Friday Gary Reynolds 1.30pm - Immunisation Advisory Centre · • Gary Reynolds, Cassandra Dias,...
Transcript of Friday Gary Reynolds 1.30pm - Immunisation Advisory Centre · • Gary Reynolds, Cassandra Dias,...
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Quote
• “These are my principles. If you don’t like them ‐ I have others”.
• Groucho Marx
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Analysis of the Auckland 2014 Measles Outbreak Indicates that Adolescents and Young Adults could
Benefit from Catch up Vaccination.
• Gary Reynolds, Cassandra Dias, Simon Thornley, Ronald King, Angela Matson, Anne Morrison & Richard Hoskins
• In Press NZ Medical Journal
• Auckland Regional Public Health Service, Private Bag 92605, Symonds Street, Auckland 1150, New Zealand
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Measles Outbreak Auckland, NZ 2014
• December 2013 to June 2014• Epidemiology• Immunology• Vaccinology
• Aim : To analyse the Measles 2014 outbreak in Auckland to guide future preventive measures
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A contagious disease…
Source: http://www.healthline.com/health/r‐nought‐reproduction‐number#Conditions4
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Background
• Measles is highly contagious (Ro = 12‐18)• Burden of disease in developing countries• Declined markedly in western countries –after mass vaccination campaigns with MMR
• 45 years of MMR vaccine ‐measles and its complications still persist
• Australia – (But not NZ) is declared by WHO “measles free”
• Notifiable in NZ since 1996
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Imported measles common
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The MMR
• Highly efficacious and safe vaccine• Live vaccine so no boost required • Second dose improves efficacy from 90 to 95%• NZ schedule 15 months and 4 years • Under 1 year – interference circulating maternally derived antibodies
• Modeling shows over 95% coverage required to eliminate disease
• Historical unjustified controversy since 1998
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Methods
• The setting • Auckland (1.4 million)• Essentially Indigenous Measles free
• The Method• All Measles Notifications go to Public Health Services• Each notification is assigned to PH Nurse• Collect clinical information, immunisation history and immune status
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Methods: The diagnosis of Measles
Confirmed Probable Under investigation
Not a case
Laboratory results consistent with measles ORFever ≥ 380Cand a generalised maculopapular rash and: cough or coryza or conjunctivitis or Koplik’s spotsand link to confirmed case
Fever ≥ 380Cand a generalised maculopapular rash and: cough or coryza or conjunctivitis or Koplik’s spots
Note: No link to confirmed case Lab work not needed
All measles notifications with outstanding diagnostic lab results
No clinically compatible illnessORLaboratory results not consistent with measles infectionORDiagnosed vaccine reaction
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Methods
• Outbreak coordination• Initiated case management• Contact tracing (Waiting rooms, schools, sport clubs, flights)
• Management of households• Identified high risk contacts of cases• Quarantine, Self isolation, Prophylaxis (Active and Passive Immunisation) as appropriate
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Methods
• Laboratory analysis• PCR if symptoms in the first 5 days• Thereafter serology (anti‐measles IgM and IgGdetection)
• Purely qualitative detection of anti measles IgM and IgG
• Serology was also requested for exposed contacts to establish immune status
• 1 sample from each linked chain of transmission –genotyped (National Measles Lab)
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Statistical Analysis
• Vaccine effectiveness (VE) was calculated using the screening method (Gail)
• Vaccine effectiveness=1‐ odds(vaccinated |case)odds(vaccinated| non‐case)
• Where: – odds(vaccinated | case) is the odds of being vaccinated against measles, among cases.
– odds(vaccinated | non‐case) is the odds of being vaccinated against measles, in the general population.
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Results
• First case visited Sydney• Later Genotyped and linked to a traveller to same international camp in the Philippines
• Total 113 Cases in the Auckland region • 13 of which were imported cases • 9 had travelled to the Philippines• 16/18 local cases linked to known imported cases• 82 (73%) were linked to either sporadic or imported cases
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The number of measles cases overseas and locally acquired in the 2014 Auckland outbreak showing a local peak in March 2014. There is a temporal seeding of local cases from people
travelling to New Zealand from overseas
Month (2014)
Cou
nt
0
10
20
30
40
50
Jan Feb Mar Apr May Jun
Overseas
Jan Feb Mar Apr May Jun
Local
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Results
• Cases peaked in March 2014• Temporal seeding of local cases from overseas• Majority of cases occurred in adolescents and young adults
• 41/113 (36.3%) in 15‐19 year age group• 27/113 (23.4%) in 10‐14 year age group
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The numbers of confirmed and probable measles cases overseas and locally acquired by age, showing peaks in the under 1 and adolescent age groups.
