An Update on immunisation for primary care staffs in NHSGGC Public Health Protection Unit NHSGGC August/September 2014
Contents An update on the rotavirus campaign An update on Pertussis epidemiology and vaccination of pregnant women Recent changes to infant programme vaccine Men C campaign for new entrant university students Update on Men B vaccine Changes to the HPV programme (for information only) An update on the Zostavax (Shingles) vaccination programme Extension of Flu vaccination for children in 2014/15 phase 2 Flu vaccines to be used in 2014/15 (this year) and rationale
Rotavirus Epidemiology Highly infectious with as few as 10 100 virus particles may cause disease Estimated 55,000 episodes of rotavirus infection occur each year in Scotland and of these approx. 1200 children admitted to hospital Almost all children become infected by age 5 years Estimated that around half of all gastroenteritis in children under 5 years caused by rotavirus
Why vaccinate against rotavirus?
Cases vs. Age
Why vaccinate against rotavirus? Rotavirus vaccination should significantly reduce rotavirus gastroenteritis in young children In the USA, vaccine had been in use since 2006 By 2010, hospital admission for rotavirus reduced by 85% If same experience in Scotland, approximately 1000 less hospital admissions
Rotavirus
Rotavirus
Comparison of percentage of calls to NHS 24 for symptoms of diarrhoea and vomiting in 2014 and average of 2010/13
Men C programme for Fresher's Students will be informed through UCAS Students will be advised to go to own GP at least 2 weeks before they attend University NHSGGC written to all Universities in the Board area with template letter to be sent out to students not admitted through UCAS Universities to remind students during the fresher's week to enrol with a local GP and get vaccinated unless done so already?
MenB
Men B vaccine: Bexsero Licensed vaccine for meningococcal B infection Procurement process underway to purchase enough vaccine for the childhood programme at a cost effective price Awaiting further announcement from the SG about a start date for the childhood programme No plan for an adolescent programme yet Bexsero should be given from now to those with splenic dysfunction, asplenia and complement disorder
What is shingles? An estimated 7,000 cases of shingles occur in people aged 70 years and above each year in Scotland Of these, 700 to 14,00 develop a very painful and long lasting condition called Post Herpetic Neuralgia (PHN) Approximately 1 in 4 adults will experience shingles in their lifetime Around 600 hospitalisation episodes recorded each year 1 in 1,000 cases of shingles are estimated to result in death
Incidence rate RCGP (1991-1992) MSGP4 (1991-1992) Hope-Simpson (1947-1972)
Vaccination against shingles: Year 2013/14 Routine Programme: all those aged 70 years on 1st Sept 2013 (born between 02/09/1942 and 01/09/1943) Catch up programme: all those aged 79 years on 1st Sept 2013 (born between 02/09/1933 and 01/09/1934) Further catch up programme: for those aged 71 to 78 years on 1st Sept 2013 yet to be decided
Shingles Vaccine uptake Age 70 56.2% Age 79 52.1%
Shingles Vaccine uptake Age 70 56.2% Age 79 52.1%
Zostavax Uptake CHP 70 Year olds 79 Year olds East Dun 65% 59.8% East Ren 69.2% 57.1% Inverclyde 52.6% 48.4% North East 52.9% 46.2% North West 51.2% 48.4% Renfrewshire 59.4% 50.6% South 55.6% 51% West Dun 56.1% 52.1% Glasgow 55.9% 50.4% Scotland 56.2% 50.4%
Zostavax Variation 3 practices with 0% uptake One practice 100% 11 practices 80% or above 105 practices below GGC average Taking top and bottom 15 practices out varies between 20% and 77%
Shingles Programme 2014/15
Flu: Possible Complications? Common: Bronchitis Otitis media (children), sinusitis Secondary bacterial pneumonia. Less common: Meningitis, encephalitis Primary influenza pneumonia Most serious illness in neonates, pregnant women, older people and those with underlying disease.
