Current News. Infection reports. Confirmed measles cases (England) to end-august. Respiratory. Immunisation. HIV-STIs

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1 Volume 7 Numbers 40 Published on: 4 October 2013 Current News Confirmed measles cases (England) to end-august Infection reports Respiratory Laboratory reports of respiratory infections made to the Centre for Infectious Disease Surveillance and Control (CIDSC*) from Public Health England and NHS laboratories in England and Wales: September, 2013 Immunisation HIV-STIs Quarterly vaccination coverage statistics for children aged up to five years in the UK (COVER programme): April to June 2013 Pertussis Vaccination Programme for Pregnant Women: vaccine coverage estimates in England, October 2012 to June 2013 Antenatal screening for infectious diseases in England: summary report for 2012 Health Protection Report Vol 7 No October 2013

2 News Volume 7 Numbers 40 Published on: 4 October 2013 Confirmed measles cases (England) to end-august For the fourth successive month the number of laboratory confirmed cases of measles in England has declined with only 21 cases confirmed in August, bringing the number reported since the start of the year to 1,386 cases. In August, South-West region reported the most cases (eight cases, see table), almost all of which were associated with an on-going outbreak in the area of a new D8 strain, MVs/Bristol.GBR/ There was a smaller cluster of cases in Yorkshire and Humber region of a B3 strain, MVs/Bradford.GBR/ Sporadic cases of MVs/Taunton.GBR/27.12 continue to be identified [1]. So far this year 274 (20%) cases have been associated with primary and secondary school outbreaks. Small outbreaks have also been reported from hard-to-reach populations with known low vaccine coverage such as the travelling community and the ultra-orthodox Jewish community in north London. Overall 294 (21%) of all cases in 2013 were admitted to hospital; 46 reported complications including pneumonia, meningitis and gastroenteritis. As previously reported, the shift towards cases in secondary school age groups during 2013 is likely to be due to the fall in routine vaccine coverage of MMR between 1999 and To reduce the risk of larger outbreaks of measles in the next academic year, Public Health England, the Department of Health and NHS England announced an MMR catch-up programme in late April [2]. The campaign has targeted children aged between 10 and 16 years who have a record of none or incomplete MMR vaccination. Returns from the NHS Areas Teams confirm that almost 5,000 practices have already signed up to participate in the programme. The service involves sending letters from general practices inviting under-vaccinated children to attend the surgery for vaccination. The primary target population was the estimated 8% of that age group who had received no vaccine (around one third of a million). Secondary targets included a similar number of that age group who had received one dose of MMR, and a similar number of children in other age groups. Data has been extracted from approximately 4,400 practices (around half of the total) on the MMR status of children turning 10 to 16 years of age in August Comparing this with children aged 9-15 years in 2012, it suggests that the proportion recorded as unvaccinated fell by around 1.8% (representing around 42,500 children in the participating practices). If this progress was replicated nationally this suggests that around 78,000 unvaccinated children have received MMR since last year. The proportion recorded as having received two doses of MMR has increased by 2.5%. Although some of this may represent data cleaning, this scale of increase is consistent with the vaccine ordering data, which suggests that around 200,000 extra doses have been used. So far, most vaccination has been conducted in primary care, although schools campaigns were conducted in response to local outbreaks in many areas during the last academic year. Plans are being developed to sustain these activities and to undertake specific programmes in some schools during the next two terms. Age group and region distribution of laboratory confirmed cases of measles in England, January to August 2013, and August 2013 Region January August 2013 Age group < Total E Midlands Eastern London N East N West S East S West W Midlands August 2013 Yorkshire & Humberside Grand total Health Protection Report Vol 7 No October 2013

3 Number of confirmed measles cases by month of onset, England: January 2008 to August 2013 References 1. PHE. Confirmed measles cases in England to end-june. Health Protection Report 7(36): news, 2. PHE. MMR catch-up programme Available at: Health Protection Report Vol 7 No October 2013

4 Infection reports Volume 7 Numbers 40 Published on: 4 October 2013 Respiratory Laboratory reports of respiratory infections made to the Centre for Infectious Disease Surveillance and Control (CIDSC*) from Public Health England and NHS laboratories in England and Wales: September, 2013 Immunisation HIV-STIs Quarterly vaccination coverage statistics for children aged up to five years in the UK (COVER programme): April to June 2013 Pertussis Vaccination Programme for Pregnant Women: vaccine coverage estimates in England, October 2012 to June 2013 Antenatal screening for infectious diseases in England: summary report for 2012 * CIDSC is a national centre located at PHE Colindale, not to be confused with the sub-national PHE Centres that serve local populations.

5 Respiratory Laboratory reports of respiratory infections made to the CIDSC from PHE and NHS laboratories in England and Wales: September, 2013 Data are recorded by week of report, but include only specimens taken in the last eight weeks (ie recent specimens). Table 1. Reports of influenza infection made to PHE Colindale, by age group Week Week 36 Week 37 Week 38 Week ending 08/09/13 15/09/13 22/09/13 Total Influenza A Isolation DIF * 1 1 PCR Other Influenza B 1 1 Isolation 1 1 DIF * PCR Other * DIF = Direct Immunofluorescence. Other = "Antibody detection - single high titre" or "Method not specified". Table 2. Respiratory viral detections by any method (culture, direct immunofluorescence, PCR, four-fold rise in paired sera, single high serology titre, genomic, electron microscopy, other method, other method unknown), by week of report Week Week 36 Week 37 Week 38 Week ending 08/09/13 15/09/13 22/09/13 Total Adenovirus * Coronavirus Parainfluenza Rhinovirus RSV* * Respiratory samples only. Includes parainfluenza types 1, 2, 3, 4 and untyped. Table 3. Respiratory viral detections by age group: weeks 36-38/2013 Age group (years) <1 year 1-4 yrs 5-14 yrs yrs yrs 65 yrs Unknown Total Adenovirus * Coronavirus Influenza A Influenza B 1 1 Parainfluenza Rhinovirus Resp/y syncytial virus * Respiratory samples only. Includes parainfluenza types 1, 2, 3, 4 and untyped.

