VACCINE-PREVENTABLE DISEASE EPIDEMIOLOGY Massachusetts Immunization Action Partnership (MIAP) Conference October 18, 2018 Nancy Harrington nancy.harrington@dph.state.ma.us
Presenter Disclosure Information I, Nancy Harrington, have been asked to disclose any significant relationships with commercial entities that are either providing financial support for this program or whose products or services are mentioned during our presentations. I have no relationships to disclose. I will discuss the use of vaccines in a manner not approved by the U.S. Food and Drug Administration. But in accordance with ACIP recommendations. MIAP Conference 2018 2
Today s Topics Vaccine-preventable Disease (VPD) Epidemiology in Massachusetts Measles Influenza Mumps Pertussis Invasive Meningococcal Disease Hepatitis A Hepatitis B Varicella MIAP Conference 2018 3
Disease 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Measles 2 2 3 24 0 1 8 0 1 0 1 Mumps 7 15 9 4 6 71 5 6 258 191 27 Rubella 1 1 0 0 1 0 0 0 0 1 0 Meningococcal Disease 22 14 8 14 6 11 11 12 11 11 11 Pertussis 761 362 296 280 653 348 298 253 198 383 142 Hepatitis B (acute) Massachusetts Department of Public Health Bureau of Infectious Disease and Laboratory Sciences - Division of Epidemiology and Immunization Vaccine-Preventable Diseases in Massachusetts*, 2008-2018 to date 63 93 87 77 76 69 33 27 35 52 31 Hib < 5 2 1 1 0 2 1 1 0 1 2 0 Tetanus 0 0 0 0 0 0 0 0 0 0 0 Diphtheria 0 0 0 0 0 0 0 0 0 0 0 Polio 0 0 0 0 0 0 0 0 0 0 0 Pneumococcal Disease < 5 83 81 72 40 51 24 27 20 31 21 13 Varicella 1584 1415 770 606 628 475 469 356 288 383 196 Data are current as of 9/11/2018 and are subject to change. *Both confirmed and probable cases are reported for measles, mumps, rubella, and varicella to better reflect the true burden of disease. 4 2018 YTD
Massachusetts Department of Public Health Bureau of Infectious Disease and Laboratory Sciences - Division of Epidemiology and Immunization Vaccine-Preventable Disease Confirmed Cases vs. Investigations Massachusetts*, 2017 Disease Investigated Confirmed* Measles 71 0 MA residents, 1 visitor Mumps 731 191 Rubella 46 1 case of CRS Hib < 5 168 all ages 2 Diphtheria 10 0 Polio 20 0 Data are current as of 9/11/2018. *Both confirmed and probable cases are reported for measles, mumps, rubella to better reflect the true burden of disease. All other diseases include confirmed cases only. MIAP Conference 2018 5
Healthcare Provider Role Vaccinate! Get vaccinated! Report suspected and confirmed cases of VPDs! Notify patient of diagnosis/suspected diagnosis Provide key information to the LBOH to complete the official Case Report per 105 CMR 300.000 Control measures: Isolate patient if still infectious Educate patient about protecting their family and close contacts Inform patient that the LBOH may be calling Assist with notification and PEP Exclude susceptible staff? MIAP Conference 2018 6
Public Health Initial Steps Confirming a case (may not be necessary) Isolation of case while infectious Determining the infectious period Based on the mode of transmission, identifying those who were exposed Facilitating notification of those who were exposed Identification of susceptibles Identification of high-risk susceptibles Post-exposure vaccination or chemoprophylaxis Exclusion from all public activities (quarantine) MIAP Conference, 2018 7
8 Million Dollar Question: Measles In August 2018, measles was confirmed in a MA resident with recent travel. Approximately how many people were potentially exposed? A. A handful of family members and friends B. A few needle-sharing partners C. >500 people D. >5000 people MIAP Conference, 2018 8
Measles Worldwide 2018 MIAP Conference 2018 9
Influenza MIAP Conference, 2018 10
A PATIENT WITH A LETTER It is the beginning of flu season. An unvaccinated teenage patient (who works part-time in a long-term care facility) has arrived at your office carrying a letter from her employer recommending that she consider a prophylactic course of Tamiflu because there have been recent flu cases in the long-term care facility. 1. Could this scenario actually occur? Yes, it is consistent with MDPH recommendations for LTCFs. 2. Isn t it too early in the fall? No. Flu season has begun, and we see flu yearround. 3. Should flu vaccine be recommended to the patient? 4. Bonus points: If the patient has fever and cough during flu season, but tests negative for flu using a rapid assay in your office, could she still have the flu? Yes! Because of sub-optimal test sensitivity, false negative results are common, especially when influenza activity is high (CDC). Yes! 11
Influenza Season 2017-2018 High severity for all age groups A lot of media attention Started building early but did not peak early (mid-february) H3N2 predominant (more flu B later in season) Moderate to low vaccine effectiveness A/H3N2 tends to impact older adults disproportionately Record year for hospitalizations for all age groups Resources taxed and stressed (hospital beds, EDs, provider offices, vaccines, antivirals, IV bags, rapid tests) One pediatric flu-related death in MA 180 pediatric deaths nationally (8/25/18) ~80% unvaccinated 12