Why preventing flu is important? Numbers, rates and relative risks with 95% lower and upper confidence intervals for seasonal influenza clinical risk factors amongst confirmed influenza related fatalities aged 6 months to 64 years, Scotland, 2010/2011. Provisional and preliminary data from HPS up to 23rd June 2011. Number of fatal cases With Laboratory Confirmed influenza Mortality rate per 100,000 population Age Adjusted Relative risk (RR)* Lower 95% Confidence Interval Upper 95% Confidenc e Interval Any risk factor (6m-64y) 31 4.7 17.8 8.5 37.4 No risk factor (6m-64y) 9 0.3 Baseline Chronic renal disease 2 6.3 23.9 5.2 110.8 Chronic heart disease 9 7.2 27.3 10.8 68.7 Chronic respiratory disease 14 4.6 17.5 7.6 40.5 Chronic liver disease 7 21.9 83.5 31.1 224.1 Diabetes 1 0.7 2.8 0.4 21.8 Immunosuppression 7 14.1 53.6 20 143.9 Chronic neurological disease incl stroke 6 7.7 29.4 10.5 82.5 Total 40 1.0
Extension of seasonal flu vaccination programme to children (2 to 17 years of age) - Recent review of burden of influenza in children Average influenza season: estimated 0.3% to 9.8% of 0-14 year old children present to a GP with influenza; 7 Incidence rates can be markedly higher in the younger age groups; Influenza associated hospitalisation rates; 8, 9, 10,11,12-83-1,038/ 100,000 children 0-59 months old (highest in <6 months) - 16-210/100,000 children 5-17 years Children with influenza contribute to the burden of influenza in all age groups because they are more likely to pass on the infection than adults. 15, 14 (Ruf & Knuf, 2013) 6
Flu Vaccination of Children Phase 1: 2013/14 - all pre-school children aged 2 and 3 years - Pilot in some primary schools
Expected Public health benefits in Scotland (based on 30% uptake) GP consultation for flu related illness Hospitalisatio n due to flu related illness Deaths due to flu related illnesses No flu vaccination programme Current programme Extended programme Prevented 100,000 75,000 42,000 33,000 5,000 2,800 1,700 1,100 900 500 300 200
Flu Uptake in Scotland Established seasonal programme (>65s, high risk groups, HCWs) 76.9% >65s 57.5% <65s at risk 48% pregnant women (65% pregnant women at risk factors) 34.7% HCWs 2-3 year olds (all) primary care 50.6% 5-11 year olds (pilot) schools 67.2% (children from P1 to P7, i.e. 5-11 year olds)
GGC Uptake - Flu Childhood Programme 51.6% At Risk 57.6% Over 65 76% School pilot: 65.2%
CHP Flu Uptake CHP Childhood At Risk Over 65 East Dun 61.5% 57.7% 77.5% East Ren 61.3% 60.6% 80.5% Inverclyde 57.3% 58.6% 76.1% North East 47.8% 56.5% 74.1% North West 49.9% 56.7% 75.3% Renfrewshire 52.6% 58.5% 76.4% South 47.8% 58.9% 76.7% West Dun 53.6% 62.6% 79.3% Scotland 50.6% 57.5% 76.9%
Variation - Flu Childhood between 5.6% and 85% At Risk between 17% and 81% Over 65 between 14% and 90% Childhood 116 practices below GGC average At Risk 115 practices below GGC average Over 65-109 practices below GGC average
Current Flu Vaccination Strategy in Scotland Vaccinate those at risk > 65y, pregnant women, chronic disease, health care workers and some carers Flu still causes significant ill health and deaths every winter
Vaccine uptake: 65s & over: 68% of practices achieved 75% uptake at risk: by practice 2% of practices achieved 75% uptake 20% of practices achieved 65% uptake 65y + at Risk vaccine uptake (%) 100 90 80 70 60 50 40 30 Vaccine uptake by Practice 2012-13 20 Mean uptake Scotland season 2012-13 10 WHO target uptake 0 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 proportion of practices vaccine uptake (%) 100 90 80 70 60 50 40 30 Vaccine uptake by Practice 2012-13 20 Mean uptake Scotland season 2012-13 10 0 WHO target uptake 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 proportion of practices
Key strategies UK survey (n=795 practices) Lead Written report Personal invitations Continue to offer after target reached Modify search to produce accurate list of eligible patients http://bmjopen.bmj.com/content/2/3/e000851.full.pdf+html
NHS GGC Pilot approach Self audit checklist Personnel, documentation, ordering, storage, call/recall, promotion, operational aspects Individualized feed back report Summary of 13/14 Own, CHP, Board Recommendations to improve uptake
NHS GGC Apply for inclusion in self audit pilot Edward.McArdle@ggc.scot.nhs.uk Undertake self audit Anytime now beg Dec Provide feedback on ease of use Thank you
Influenza the virus Three types of influenza virus - A, B and C Flu A and B are responsible for most clinical illness Most cases in the UK usually occur within an 8-10 week period during the winter - Timing, extent and severity will vary, partly related to flu type(s) circulating
Knowing your A s and your B s Flu A - Causes outbreaks most years - Usual cause of any large epidemics which occur intermittently Flu B - Tends to cause less severe disease and smaller outbreaks - Burden of most disease is in children In whom illness severity can be similar to Flu A
Drifts and Shifts Flu viruses have certain surface structures (antigens) which the immune system recognises and (attempts to) respond to - Haemagglutinin and neuraminidase In order to avoid recognition, minor changes occur in these antigens each season ANTIGENIC DRIFT Periodically, more major changes occur and a new flu subtype may be produced ANTIGENIC SHIFT Changes are more frequent with Flu A than Flu B