6 Table 4 Laboratory reports of infections associated with atypical pneumonia, by week of report Week Week 36 Week 37 Week 38 Week 39 Week ending 08/09/13 15/09/13 22/09/13 29/09/13 Coxiella burnettii 1 N/a 1 Total Respiratory Chlamydia sp. * N/a 14 Mycoplasma pneumoniae N/a 18 Legionella sp *Includes Chlamydia psittaci, Chlamydia pneumoniae, and Chlamydia sp detected from blood, serum, and respiratory specimens. Weeks only; full-month data will be provided in the November report. Table 5a Reports of Legionnaires Disease cases in England and Wales, by week of report Week Week 36 Week 37 Week 38 Week 39 Week ending 08/09/13 15/09/13 22/09/13 29/09/13 Total Nosocomial Community Travel Abroad 2 2 Travel UK Total Male Female Thirty-eight cases were reported with pneumonia. Thirty-one males aged 43-82yrs and seven females aged 45-79yrs. Twenty-eight cases had community-acquired infection. Two deaths were reported in one male and one female aged 56yrs. and 68yrs. respectively. Ten cases were reported with travel association: Cyprus (1), Italy (1) and United Kingdom (8).

7 Table 5b. Reports of Legionnaires Disease cases in England and Wales, by PHE Centre: weeks 36-39/2013 Region/Country North of England Nosocomial Community Travel Abroad Travel UK North East 1 1 Cheshire & Merseyside Greater Manchester Cumbria & Lancashire 1 1 Yorkshire & the Humber 1 1 South of England Devon, Cornwall & Somerset Avon, Gloucestershire & Wiltshire Total Wessex Thames Valley Sussex, Surrey & Kent Midlands & East of England East Midlands South Midlands & Hertfordshire Anglia & Essex West Midlands London Integrated Region London Public Health Wales Mid & West Wales North Wales South East Wales Miscellaneous Other 1 1 Not known Total

8 Immunisation Quarterly vaccination coverage statistics for children aged up to five years in the UK (COVER programme): April to June 2013 Pertussis Vaccination Programme for Pregnant Women: vaccine coverage estimates in England, October 2012 to June 2013 Quarterly vaccination coverage statistics for children aged up to five years in the UK (COVER programme): April to June 2013 UK vaccine coverage continues to improve and all childhood vaccines evaluated for children reaching 12 months, 24 months and five years of age in the quarter April to June 2013 increased marginally compared to levels reported in the previous quarter, with the exception of third dose DTaP/IPV/Hib coverage at 24 months and five years which remain the same [1]. Country-specific comparisons for minimum coverage levels achieved for all three immunisations evaluated at 12 months (DTaP/IPV/Hib3, MenC2 and PCV2) show Scotland and Northern Ireland achieved at least 97% coverage, Wales at least 96% and England at least 94%; within England all but four Area Teams achieved at least 95%. PCV and Hib/MenC booster coverage for two year olds in the UK also continues to improve and is now 93.2% and 93.4% respectively, up around 0.2% compared to the previous quarter [1]. Across the UK MMR coverage at two years is now 93% and the WHO target of 95% coverage has been achieved for the second successive quarter by all three devolved administrations. In England, eight of 25 English Area Teams also achieved the 95% target and a further eight English Area Teams achieved 94%, increasing national coverage in England by 0.4% to 92.6%. UK coverage of the first dose of MMR evaluated at five years increased by 0.4% to 94.8% with Scotland, Northern Ireland, Wales and 15 English Area Teams achieving at least 95% coverage. Coverage of the second dose of MMR in the UK increased by 0.4% to 89% compared to the previous quarter, with Northern Ireland, Scotland and 17 English Area Teams achieving at least 90%. Last week the Health and Social Care Information Centre (HSCIC) published NHS Immunisation Statistics, England as national statistics, and are available from the HSCIC website [2]. New format for COVER data in England from April 2013 From April 2013, commissioning and coordination of immunisation programmes is the responsibility of NHS England [3]. Given the transfer of responsibility for public health, however, to local authorities (LAs) on 1st April 2013, population vaccination coverage is included in the Public Health Outcomes Framework (PHOF) (Indicator 3.3) [4]. In line with all the outcomes indicators, population vaccination coverage is expected to be collected for LA resident population. Primary Care Trusts (PCT) coverage collections in the NHS have been based around responsible population (i.e. patients who are registered with a GP in the PCT or unregistered patients who reside in the PCT area). In order to ensure that accurate PHOF vaccine coverage data are available, the Health Protection Agency (HPA) Immunisation Department surveyed Primary Care Trusts (PCTs) immunisation coordinators and Child Health Information System (CHIS) managers in February The aim was to understand which CHIS systems can currently produce reliable LA resident population data. Several responses indicated that u sing LA resident population data would lead to a drop in vaccination coverage because the organisation with responsibility for delivery of the immunisation programme is different from the organisation with responsibility for data. It was therefore proposed, and agreed with the PHOF team, that vaccination coverage data (Indicator 3.3) be collected by LA responsible population meaning coverage would be supplied for patients registered with GPs based in that LA and for unregistered patients who were resident in that LA. For LAs that are co-terminus with a PCT this will approximate to the PCT responsible population. Those LAs not coterminous with PCT boundaries may need to collate data from more than one CHIS to provide LA responsible population coverage data.

