Closing MR Immunity Gaps Experiences from the Regions Italy Overview on a changed epidemiology

Transcription

1 Closing MR Immunity Gaps Experiences from the Regions Italy Overview on a changed epidemiology Stefania Iannazzo MD PhD Infectious Diseases and International Prophylaxis Unit Directorate General for Health Prevention Ministry of Health, Italy

2 Background of the NIP and epidemiology of MR

3 Italy: Country information 21 Regions: Regional Health Authorities 146 Local Health Units Total population: 60,626,442

4 Italian National Health System Italian Ministry of Health The Regions Definition of objectives to reach in order to improve population health status National health planning Determination of Essential Levels of Assistance to be provided to any citizen, uniformly throughout the whole national territory Autonomous in operating strategies Ability to legislate on health issues, respecting the general principles Determination of further Levels of Assistance to be provided to any citizen, uniformly throughout the whole regional territory State-Regions Conference Approval of Agreements concerning National Health Policy

5 Organization of the vaccinations: where and who? Regional Health System Local Health Unit Local Health Unit Local Health Unit Local Health Unit Department of Prevention Department of Prevention Department of Prevention Department of Prevention Vaccination Service Vaccination Service Vaccination Service Vaccination Service Vaccination Service Vaccination Service Vaccination Service Vaccination Service

6 National Vaccination Schedule (NVP 2012) Vaccine Birth 3 m 5 m 6 m 11 m 13 m 15 m 5-6 y y >65 y Every 10 y DTaP DTaP DTaP DTaP DTaP dtap dt IPV IPV IPV IPV IPV HBV HBV 3 HBV HBV HBV Hib Hib Hib Hib MMR MMR MMR MMR 4 PCV PCV PCV PCV Men C Men C 5 Men C 5 HPV Flu HPV 6 (3 doses) Flu Varicella Var 7 (2 dosi)

7 N. of cases N. of reported measles cases and measles vaccination coverage (in 24 month-old children), by year. Italy, Source: MOH, statutory notification system ( ) Source: ISS, enhanced measles surveillance ( ) Source: ISS, integrated measles-rubella surveillance ( ) Vaccination coverage at 24 months (%) Monovalent vaccine available MMR MMR in national immunization schedule Second First elimination elimination plan plan ( ) ( ) SPES Sentinel Surveillance Year cases Vaccination coverage (%)

8 N. of cases N. of reported rubella cases and rubella vaccination coverage (in 24 month-old children), by year. Italy, Vaccination coverage at 24 months (%) Monovalent vaccine available MMR MMR in national immunization schedule Second First elimination elimination plan plan ( ) ( ) SPES Sentinel Surveillance Year cases Vaccination coverage (%)

9 2000: Italian national pediatric sentinel surveillance system for selected vaccine-preventable diseases Network of 600 NHS primary care pediatricians Data analysed by geographical area, age, sex and vaccination status SPES 4X more sensitive than statutory notification in detecting measles cases at national level (22X more sensitive in southern Italy) February 2002: timely detection of increased measles incidence in Italy. Large outbreak in Campania, in Southern Italy, where vaccination coverage was low. Documented cases and clinical severity - Ciofi Degli Atti ML, Salmaso S, Vellucci L. New measles epidemic in southern Italy: 1217 cases reported to sentinel surveillance, January- May Euro Surveill. 2003;7(27):pii= Ciofi Degli Atti ML, Salmaso S, Pizzuti R. Epidemic measles in the Campania region of Italy leads to 13 cases of encephalitis and 3 deaths. Euro Surveill. 2002;6(27):pii= Ciofi Degli Atti ML, Salmaso S, Bella A, Arigliani R, Gangemi M, Chiamenti G, et al; Pediatric Sentinel Surveillance Study Group. Pediatric sentinel surveillance of vaccine-preventable diseases in Italy. Pediatr Infect Dis J 2002; 21: 763-8

10 Surveillance of measles and postnatal rubella in Italy Statutory surveillance of measles and rubella physicians report cases to LHU within 2 days of diagnosis (too late for postexposure prophylaxis of susceptible contacts) laboratory confirmation not required monthly reporting of clinical cases to national level no information on complications and hospitalizations Enhanced surveillance system for measles (April 2007) improved timeliness of reporting by physicians (within 12 hrs of diagnosis) improved collection of data on symptoms, vaccination status, complications, hospitalizations, source of infection laboratory confirmation of cases and genotyping classification of cases according to European case definition Integrated measles and rubella surveillance (January 2013) integration of rubella surveillance with measles surveillance improved collection of data, case investigation and laboratory confirmation of RUBELLA cases improved timeliness of reporting (web-based) introduction of monthly zero reporting from Regional Health Authorities to national level