What to Report to MDPH Please report any pediatric flu-related deaths immediately Please report any unusual clusters of influenza-like illness Please report any suspected cases of novel flu, avian flu, or flu associated with contact with swine In general, labs report results of flu testing Faxed teleform reports of rapid flu test results no longer necessary MIAP Conference, 2018 13
Mumps 14 A systemic disease characterized by: Non-specific prodrome consisting of myalgia, loss of appetite, malaise, headache, low-grade fever Swelling of one or more salivary glands, usually the parotid glands, often tender or painful, with orchitis commonly reported in males after puberty 1/3 of infections may be asymptomatic or manifest as respiratory illness Rare complications include arthritis, encephalitis, thyroiditis, mastitis, ataxia, oophoritis, hearing loss, and others Infectious 2 days before onset of swelling, and five days after MIAP Conference, 2018 14
A PATIENT WITH PAROTID SWELLING A patient wakes up with swelling under her jaw. She is a student at a local college where there have been cases of mumps. She had flu-like illness for a couple of days before the onset of swelling. She has plans to attend a wedding in two days. She has two documented doses of MMR. She promises to keep a low profile at the event. 1. Should she attend the wedding? 2. What testing can be done? 3. Will the mumps test results influence isolation requirements? 4. Should she get a third dose of MMR? No. Not unless another cause of the parotitis is found. PCR at MA SPHL. IgM serology also a possibility. Consider testing for other causes of parotitis. No. Patient should remain isolated even with a negative PCR result. In consultation with Public Health, if she is part of an ongoing outbreak, a 3 rd dose may be recommended. New! MIAP Conference 2018 15
Number of cases 2016: 258 cases 2017: 191 cases 2018: 27 cases Month and Year * Includes probable cases to better reflect disease burden. 2018 data are preliminary and subject to change.
Mumps in Massachusetts 2016 2018 to date Pediatric cases of mumps: only 5% (26/475) of all confirmed* cases in MA have been in the 17 and under age group. 400/1823 (21%) of all cases investigated were <18 years of age. 57% of confirmed* cases were ages 18-24. Outbreaks: Waning immunity following vaccination plays a role, in settings of intense close contact (for example in college dorms/college parties). Effectiveness of two doses of MMR against mumps: 88% (range of 31-95%) NEW: 3 rd dose of MMR can be used in outbreaks following consultation with MDPH. Two dose schedule sufficient for control in general population. * Includes probable cases to better reflect disease burden. 2018 data are preliminary and subject to change.
3 rd dose of MMR Considerations Persons previously vaccinated with 2 doses of a mumps virus containing vaccine who are identified by public health authorities as being part of a group or population at increased risk for acquiring mumps in certain outbreak settings should receive a 3 rd dose of a mumps virus containing vaccine to improve an individual s protection against an risk mumps disease and related complications. Factors to be considered include: Size of target population; Mumps incidence/number of cases MMR3 vaccine coverage needed to impact the outbreak Timing of MMR3 vaccination Social networks Intensity and duration of close contact Call MDPH Division of Epidemiology and Immunization at 617-983-6800 for consultation. CDC. MMWR 2018;67(1):33. January 2018. MIAP Conference 2018 18
Pertussis - Whooping Cough Can start like a common cold runny nose, low-grade fever, and coughing some people might not know they have it. Infants suffer the most serious consequences. Infants younger than 1 year old who get whooping cough, ½ are hospitalized. Of those hospitalized, 1 out of 4 get pneumonia Of those hospitalized, 1 to 2 out of 100 dies. Peak in 2012 in US: More than 48,000 cases of whooping cough reported 15 infants younger than 3 months died. Baby Brady, Massachusetts 2012 http://shotbyshot.org/pertussis/bradys-story/ MIAP Conference, 2018 19
AN EXPOSURE CLOSE TO HOME You have recently learned that a patient you evaluated has tested PCR positive for pertussis. The patient had classic pertussis symptoms including paroxysmal cough, with a cough onset two weeks before the evaluation. You are vaccinated with a dose of Tdap. You did not wear a mask during the evaluation. Should you cancel your plans to attend a friend s wedding? 1. Was the patient infectious during the evaluation? Yes. 2. Could you have been exposed? Yes. 3. Could you get pertussis? 4. Is post-exposure chemoprophylaxis recommended? Yes. 5. Can you attend the wedding? Yes, if you do not have a cough. Yes. (Incubation period is 7 to 10 days, with a range of 4-21 days.) Which groups are the priority targets of Public Health investigations and control measures for pertussis? Infants Pregnant women Immunocompromised people Healthcare workers All of the above MIAP Conference 2018 20
Confirmed Pertussis in MA 2000-2017 by Month of Onset Range: 7 to 441 cases per month Average: 63 cases Number of cases MIAP Conference 2018 21