9 The April to June 2013 quarter request parameters for COVER data in England were simplified in line with the PHOF outcome sub-indicators [4], and were requested in two formats, (i) by PCT responsible population to allow for continuity with historical data and (ii) by LA responsible population (as defined above). However, some areas were unable to provide LA data in the correct format and therefore only PCT level data are published on the COVER pages of the legacy HPA website this quarter [5]. To reflect the new NHS organisations in England this COVER report includes additional tabulations for England only presenting coverage data by Area Team (tables 1b, 2b and 3b). Results for April to June 2013 This report presents quarterly coverage data for children in the UK who reached their first, second, or fifth birthday during the evaluation quarter (April to June 2013). This is the first quarterly data to be collected since the reorganisation of the NHS in England. Children who reached their first birthday in the quarter (born April to June 2012) would have been scheduled to receive their primary vaccinations according to the schedule introduced on 4 September 2006 [6] (three doses diphtheria, tetanus, acellular pertussis, polio, and Haemophilus influenzae type b vaccine (DTaP/IPV/Hib vaccine), two doses each of meningococcal serogroup C conjugate vaccine (MenC vaccine) and pneumococcal conjugate vaccine (PCV). Children who reached their second birthday in the quarter (born April to June 2011) would have been scheduled to receive their third dose primary vaccinations between August and November These children are the seventh quarterly birth cohort to be routinely scheduled to receive their first measles, mumps and rubella (MMR) vaccination, a booster dose of Hib and MenC vaccine (given as a combined Hib/MenC vaccine) and PCV vaccine at the same visit at 12 months of age, between May and July 2012 [6]. Children who reached their fifth birthday in the quarter (born April to June 2008) would have been scheduled to receive their third dose DTaP/IPV/Hib and second MenC and PCV vaccinations between August and November 2008 and are the eighth quarterly cohort to have been exclusively offered their primary vaccinations under to the revised schedule introduced on 4 September 2006 [4]. They would have been scheduled to receive their first MMR between May and July 2009, their pre-school diphtheria, tetanus, acellular pertussis, inactivated polio booster and second dose MMR from July Children born between April to June 2008 were the eleventh quarterly birth cohort to be scheduled to receive Hib/MenC booster vaccine at 12 months and PCV booster vaccine at 13 months [7]. Methods of data collection for COVER coverage are described on the legacy HPA website [8]. Analysis of the neonatal hepatitis B vaccine coverage data in England for April to June 2013 will appear in the HPR to be published on 25 October. Participation and data quality Data were received from all Health Boards (HBs) in Scotland, Northern Ireland and Wales. In England, this is the first quarter collecting data from the new structures in the reorganised NHS and the first to request coverage data in two formats; by PCT and by Local Authority (LA). There are some challenges in maintaining data flows for the PCT level collection as these organisations formally ceased to exist on 1 April 2013 and some Child Health Information Systems (CHISs) have moved to extracting at the Clinical Commission Group (CCG) level, these data were aggregated to PCT level based on CCG postcode. In addition, many CHISs are not able to currently provide accurate LA level coverage data by the resident population, however, where LAs are coterminous with a former PCT boundary coverage data for the responsible population PCT will approximate to the LA responsible population [1]. For those LAs not coterminous with PCT boundaries many areas were not able to provide LA responsible population coverage data and therefore only individual PCT data for this quarter are published on the HPA website [8]. Area Teams (AT) and Child Health Records Departments (CHRDs) submitted data for all PCTs in England, however, data for three London PCTs have been omitted from this report due to data quality issues, and one PCT reported a data quality issue with five-year data, which have also been omitted from the analysis.

10 Coverage at 12 months UK coverage at 12 months for DTaP/IPV/Hib3, MenC2 and PCV2 increased marginally compared to levels in the previous quarter and were 95.1% (0.2% increase), 94.6% (0.1% increase) and 95.0% (0.1% increase) respectively (table 1a) [1]. Country-specific comparisons for minimum coverage levels achieved for all three immunisations evaluated at 12 months show Scotland and Northern Ireland achieved at least 97% coverage, Wales at least 96% and England at least 94%; within England all but four ATs achieved at least 95% (tables 1a and 1b). Within the UK, 126 of the 173 participating PCTs/HBs (73%) achieved at least 95% coverage at 12 months for DTaP/IPV/Hib3, 119 (69%) achieved 95% for two doses of PCV, and 113 (65%) for two doses of MenC vaccine. Table 1a. UK completed primary immunisations at 12 months: April to June 2013 (January to March 2013) Strategic Health Authorities (SHAs)/Country English SHAs PCT/HB/LHB * (total) DTaP/IPV/Hib3 % MenC2 % PCV2 % North East (96.6) 96.4 (96.2) 96.5 (96.4) North West (95.2) 95.9 (95.1) 96.1 (95.2) Yorkshire and Humber (96.3) 95.6 (95.6) 96.0 (96.0) East Midlands (96.2) 96.0 (95.4) 96.3 (95.9) West Midlands (94.4) 94.3 (94.2) 94.6 (94.4) East of England (96.4) 95.8 (96.0) 95.9 (96.2) London (90.4) 89.2 (89.6) 90.3 (90.4) South Central (95.3) 95.0 (95.0) 95.6 (95.2) South East Coast (93.3) 92.8 (93.1) 92.8 (93.1) South West (96.1) 95.5 (95.7) 95.8 (96.0) England (Total) (94.5) 94.1 (94.1) 94.6 (94.4) Wales (96.5) 96.4 (96.3) 96.2 (96.1) Northern Ireland (97.4) 97.7 (97.4) 97.7 (97.4) Scotland (97.5) 97.3 (97.1) 97.7 (97.7) United Kingdom (94.9) 94.6 (94.5) 95.0 (94.8) * Primary Care Trusts/health boards/health boards. Number of trusts reporting DTaP/IPV/Hib3 coverage. Three PCTs' data omitted due to data quality issues.