11 Integrated measles-rubella surveillance system Physicians within 12 hrs of diagnosis Collect clinical information on suspected case (measles or rubella); report to local health authorities (LHA) Local health authorities Local lab Regional reference lab -Epidemiological investigation + collection of samples -Contact tracing and vaccination of susceptible contacts -Completion of surveillance form and transmission to regional health authorities (LHAs of 14 Regions) OR webbased reporting (7 Regions) Regional health authorities Report individual cases to national level by web-based platform National reference lab WEB-BASED PLATFORM (managed by ISS) Ministry of Health Monthly reporting of individual cases to ECDC/WHO via TESSy

12 N. of reported measles cases, by month of rash onset, Italy Total cases (conf., prob., poss.) Confirmed cases only Source: Bella A, Filia A, Del Manso M, Declich S, Nicoletti L, Magurano F, Rota MC. Morbillo & Rosolia News, Gennaio Available online at:

13 Measles incidence (x million) by region. Italy: Italy: year Incidence: 4.0 Number cases: n = 220 (67.3% lab-conf) Italy: year 2014 Incidence: 27.6 Number cases: n = 1,389 (59.1% lab-conf.) Italy: year 2013 Incidence: 40.7 Number cases: n = 2,251 (53.2% lab-conf) 5.6 Not available 1.0 < 1.0 (WHO elimination target) Italy: year Incidence: 4.0 > 49.9 Number cases: n = 251 (60.6% lab-conf)

14 How did you diagnose that older teenager/adult susceptibility is (was) an issue in your country?

15 % Distribution of reported measles cases by age group, and median age of cases, by year. Italy, Year 2008 median age 17 yrs Year 2009 median age 17 yrs Year 2010 median age 18 yrs Year 2011 median age 18 yrs Year 2012 median age 21 yrs Year 2013 median age 22 yrs Year 2014 median age 23 yrs

16 Measles incidence (x million), by age group, Italy Measles incidence (per million) ,8 85, ,6 58, ,7 56, ,7 0,3 8,7 0, Age group

17 % Distribution of reported measles cases by age group, median age of cases, and incidence (x 100,000) by age group, Italy Incidence (per 100,000) % Incidence (per 100,000) 2015 median age = 23 y Age group 2016 median age = 23 y Age group

18 Measles complications (n=1,389) among 3,931 reported cases, Italy Diarrhea 31 Stomatitis 11 Other 13 Pneumonia Keratoconjunctivitis Otitis media 7 Hepatitis 5 Respiratory insufficiency 3 Laringotracheobronchitis 4 Thrombocytopenia 3 Convulsions Encephalitis % of total number of complications - 23% of cases had at least 1 complication (N=919) - 29% of cases was hospitalised (N=1,030) - No deaths reported

19 Measles complications (n=68) among 251 reported cases, Italy 2015 Diarrhea 31 Stomatitis 11 Other 13 Pneumonia Keratoconjunctivitis Otitis media 7 Hepatitis 5 Respiratory insufficiency 3 Laringotracheobronchitis 4 Thrombocytopenia 3 Convulsions Encephalitis % of total number of complications % of cases had at least 1 complication (N=68) % of cases was hospitalised (N=107) % of cases requested a visit by the First Aid (N=37)

20 Distribution of complicated measles cases by age group. Italy, % of cases (99/ 220) had at least 1 complication 26 cases < 5ys

21 Vaccination status of reported measles cases, Italy % of measles cases Not vaccinated 1 dose 2 doses vaccinated, uknown n. of doses Vaccination status

22 Who is susceptible to measles and rubella in Italy? 1) Newborns (<12 months) 2) Non-immunized adolescents and young adults (women of childbearing age) 3) Health care workers 4) Individuals for whom vaccination is controindicated 5) Children (95% VC not achieved yet) 6) Children who are immunized late 7) Children not immunized due to parents choice

23 How did you design a specific approach or strategy for closing immunity gaps, if any? Main facilitators and barriers for action

24 Vaccination coverage for 1st dose of measles vaccine, in 24-month-old children, by Region. Italy: 2000, 2007 and Italy: 74.1% < 85% 85% - 90% > 90% Italy: 89.6% Italy: 88.3% Not available Source: Italian Ministry of Health

25 Vaccination coverage for 1st dose of measles vaccine, in 24-month-old children, by Region. Italy, 2015 National VC=86.7%

26 Vaccination coverage for 2nd dose of measles vaccine, in 7 year-old children, by Region. Italy, 2014 National VC=82.7% < 85% 85% - 90% > 90% Not available

27 Approach and challenges on which we are thinking What have we done What are we going to do What we should do (likely)

28 Acknowledgements Infectious Diseases Epidemiology Unit (ISS): Antonietta Filia, Cristina Giambi, Antonino Bella, Maria Cristina Rota, Silvia Declich Virology Lab (ISS): Loredana Nicoletti, Fabio Magurano Italian local and regional health authorities 28

29 I hope that I did not reduce you so!

30 Knowing is not enough; we must apply. Willing is not enough; we must do. Goethe