Cou
nt
0
10
20
30
40
Overseas
0 10 20 30 40
Local
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Results
• Among cases 44/113 (38.9%) occurred in the unimmunised
• 36/113 (31.8%) unknown immune status• 16/113 (14%) occurred in infants too young to vaccinate
• 17/113 (15%) had received one or two doses of vaccine
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0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Age appropriately immunised Unimmunised
2014 Surveillance Year Measles Cases by Immunisation StatusConfirmed and Probable Cases only
Unknown / Uncertain
Unimmunised
Too young
First MMR post exposure
Age appropriately immunised (1 dose)
Age appropriately immunised (2 doses)
Extract Date: 1/07/2014
Source: NDCMS Index Case records
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Incidence by age & ethnic group
0.0
5.0
10.0
15.0
20.0
25.0
30.0
0 to 4 5 to 14 15 to 24 25 to 44 45 to 64
Incide
nce rate (p
er 100
,000
)
Age category (years)
European or Other ethnicity
Maori
Pacific peoples
Asian
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Results
• Of the total cases 26/113 (23%) required hospital treatment
• Secondary cases linked by contact at 1 school (n=37)
• Household contact (n=29)• Social contacts (n=8)• Primary care (n=3)• Hospital (n=5)
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Results‐Contacts
• 3113 Contacts were traced by ARPHS• Immune status established by ‐
• Documented 2x MMR vaccination history• Or proven Serology• n= 2,594• Highest non immune gp was under 1 year olds 68/75 ; 90.7%)
• Non immune 20‐29 year olds (60/ 325; 18.5%)• Non immune 15‐19 year olds (28/186; 15.1%)• Non immune 10‐14 year olds (22 /149; 14.8%)
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Results – Contacts
• Contacts underwent serological (IgG) testing• N= 737• Tested negative median age 27.4• Tested equivocal median age 26.6• Tested positive median age 34.0
• Serological immunity lower in people aged 10‐24 years
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Proportion of tested exposed contacts who were either serologically immune or equivocal, by age (n=737; 597 positive, 57 equivocal and 83 negative).
0.00
0.25
0.50
0.75
1.00
< 1 1 to 4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 29 30 to 39 40 plus
Age group (years)
pg
yq
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Serological testing of contacts
0.00
0.25
0.50
0.75
1.00
< 1 1 to 4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 29 30 to 39 40 plus
Age group (years)
pg
yq
Proportion immune or equivocal
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The contacts
101 247 203 163 240 455 475 465 7790
10
20
30
40
50
60
70
80
90
100
<1 1 to 4 5 to 9 10 to 14 15 to 19 20 to 29 30 to 39 40 to 49 +50
Prop
ortio
n of Im
mun
e Expo
sed Co
ntacts
Age Group
Proportion of exposed contacts who were assessed as immune
Source: NDCMS Exposed Contacts records
Exposed contacts with assessed immune status showing 95% Confidence Intervals and total number in each group
Extract Date: 1/07/2014
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Vaccine Effectiveness Calculation
• 60/113 (53%) Unimmunised• 16 were less than 15 months (too young)• 44 known unimmunised • 36 unknown vaccine status • Prevalance of vaccination 90%• VE if 36 unknown vaccinated = 89%• VE if 36 unknown unvaccinated = 98%• VE Range = 89‐98%
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Discussion
• Adolescents are susceptible• So are the under 1 year olds • MOH figures 400,000 in NZ from a population of 4 million (10%)
• The MMR vaccine is safe and effective 89‐98%• Reasons previous poor uptake due to safety concerns and structural issues with delivery
• Effective cold chain did not start until 2004 in NZ• ?waning immunity low immunity without natural boosting
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Limitations of this Analysis
• It is only one part of an outbreak • Countrywide 280 cases
• Relative small numbers affecting power• Lack of Quantitative Serology Analysis
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Conclusion
• Rapid expansion of Outbreak likely due to• Unimmunised European adolescents and young adults in a close contact environment ‐ school
• Measles is highly contagious nature of disease
• Outbreaks will likely continue until coverage is improved in at risk groups (up to 30 years)
• Most secondary cases occurred at school and were bought home
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Recommendations
• Early prompt reporting • Check all adolescence have 2x recorded MMR• ?Use of Dose 0 for under 1 year olds• ? A targeted Catch up campaign
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Acknowledgements
• Richard Hoskins• Simon Thornley • Cassandra Dias• Angela Matson• Anne Morrison• Ronald King• Staff at ARPHS