11 Table 1b. Completed primary immunisations at 12 months by Area Team, England: April to June 2013 (January to March 2013) ENGLAND by Area Team (AT code) Numbers of PCTs in AT DTaP/IPV/Hib3 % MenC2 % PCV2 % Cheshire, Warrington and Wirral (Q44) (95.5) 96.7 (95.8) 97.0 (95.8) Durham, Darlington and Tees (Q45) (96.7) 96.6 (96.1) 96.4 (96.3) Greater Manchester (Q46) (96.7) 96.0 (96.3) 96.2 (96.7) Lancashire (Q47) (90.3) 94.5 (90.2) 94.2 (89.9) Merseyside (Q48) (95.8) 96.2 (96.1) 96.4 (96.0) Cumbria, Northumberland, Tyne and Wear (Q49) (96.8) 96.4 (96.5) 96.8 (96.7) N Yorkshire and Humber (Q50) (96.2) 96.0 (95.7) 96.5 (96.3) S Yorkshire and Bassetlaw (Q51) (95.6) 94.9 (94.5) 95.6 (95.4) W Yorkshire (Q52) (96.6) 95.7 (96.2) 95.9 (96.2) Arden, Herefordshire and Worcestershire (Q53) (96.3) 95.7 (96.0) 95.9 (96.1) Birmingham and the Black Country (Q54) (91.9) 92.2 (91.8) 92.6 (92.1) Derbyshire and Nottinghamshire (Q55) (95.9) 95.4 (94.9) 95.7 (95.6) East Anglia (Q56) (96.0) 95.3 (95.4) 95.3 (95.7) Essex (Q57) (96.6) 96.0 (96.5) 96.1 (96.5) Hertfordshire and the S Midlands (Q58) (96.7) 96.1 (96.2) 96.3 (96.6) Leicestershire and Lincolnshire (Q59) (96.2) 96.6 (95.4) 97.0 (95.9) Shropshire and Staffordshire (Q60) (97.3) 97.0 (97.4) 97.0 (97.2) Bath, Gloucestershire, Swindon and Wiltshire (Q64) Bristol, N Somerset, Somerset and S Gloucestershire (Q65) (96.6) 95.3 (96.2) 95.5 (96.3) (96.0) 95.9 (95.6) 96.5 (96.2) Devon, Cornwall and Isles of Scilly (Q66) (95.8) 95.2 (95.5) 95.4 (95.7) Kent and Medway (Q67) (96.4) 95.3 (96.1) 95.5 (96.3) Surrey and Sussex (Q68) (91.2) 91.1 (91.0) 91.1 (90.9) Thames Valley (Q69) (95.1) 94.6 (94.6) 95.4 (94.7) Wessex (Q70) (95.6) 95.6 (95.6) 95.9 (95.8) London (Q71) (90.4) 89.2 (89.6) 90.3 (90.4)

12 Coverage at 24 months UK coverage of DTaP/IPV/Hib3 at 24 months remained at 96.6% compared to the previous quarter [1]. Surrey and Sussex (Q68) and London (Q71) are the only ATs with DTaP/IPV/Hib3 coverage below the 95% target at 92.1% and 93.7% respectively (table 2b). Both UK PCV booster and Hib/MenC coverage increased compared to the last quarter and are now 93.2% and 93.4% respectively (table 2a) [1]. At least 92% coverage was achieved for both booster vaccines in all countries, and in all English ATs except Birmingham and the Black Country (Q54), Surrey and Sussex (Q68) and London (Q71). Compared to the previous quarter, UK MMR coverage increased by 0.3% to 93.0% (table 2a) [1]. In Northern Ireland coverage is now over 96%, in Wales coverage increased a further 0.8% to 95.9% and in Scotland is 95.2%, making England, at 92.6%, the only country in the UK below the WHO 95% target (table 2a). Within England, 8 of the 25 ATs exceeded 95% (table 2b). Country-specific comparisons for minimum coverage levels achieved for all four immunisations evaluated at 24 months show Wales, Northern Ireland and Scotland achieved at least 95% coverage and England at least 92% (table 2a); within England 8 ATs achieved at least 95% for all four immunisations (table 2b). Within the UK, at least 95% coverage at 24 months was achieved by 148 of the 173 PCTs/HBs (86%) for DTaP/IPV/Hib3, 84 for Hib/MenC booster (49%), 77 (45%) for PCV booster, and 66 (38%) for MMR. Table 2a. UK completed primary immunisations at 24 months by SHA and country: April to June 2013 (January to March 2013) SHA/Country English SHAs PCT/HB* (total) DTaP/IPV /Hib3 % PCV booster% Hib/MenC% MMR1% North East (97.7) 95.6 (95.1) 96.4 (95.7) 94.8 (94.1) North West (97.4) 94.7 (95.1) 94.5 (95.0) 94.7 (95.0) Yorkshire and Humber (97.6) 95.0 (95.4) 95.5 (95.2) 94.3 (94.2) East Midlands (97.7) 95.4 (94.8) 95.4 (94.9) 94.7 (94.1) West Midlands (96.6) 93.0 (93.0) 92.4 (91.8) 92.8 (92.8) East of England (96.8) 94.2 (94.1) 95.1 (94.9) 93.2 (92.9) London (93.4) 87.3 (86.3) 87.9 (87.0) 87.5 (86.6) South Central (96.3) 93.8 (93.4) 93.7 (93.2) 94.0 (93.4) SE Coast (94.9) 89.9 (91.1) 90.9 (91.8) 91.0 (91.7) South West (97.6) 94.2 (94.7) 93.2 (93.5) 93.7 (93.5) England (total) (96.3) 92.8 (92.6) 92.9 (92.7) 92.6 (92.2) Wales (97.7) 95.8 (95.8) 94.9 (95.1) 95.9 (95.1) North. Ireland (98.4) 96.2 (95.8) 96.4 (95.9) 96.1 (95.3) Scotland (98.4) 95.8 (95.8) 96.0 (95.9) 95.2 (95.3) UK (96.6) 93.2 (93.1) 93.4 (93.1) 93.0 (92.7) * Primary Care Trusts/health boards/health boards. Three PCTs' data omitted due to data quality issues.