Pertussis Cases by Age Group MIAP Conference 2018 22
Acceptable Pertussis Diagnostic Tests 1. Culture at MA SPHL or any commercial lab 2. PCR from any commercial lab (risk of false positives*) 3. Serology performed at MA SPHL Must be drawn >3 years after a pertussis containing vaccine DURATION OF COUGH CHILDREN (<11 yrs) DIAGNOSTIC METHOD ADULTS (> 11 yrs) < 14 DAYS 14-28 DAYS NP Swab(s) (for Culture & PCR Testing) NP Swab(s) (for Culture & PCR Testing) Serology at MA SPHL -OR- Serology at MA SPHL & Consider NP Swab(s) (for Culture & PCR Testing) 29-56 DAYS Serology at MA SPHL *Because of the possibility of false positive PCR results, and the need to avoid antibiotic overuse, and the need for caution when using isolation and quarantine regulations, MDPH only makes formal control measures when patients who are PCR-positive have symptoms which are consistent with the pertussis clinical case definition: 2 weeks of cough and either post-tussive vomiting, the whoop, paroxysmal 23 cough, or apnea (infants <1). MIAP Conference, 2018
Pertussis Notifications Schools/teams/camps may send out notifications when there has been an exposure. Read the advisory closely to determine if this is a general notification, or if the patient has been identified as a close contact. MIAP Conference, 2018 24
MenB Vaccine Recommended? Several of your patients are headed to UMASS Amherst. They inquire about MenB vaccine. Is the outbreak of group B meningococcal disease still happening in the 5 College Consortium? Yes. Is MenB vaccine recommended for UMASS Amherst students? Yes. When will the outbreak be over? One year after the last case, according to CDC guidelines. Bonus: Is MenB vaccine recommended for all college students, regardless of college/university? MIAP Conference, 2018 No. There is no routine recommendation for MenB vaccine for college-age individuals. 25
2017-2018 Outbreak of Invasive Meningococcal Disease: 5 College Consortium Began in November 2017 Three cases by February 2018 Two UMASS students One Smith College student Identification and prophylaxis of close contacts Very large vaccination efforts Smith: >1010 1 st doses* (undergrad population of 2500) >575 2 nd doses* UMASS: >7600 1 st doses* (undergrad population ~23,000) > 3440 2 nd doses* *Data are preliminary as of 8/2/18 and subject to change. Students also obtained vaccine independent of the college/university. Source: UMASS Amherst, Smith College. MIAP Conference 2018 26
1 dose MenACWY recommended 2nd dose MenACWY recommended 2015 MenB vaccine for high risk recommended and permissive use for 16-23 can be considered Data are current as of 12/13/2017 and are subject to change. MDPH, 2017 MIAP Conference 2018 27
Summary: Epidemiology of Meningococcal Disease in the U.S. Rates of disease have declined from approximately 1 to 0.1 cases per 100,000 population in the past 20 years. Decline seen in all serogroups, including serogroup B. Outbreaks are rare (only 2-3 out of every 100 cases). In recent years, several serogroup B outbreaks in universities and serogroup C outbreaks among MSM and other communities have been reported. Incidence of serogroup B meningococcal disease in college students is low (20 cases per year out of nearly 9 million students 18-21 enrolled in college, with 2-4 outbreaks reported annually); however, college students aged 18-21 years are at increased risk compared to non-college students. Incidence of serogroups C, W, and Y disease in this age group is even lower and similar in college students and non-college students, likely in part due to the adolescent MenACWY program. Presented by Dr. Sarah Meyer, ACIP Meeting 2-22-17 MIAP Conference 2018 28
Groups at Increased Risk for N. meningitidis MenACWY MenB Complement deficiency, or taking eculizumab (Soliris) Anatomic/Functional asplenia Outbreak setting Microbiologist Complement deficiency, or taking eculizumab (Soliris) Anatomic/Functional asplenia Outbreak setting Microbiologist HIV Infection Traveler to hyperendemic area First year college student. Military Recruit (Category B) MMWR October 23, 2015/64(41);1171-1176. MMWR May 19, 2017/66(19);509-513. MIAP Conference MDPH 2017 2018 29
MA College Requirement for Meningococcal ACWY Vaccine New for fall of 2018: All newly enrolled full-time students 21 years of age and younger will be required to show documentation of a dose of MenACWY vaccine administered on or after their 16 th birthday, regardless of housing status. Meningococcal B vaccine does not fulfill this requirement. Previously was One dose for newly enrolled full-time residential students. MIAP Conference 2018 30
31 Million Dollar Question: Hepatitis A In August 2018, MDPH issued a clinical advisory concerning HAV infection among people: A. Experiencing homelessness B. Injecting drugs C. Working in office settings D. Both A and B MIAP Conference, 2018 31
Acute Hepatitis A Infection in Massachusetts, 2018 Since April, 2018, 65 cases of acute hepatitis A virus (HAV) infection have been reported to the Massachusetts Department of Public Health (MDPH). These cases are all individuals who have recent experience of homelessness, unstable housing, and/or substance use disorder.
