well integrated into our prevention efforts and during responses to outbreak events Susceptibility gaps in the population: infants, vaccine failure after first dose until second dose, non-immunizers and vaccine hesitant persons 29

29 4. Other Lessons Learned Seroconversion lower with decreasing age at dose 1 Permanent blunting effect? Dose 2 at 4-6 maintains a four-year gap between doses 1 and 2 We experience regular importation underreported Each case or cluster/outbreak: extremely resource intensive It s Measles! 30

30 4. Other Lessons Learned Significant ongoing efforts are necessary to maintain and even improve control of Measles in Alberta Current international situation is a significant challenge and threat Infections know no borders, and our planet is a small place We are as weak as the weakest link 31

31 5. What should we do next? Increase immunization rates in general, but this is particularly challenging in non-immunizing groups Adapt immunization schedule to reduce immunity gaps (age at 1 st dose, age at 2 nd dose, infant dose during outbreaks) Better prevent international importation Be ready to aggressively manage cases and outbreaks Support international elimination efforts Eradication is still possible. 32

32 Supplementary slides 33

33 Number of cases measles (n=127) and rubella (n=1), by week of rash onset, as reported to the Canadian Measles/ Rubella Surveillance System (CMRSS) and Measles and Rubella Surveillance system (MARS), for the period ending November 8,

34 35

35 3. Recent outbreaks of Measles in Alberta April to May

36 3. Recent outbreaks of Measles in Alberta April to May