13 Table 2b. Completed primary immunisations at 24 months by Area Team, England: April to June 2013 (January to March 2013) ENGLAND Area Team (AT) code* Numbers of PCTs in AT DTaP/IPV/Hib3 % PCV booster % Hib/MenC % MMR % Q (98.0) 95.1 (95.5) 95.9 (96.1) 95.2 (95.3) Q (97.1) 95.2 (94.2) 95.6 (94.6) 94.2 (93.2) Q (97.7) 94.6 (95.3) 94.0 (94.8) 94.9 (95.3) Q (96.7) 92.9 (93.3) 92.6 (83.4) 92.4 (83.1) Q (96.7) 95.9 (95.6) 95.8 (95.8) 95.6 (95.3) Q (98.3) 96.1 (96.1) 96.8 (96.7) 95.7 (95.3) Q (97.5) 95.5 (95.4) 95.0 (95.0) 95.3 (94.8) Q (97.1) 93.6 (94.9) 95.0 (94.6) 92.1 (92.9) Q (97.9) 95.5 (95.6) 96.1 (95.7) 94.7 (94.5) Q (98.0) 96.2 (95.6) 95.7 (94.8) 96.0 (96.0) Q (95.2) 89.2 (90.1) 88.1 (88.5) 89.6 (90.0) Q (97.7) 94.4 (93.9) 94.9 (94.7) 94.0 (93.4) Q (96.6) 94.2 (93.3) 94.2 (94.1) 92.6 (92.5) Q (97.1) 93.0 (94.0) 95.2 (95.5) 92.3 (92.7) Q (97.1) 95.4 (95.6) 95.7 (95.3) 94.7 (93.8) Q (97.7) 95.6 (94.7) 95.8 (94.6) 95.2 (94.5) Q (98.0) 97.1 (95.9) 97.5 (95.3) 95.7 (95.1) Q (97.8) 94.4 (96.0) 94.2 (94.8) 94.4 (95.4) Q (97.4) 93.6 (93.2) 92.1 (91.9) 93.0 (92.3) Q (97.4) 94.1 (94.4) 93.1 (93.5) 93.6 (92.7) Q (97.9) 95.4 (95.6) 95.2 (95.4) 95.6 (95.3) Q (93.1) 86.5 (88.3) 88.3 (89.6) 88.2 (89.5) Q (96.4) 93.8 (93.2) 94.1 (92.9) 94.1 (93.3) Q (96.5) 94.4 (94.2) 93.7 (93.9) 94.1 (93.8) Q (93.4) 87.3 (86.3) 87.9 (87.0) 87.5 (86.6) * See table 1b for key to Area Team organisational code

14 Coverage at five years UK coverage at five years for primary course DTP/Pol3 remained at 96.6% compared to the previous quarter, with all countries and all but two English ATs (Surrey and Sussex (Q68), and London (Q71)) achieving at least 95% coverage [1] (tables 3a and 3b). UK coverage of MMR1 at five years increased by 0.4% to 94.8% and all countries and all but one English AT achieved at least 90%. Scotland, Northern Ireland, Wales and 15 English ATs achieved at least 95% coverage. UK coverage for MMR2 also increased, by 0.4% to 89% compared to the previous quarter, with Northern Ireland, Scotland and 17 English ATs achieving at least 90% (tables 3a and 3b). Coverage of UK DTaP/IPV booster coverage increased 0.2% to 89.8% with all countries, and all but five English ATs achieving at least 90% coverage. The five-year birth cohort evaluated this quarter (born between April and June 2008) were the eighth to have had all their primary immunisations scheduled according to the revised schedule from September 2006 when Hib/MenC booster was included for the first time [4]. UK coverage of Hib/MenC increased by 0.2% to 92.8% compared to the previous quarter [1] (table 3a). Table 3a. UK completed primary immunisations and boosters at five years by SHA and country: April to June 2013 (January to March 2013) SHA/ country English SHAs PCT/ HB* DTaP/ Hib % Primary MMR1 % MMR2 % Booster DTaP/ IPV % Hib/ MenC North East (97.9) 96.5 (96.4) 92.7 (91.5) 93.2 (92.5) 95.1 (94.9) North West (97.3) 96.2 (96.1) 91.1 (91.0) 91.6 (91.7) 92.9 (92.7) Yorkshire & Humber (97.4) 95.7 (95.6) 91.2 (90.9) 91.9 (91.9) 95.4 (95.3) East Midlands (97.3) 95.7 (95.4) 91.2 (89.9) 92.8 (92.5) 94.2 (94.7) West Midlands (97.0) 95.3 (95.3) 89.2 (89.1) 90.4 (90.2) 93.2 (93.4) East of England (96.4) 94.0 (93.7) 89.9 (89.3) 91.3 (91.1) 93.6 (94.2) London (92.9) 91.6 (90.2) 81.2 (80.4) 80.5 (79.8) 88.7 (87.2) South Central (96.1) 94.6 (94.6) 89.7 (89.7) 90.6 (90.7) 92.2 (92.6) Sth. East Coast (93.8) 91.9 (91.5) 84.7 (86.0) 86.8 (88.2) 87.9 (88.1) South West (97.3) 95.1 (95.2) 89.8 (89.5) 91.5 (91.5) 93.3 (93.1) England (total) (96.0) 94.4 (94.0) 88.4 (88.0) 89.2 (89.0) 92.3 (92.1) Wales (97.1) 96.9 (96.1) 92.2 (90.4) 92.7 (92.2) 94.0 (94.2) North. Ireland (98.3) 97.7 (97.2) 92.4 (91.4) 93.3 (92.4) 96.1 (95.8) Scotland (98.5) 97.4 (97.0) 92.7 (92.1) 93.6 (93.2) 96.4 (95.8) UK (96.3) 94.8 (94.4) 89.0 (88.5) 89.8 (89.6) 92.8 (92.6) * Primary Care Trusts/health boards/health boards. Three PCTs' data omitted due to data quality issues. One PCT's data omitted due to data quality issues.