Predicting the Future Each year, WHO monitors flu viruses throughout the world and makes recommendations about the strains to be included in vaccines for the forthcoming winter for the northern and southern hemispheres
Historical Influenza Vaccines Trivalent - Containing two subtypes of Flu A and one Flu B - Numerous pharma companies with their own product but all contain the same subtypes Most inactivated, one (Fluenz ) is live attenuated - Over more recent years, the Flu A vaccines have matched the circulating strains fairly well
Why change a winning formula? Two lineages of B strain can (co-) circulate - Yamagata lineage - Victoria lineage Mismatch between circulating Flu B strains and vaccine more common
Flu B strains and Vaccine Match For 2014-15 Flu season, Trivalent vaccine contains: - A/California/2009(H1N1) like virus - A/Victoria/2001(H3N2) like virus - B/Massachusetts/2012(Yamagata) 2014-15 vaccine same as for 2013-14 and 2012-13 seasons In 2012-13 season (Sep 2012 to Feb 2013) - 77% of Flu viruses were type A - 23% of Flu viruses were type B Of Flu B strains 52% were Victoria lineage and 48% were Yamagata lineage
Quadrivalent Flu Vaccine Contains two Flu A strains and two Flu B strains The first quadrivalent Flu vaccine was made available for use in the UK in 2013 but too late in the season for practices to order
Vaccine for 2014/15 Flu Season Fluenz Tetra: Intra nasal live vaccine contains 2 Flu A and 2 Flu B strains; Age 2 to under 18 years Fluarix Tetra: Inactivated vaccine contain 2 Flu A and 2 Flu B strains given by i.m injection; from age 3 years Trivalent vaccine: Inactivated vaccine contain 2 Flu A and 1 Flu B strains given by i.m injection; from age 6 months onwards but check age restrictions on specific products
Fluenz Tetra: Contraindication A history of active wheezing at the time of vaccination (until at least 7 days after wheezing has stopped) or Those who are currently taking or have been prescribed oral steroids in the last 14 days or Those who are currently taking a high dose inhaled steroid budesonide at a dose greater than 800 microgram per day or equivalent.
Assessment of suitability for Fluenz Tetra Name of Inhaler Strength Manufacturer Number of Puffs Per Day Flixotide Evohaler (Fluticasone Inhaler) Flixotide (Fluticasone) Accuhaler Flixotide (Fluticasone) Accuhaler Pulmicort (budesonide) turbohaler Pulmicort (budesonide) turbohaler Pulmicort (budesonide) turbohaler 50 microgram per dose 50 microgram per dose 100 microgram per dose 100 microgram per dose 200 microgram per dose 400 microgram per dose Allen & Hanbury Ltd 8 Allen & Hanbury Ltd 8 Allen & Hanbury Ltd 4 Astra Zeneca 8 Astra Zeneca 4 Astra Zeneca 2
Assessment of suitability for Fluenz Tetra Name of Inhaler Strength Manufacturer Number of Puffs per Day Budelin (budesonide) novoliser Budesonide easyhaler Budesonide easyhaler Budesonide easyhaler Beclometasone easyhaler Beclometasone easyhaler Beclometasone easyhaler 100 microgram per dose 100 microgram per dose 200 microgram per dose 400 microgram per dose 100 microgram per dose 200 microgram per dose 400 microgram per dose Meda Pharmaceuticals 8 Orion Pharma UK 8 Orion Pharma UK 4 Orion Pharma UK 2 Orion Pharma UK 8 Orion Pharma UK 4 Orion Pharma UK 2
Assessment of suitability for Fluenz Tetra Name of Inhaler Strength Manufacturer Number of Puffs per day Asmabec (Beclometasone) Clickhaler Asmabec (Beclometasone) Clickhaler Clenil Modulite (Beclometasone) Clenil Modulite (Beclometasone) Pulvinal Beclometasone Pulvinal Beclometasone 100 microgram per dose 100 microgram per dose 50 microgram per dose 100 microgram per dose 100 microgram per dose 200 microgram per dose RPH 8 RPH 8 Chiesi 16 Chiesi 8 Chiesi 8 Chiesi 4 Pulvinal 400 microgram Chiesi 2
Assessment of suitability for Fluenz Tetra Name of Inhaler Strength Manufacturer Number of Puffs per Day Seretide Evohaler Seretide Accuhaler Seretide Accuhaler Symicort 100/6 turbohaler 50 microgram per dose 50 microgram per dose 100 microgram per dose 100 microgram per dose Allen & Hanbury Ltd Allen & Hanbury Ltd Allen & Hanbury Ltd 8 8 4 Astra Zeneca 8
Administration of Childhood Flu Immunisation (birth to pre-school age groups) Birth to under six months Six months to under two years In Clinical Risk Group? (see table 19.5 Green Book flu chapter for further details) Vaccination not required No Yes Vaccination not required One dose of trivalent inactivated vaccine If never had flu vaccine before give a second dose at least four weeks later
Pre-school aged two five years Suitable for Fluenz Tetra Yes No One dose of Fluenz Tetra Aged three years or above? If at risk Clinical Group and never had flu vaccine before, give a second dose at least 4 weeks later No One dose of trivalent inactivated vaccine Yes One dose of quadrivalent inactivated vaccine (Fluarix Tetra) If never had flu vaccine before give a second dose at least four weeks later If never had flu vaccine before give a second dose at least four weeks later