Hepatitis A Outbreak/Advisory Recommendations: Vaccination of those at high risk Vaccinate close contacts of those with hepatitis A Handwashing Environmental cleaning Sanitary facilities Education about prevention Early recognition of cases Reporting of new cases Vaccination Sanitation - Education MIAP Conference 2018 33
34 Million Dollar Question: Hepatitis B In April 2018, MDPH issued a clinical advisory concerning HBV infection among people: A. In Bristol County B. Injecting drugs C. Who were unvaccinated D. A, B and C MIAP Conference, 2018 34
Hepatitis B Outbreak in MA 2017: 78% increase in acute hepatitis B cases in Bristol County Geographic cluster within county with high rate of IDU More males than females Median age 38.5 Where known, mostly white non-hispanic Many diagnosed in emergency department High rate of hospitalization Many with lab evidence of hepatitis C exposure Vaccination efforts during March 2018 resulted in >50 doses being given during the first two weeks, and testing for HBV infection MIAP Conference 2018 35
Number of cases Reported Number of Acute Hepatitis B Cases United States, 2000-2015 9,000 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 Increase associated with concomitant rise in injection-drug use Year National Notifiable Diseases Reporting System Surveillance for Viral Hepatitis United States, 2015 (www.cdc.gov/hepatitis/statistics/2015surveillance) MIAP Conference 2018 36
Reported cases/100,000 population Immunization Update 2018 37 ncidence of Acute Hepatitis B by Age Group United States, 2000-2015 6 5 4 3 0-19 yrs 20-29 yrs 30-39 yrs 40-49 yrs 50-59 yrs 60+ yrs 2 1 0 Year National Notifiable Diseases Reporting System Surveillance for Viral Hepatitis United States, 2015 (www.cdc.gov/hepatitis/statistics/2015surveillance
Persons Recommended to Receive Hepatitis B Vaccine 20 Groups in Brief! All infants Unvaccinated children <19 Persons at risk by sexual exposure Sex partners of hepatitis B surface antigen-positive persons Sexually active persons not in a long-term monogamous relationship Persons seeking evaluation or treatment for an STI Men who have sex with men Persons at risk for infection by percutaneous or mucosal exposure to blood Current or recent infection-drug users Household contact of HBsAg-positive persons Residents and staff of facilities for developmentally disabled persons Healthcare and public safety personnel with anticipated risk for blood exposure Hemodialysis patients Persons with diabetes aged 19-59 years (and 60 at discretion of provider) International travelers to countries with high or intermediate endemnicity Persons with HCV infection Persons with chronic liver disease Persons with HIV infection Incarcerated persons All others seeking protection from HBV infection Schillie S, Vellozzi C, Reingold A, et al. Prevention of Hepatitis B Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep 2018;67(No. RR-1):1 31. DOI: http://dx.doi.org/10.15585/mmwr.rr6701a1 MIAP Conference 2018 38
39 Million Dollar Question: Varicella The following are considered to be presumptive evidence of immunity to varicella: A. Two doses of varicella vaccine B. A positive varicella titer C. Lab evidence of varicella disease D. Health-care provider verification of a history of chickenpox or shingles E. All of the above MIAP Conference, 2018 39
Varicella 40 Remember to Report Use the MDPH Varicella Teleform MDPH is particularly interested in clusters of 3 or more related/connected cases. Use the varicella cluster teleform. MIAP Conference, 2018 40
Questions? Division of Epidemiology and Immunization, 24/7 telephone line: 617-983-6800. MIAP Conference 2018 41
42 Resources Massachusetts Immunization Program 1-617-983-6800 1-888-658-2850 Website http://www.mass.gov/dph/imm CDC/NIP English and Spanish 1-800-232-INFO 1-800-232-4636 TTY 888-232-6348 Website http://www.cdc.gov/vaccines MIAP Conference, 2018 42 42