15 Table 3b. Completed primary immunisations and boosters by Area Team: April to June 2013 (January to March 2013) ENGLAND Area Team (AT) code* Number of PCTs in AT DTaP/ Hib % Primary MMR1 % MMR2 % Booster DTaP/ IPV % Hib/ MenC Q (96.2) 95.9 (95.1) 90.6 (89.7) 91.7 (90.6) 94.1 (93.5) Q (97.4) 96.7 (96.4) 92.1 (90.8) 92.4 (91.9) 94.8 (95.1) Q (97.3) 95.9 (96.3) 92.1 (92.3) 92.6 (93.0) 91.7 (91.8) Q (97.5) 96.1 (95.7) 88.2 (88.1) 88.4 (88.5) 94.5 (94.1) Q (97.9) 96.8 (97.1) (91.7) 91.6 (92.4) 92.8 (92.8) Q (98.3) 96.5 (96.5) 93.3 (92.3) 93.9 (93.3) 94.8 (94.1) Q (97.1) 94.8 (94.8) 91.5 (90.6) 92.0 (92.1) 94.0 (93.5) Q (97.1) 95.5 (95.0) 89.8 (89.1) 90.8 (89.9) 95.4 (96.1) Q (97.8) 96.4 (96.3) 91.8 (91.8) 92.5 (92.2) 96.0 (95.9) Q (97.3) 96.6 (96.3) 93.2 (92.0) 94.8 (93.4) 92.1 (91.9) Q (96.3) 93.9 (94.4) 85.3 (85.7) 85.9 (86.5) 92.0 (92.6) Q (97.4) 95.4 (95.4) 90.2 (88.7) 90.0 (89.9) 93.9 (95.4) Q (96.0) 93.6 (93.4) 87.5 (87.3) 89.3 (88.8) 91.5 (93.1) Q (97.0) 94.6 (94.2) 91.2 (90.1) 92.4 (92.3) 95.8 (95.5) Q (96.5) 94.4 (93.9) 91.5 (91.1) 92.7 (92.8) 94.0 (94.4) Q (97.5) 96.2 (95.8) 92.0 (90.9) 95.5 (95.4) 94.6 (93.9) Q (97.9) 96.3 (96.1) 91.9 (92.2) 93.4 (93.8) 96.4 (96.5) Q (96.5) 94.9 (95.2) 90.0 (91.1) 91.5 (93.0) 92.7 (92.0) Q (97.6) 94.9 (95.3) 88.8 (88.6) 90.8 (90.8) 83.4 (93.7) Q (97.3) 95.6 (95.2) 90.7 (88.9) 92.3 (90.6) 92.8 (92.7) Q (96.6) 95.4 (95.7) 91.5 (92.2) 94.0 (94.8) 94.2 (94.4) Q (92.1) 89.8 (88.9) 80.9 (82.2) 82.6 (84.1) 84.3 (84.2) Q (96.0) 95.0 (95.1) 89.3 (89.8) 90.2 (90.8) 93.5 (93.9) Q (96.5) 94.3 (94.4) 90.1 (89.7) 91.2 (90.9) 91.8 (92.0) Q (92.9) 91.6 (90.2) 81.2 (80.4) 80.5 (79.8) 88.7 (87.2) * See table 1b for key to Area Team organisational code

16 Relevant links for country-specific coverage data England Northern Ireland Scotland Wales Other relevant links References 1. Health Protection Agency. Vaccination coverage statistics for children up to the age of five years in the United Kingdom, January to March HPR 7(26): immunisation. Available at: 2. HSCIC. NHS Immunisation Statistics, England V1.0. Health and Social Care Information Centre. 26 September Available from: 3. Department of Health. National screening and immunisation programmes. Letter setting out the agreement between the Department of Health, Public Health England and the NHS Commissioning Board 23 August Available from: 4. Public Health Outcomes Framework 2013 to 2016 and technical updates. Available from: 5. Health Protection Agency. Quarterly COVER Reports: United Kingdom. Available from: 6. Department of Health. Vaccinations at 12 and 13 months of age. Letter from the Chief Medical Officer (interim), the Chief Nursing Officer and the Chief Pharmaceutical Officer 17 November PL/CMO/2010/3, PL/CNO/2010/4, PL/CPHO/2010/2. Available at: prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_ pdf 7. Department of Health. Important changes to the childhood immunisation programme. PL CMO (2006) 1. Available online at: Chiefmedicalofficerletters/DH_ Health Protection Agency. Methods of collection and publication of data for the COVER programme. Legacy HPA website: Home Topics Infectious Diseases Infections A-Z Vaccine coverage and COVER (Cover of Vaccination Evaluated Rapidly) COVER Methods.

17 Pertussis Vaccination Programme for Pregnant Women: vaccine coverage estimates in England, October 2012 to June 2013 Background to the pertussis vaccination in pregnancy programme In the UK the introduction of routine national immunisation against pertussis in 1957 resulted in a marked reduction in pertussis notifications and deaths [1]. Despite a sustained period of high vaccine coverage since the early 1990s, however, pertussis continues to display 3-4 yearly peaks in activity with a yearly average of; 800 cases of whooping cough, over 300 babies admitted to hospital and four deaths in babies each year [HPA unpublished reconciled data]. The highest disease incidence occurs in infants under three months of age who are too young to have completed the primary vaccine course and have the greatest risk of complications and death. In 2012, pertussis activity increased beyond levels reported in the previous 20 years and extended into all age groups, including infants less than three months of age. This young infant group is considered a key indicator of pertussis activity [2] and the primary aim of the pertussis vaccination programme is to minimise disease, hospitalisation and death in young infants. A national outbreak (level 3 incident) was declared in April 2012 by the Health Protection Agency to coordinate the response to the increased pertussis activity [3]. In response to this on-going outbreak, the Department of Health announced on 28 September [4] that pertussis immunisation would be offered to pregnant women from 1 October 2012 to protect infants from birth whilst disease levels remain high. This programme aims to passively protect infants from birth, through intrauterine transfer of maternal antibodies, until they can be actively protected by the routine infant programme with the first dose of pertussis vaccine scheduled at eight weeks of age. It has been confirmed that this programme will be continued in 2013/2014 until further notice, pending further advice from the Joint Committee on Vaccination and Immunisation [5]. Early epidemiological data are encouraging and consistent with a specific programme effect on infants but immunisation of pregnant women continues to be important in the face of persisting raised levels of pertussis in non-infant age groups [6]. Vaccine coverage collection In England, monthly data on the uptake of pertussis immunisation in pregnancy are collected through the ImmForm website and are monitored, validated and analysed by PHE. This data collection is vital to monitor the uptake of the programme, to identify areas of low coverage and inform public health actions. Methods GPs will have identified those women in their practice that are eligible for vaccination on their GP systems. The monthly denominator to be reported is the number of pregnant women with an estimated date of delivery (EDD) in that month. GPs should record the EDD through the patient's electronic health record. The monthly numerator is the number of women identified in the denominator defined above who received a dose of Repevax at or after the twenty-eighth week of their pregnancy and before the EDD. At the start of the programme in October 2012 until March 2013 PCT Immunisation Co-ordinators were responsible for collating coverage data from GP practices and manually entering it on the ImmForm website. Since 1 April 2013 local area teams (LATs), together with clinical commissioning groups (CCGs), have been responsible for commissioning public health services and vaccine coverage statistics will henceforth be collated according to LAT (see also the COVER report in this issue). Area Team Screening and Immunisation teams are responsible for the timely submission and accuracy of vaccine coverage data. To aid data collection from practices and reduce burden on Area Teams, a new data entry collection tool is now available on ImmForm for GPs and other vaccinating organisations to use. All submitted GP data are reviewed and collated by the Area Team before submission to the monthly survey. Data collections were requested at different organisational levels; for the October 2012 to March 2013 surveys data were submitted at PCT level and from April 2013 data were provided at Area Team level. To allow direct comparison of monthly coverage estimates PCT data were aggregated to Area Team level (see table). Results The table shows the monthly estimates of pertussis vaccine coverage in pregnant women by Area Team. Coverage at the national level increased during the first five monthly surveys from 43.7% in October 2012 to 59.4% in February More recent data shows that this has fallen since March 2013 to only 50% of women giving birth in May and June. The total number of pregnant women reported with an estimated delivery date in the months

18 October 2012 to June 2013 was 332,594. The number of these women reported to have received a dose of Repevax at or after the twenty-eighth week of their pregnancy and before the EDD was 175,767. Based on a total of 679,100 live births in England (2011), the number of pregnant women with an EDD in any one month is estimated to around 56,600. The reported number of women reported in each survey varied considerably, both by month of report and by Area Team. The highest number of pregnant women reported in the denominator was for December 2012 when 45,793 pregnant women with an EDD in that month were reported (approximately 81% of the expected England total); vaccine coverage for this month was 54.5%. The smallest number of pregnant women reported was for February, 29,790 which is only around 53% of the expected coverage for February was the highest in the period studied. Considerable variation was observed between the number of pregnant women reported by Area Teams within a month, and between different months for the same Area Teams. Coverage estimates have declined dramatically in some Area Teams (eg Durham, Darlington and Tees from 77.5% to 10.5%; North Yorkshire and Humber from 60.8% to 15.9%) whereas in London reported coverage was consistently below the national monthly average (table). However, as monthly denominators varied markedly these changes may be related to data quality issues. Discussion The coverage estimates reported in the first nine month of this surveillance programme suggest that at least 50% of eligible pregnant women have received pertussis vaccine before their EDD, rising to 60% earlier this year. Since the peak in February 2013, there has been a decrease in the level of uptake of this vaccine by pregnant women. This is of particular concern given that there are still high levels of pertussis activity in the population and a further increase in cases was observed around this time last year. However, these data should be interpreted with caution, particularly at the Area Team level as denominators reported vary considerably month-on-month, and it is possible that coverage levels are indeed higher due to under-reporting of pregnant women in the surveys. Continued support in the delivery of this important programme is being sought from service providers (GP practices and maternity units) through Screening and Immunisation Teams to update them on the current epidemiology of the disease, the effectiveness of the vaccination programme and the need to maintain and improve the high coverage achieved. Further information on the pertussis vaccination programme for pregnant women is available at: InfectiousDiseases/InfectionsAZ/WhoopingCough/ImmunisationForPregnantWomen/

19 Pertussis vaccine coverage (%) for pregnant women by month Area Team Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Apr 13 May 13 Jun 13 Cheshire, Warrington and Wirral (Q44) Durham, Darlington and Tees (Q45) Greater Manchester (Q46) Lancashire (Q47) Merseyside (Q48) Cumbria, Northum/d, Tyne & Wear (Q49) N Yorkshire and Humber (Q50) S Yorkshire and Bassetlaw (Q51) W Yorkshire (Q52) Arden, Herefordshire and Worcs. (Q53) Birmingham and the Black Country (Q54) Derbyshire and Nottinghamshire (Q55) East Anglia (Q56) Essex (Q57) Hertfordshire and the S Midlands (Q58) Leicestershire and Lincolnshire (Q59) Shropshire and Staffordshire (Q60) Bath, Gloucestershire, Swindon and Wiltshire (Q64) Bristol, N Somerset, Somerset and S Gloucestershire (Q65) Devon, Cornwall and Isles of Scilly (Q66) Kent and Medway (Q67) n/a n/a 64.3 Surrey and Sussex (Q68) Thames Valley (Q69) Wessex (Q70) London (Q71) ENGLAND References 1. Amirthalingam G, Gupta S, Campbell H. Pertussis immunisation and control in England and Wales, 1957 to 2012: a historical review. Euro. Surveill. 2013; 18(38):pii= Available online: 2. Campbell H, Amirthalingam G, Andrews N, Fry NK, George RC, Harrison TG, Miller E. Accelerating control of pertussis in England and Wales. Emerging Infectious Diseases 2012; 18(1): A level 3 incident is the third of five levels of alert under the HPA's Incident Reporting and Information System (IERP) according to which public health threats are classified and information flow to the relevant outbreak control team is coordinated. A level 3 incident is defined as one where the public health impact is significant across regional boundaries or nationally. An IERP level 3 incident was declared in April 2012 in response to the ongoing increased pertussis activity (HPR 6(15), 4. Pregnant women to be offered whooping cough vaccination, 28 September Department of Health website, 5. Department of Health, Public Health England, NHS England. Continuation of temporary programme of pertussis (whooping cough) vaccination of pregnant women 6. PHE Health Protection Report. Volume 7 Numbers 39 Published on: 27 September

20 Infection reports Volume 7 Numbers 40 Published on: 4 October 2013 HIV-STIs Antenatal screening for infectious diseases in England: summary report for 2012 This report presents a summary of the uptake and test results of antenatal screening for hepatitis B, HIV, syphilis and rubella susceptibility in 2012 in England, updating the previous HPR report that included data to the end of 2011 [1]. Uptake of screening for all infections remains high (>95%) and the number of women with a positive test result for HIV, syphilis or hepatitis B remains stable, whilst the number of women with a rubella antibody level <10 IU/ml increased. Background Since 2004, the National Antenatal Infections Screening Monitoring (NAISM) Programme has been monitoring the uptake and test results of antenatal screening for hepatitis B, HIV, syphilis and rubella susceptibility. This screening is offered to all pregnant women in England as part of the NHS Infectious Diseases in Pregnancy Screening Programme [2]. The screening aims to identify women with hepatitis B, HIV or syphilis early in pregnancy so that strategies can be offered which prevent mother-to-child transmission and benefit the woman s health. Additionally, women identified as rubella susceptible are offered postnatal MMR vaccination for protection during future pregnancies. The 2003 Department of Health s Screening for Infectious Diseases in Pregnancy Standards set a target of 90% for the uptake of antenatal screening for HIV [3]. The 2010 revised Standards retained this 90% uptake target as a reference point for all four infections [4]. In 2009, the UK National Screening Committee agreed on a set of Key Performance Indicators (KPIs) as part of a Quality Assurance strategy for the collation and return of performance data. Two of these indicators are related to infectious disease screening in pregnancy: HIV coverage and timely referral of hepatitis B positive women for specialist care [5]. Methodology Data collection Data are collected at maternity unit or trust level on the number of pregnant women attending for antenatal care; the number screened for each of the four infections and the results of the screening tests, together with the number previously diagnosed with hepatitis B or HIV. These data are requested and collated by PHE s Field Epidemiology Teams in collaboration with the Regional Antenatal & Child Health Screening Teams and sent to PHE s National Centre for Infectious Disease Surveillance and Control, where national figures and trends are generated. Uptake Uptake of antenatal screening is calculated as the proportion of women booked for antenatal care who have a screening test, as reported by maternity services. Where maternity unit booking data were not available, a proxy was used, such as the number of laboratory tests for syphilis or rubella, under the assumption that most booked women are screened for these infections. Use of this proxy data would lead to an overestimate of the uptake of screening as not all women who are offered screening choose to accept. The number of maternity units able to report booking data has increased steadily and significantly from less than half in 2008 to 82% in As part of the data processing, data exclusions and adjustments were made, mainly when the denominator, numerator or both were unavailable or when the screening uptake for a particular infection was over 100%.

21 Women previously diagnosed with hepatitis B or HIV The UK NSC Infectious Diseases in Pregnancy Screening Programme Standards (2010) [3], which came into effect in April 2011, state that screening for hepatitis B or HIV is not required if the woman is already known to be positive and reliable results evidence is documented and known to the healthcare professional. Both newly and previously diagnosed women should be promptly referred for specialist care (KPI ID2 within six weeks of the test result). In 2009 and 2010, prior to the introduction of these standards, data were collected on the number of women previously diagnosed with hepatitis B or HIV, and the percentage rescreened in the current pregnancy. The percentage of women newly diagnosed with hepatitis B or HIV and the total percentage of women positive for these infections were then calculated. In 2011, in line with the new standards, a new data collection form was introduced which requested the number of women not screened as a result of prior diagnosis. Some maternity units could not supply information on previously diagnosed women and, therefore, data from these units were excluded from the newly diagnosed calculations. In 2012, all maternity units provided data on women who were newly diagnosed, those previously diagnosed but rescreened, and those not screened because they were previously diagnosed. The positivity rate is calculated using the following equation: #newly diagnosed + #previously diagnosed (not rescreened & rescreened) % positive = *100 #screened + #previously diagnosed, not rescreened The positivity is therefore measuring how many pregnant women who accept screening are found positive during this pregnancy or were diagnosed previously. The percentage of women newly diagnosed is presented separately, and only takes into account women who are screened during this pregnancy, as presented in the following equation: #newly diagnosed % newly diagnosed = * 100 #screened Limitations Data quality has improved since 2004, though data still need to be interpreted cautiously as limitations remain. The data analysis methodology can be found on the NAISM website and limitations to data quality have been detailed in previous reports [6]. Reported uptake of antenatal screening Screening uptake for all four infections was high in the period from 2008 to 2012, with values >95% (figure 1). The drop in screening uptake between 2008 and 2009 presented in figure 1 is likely to be a reflection of improved data quality, rather than a true decrease, as fewer maternity units relied on numbers of laboratory tests as a proxy for booking data. The difference in uptake for HIV, in comparison to uptake for the other infections has declined over recent years, reaching similar uptake rates.

22 Figure 1. National reported uptake of antenatal screening by infection (England, ) Pregnant women screening positive for HIV, hepatitis B, syphilis or with a rubella antibody level <10 IU/ml Among women who accepted screening, the percentage who screened positive for HIV or syphilis remained relatively stable from (figure 2). Nationally in 2012, 0.19% (1,306/684,566) of pregnant women tested positive for HIV and 0.15% (1,026/688,869) was screen positive for syphilis (tables 1a and 1b). For syphilis however, recent research showed that less than a third of screened positive women had an active infection requiring treatment [7]. There was an increase in women testing positive for hepatitis B after a slight decline in recent years, reaching a positivity of 0.46% (3,178/686,004 in 2012). Regional variation was apparent, with women in London presenting the highest positivity rates for each of the three infections. Over the same five year period, there has been a significant increase in the percentage of women with a rubella antibody level <10 IU/ml (Figure 2). In 2012, 5.9% (40,710/690,734) of women screened positive, compared to 3.9% (25,711/659,256) in However, this may not represent a true increase in susceptibility due to variation in laboratory testing assays and cut-off values used [8]. Figure 2. Percentage of pregnant women positive for hepatitis B, HIV or syphilis or with a rubella antibody level <10 IU/ml, (England, )