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

Background of the NIP and epidemiology of MR

21 Regions: Regional Health Authorities

146 Local Health Units

Total population: 60,626,442

Italy: Country information

Ministry of Health, Directorate General for Health Prevention

Ministry of Health, Directorate General for Health Prevention

Italian National Health System

Italian Ministry of Health

• 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

The Regions

• 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

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

Organization of the vaccinations: where and who?

Vaccination Service

Vaccination Service

Vaccination Service

Vaccination Service

Vaccination Service

Vaccination Service

Vaccination Service

Vaccination Service

Ministry of Health, Directorate General for Health Prevention

National Vaccination Schedule (NVP 2012)

Vaccine Birth 3° m 5° m 6° m 11° m 13° m 15° m 5-6 y 11-18 y >65 y Every

10 y

DTaP DTaP DTaP DTaP DTaP dTap dT

IPV IPV IPV IPV IPV

HBV HBV3 HBV HBV HBV

Hib Hib Hib Hib

MMR MMR MMR MMR4

PCV PCV PCV PCV

Men C Men C5 Men C5

HPV HPV 6

(3 doses)

Flu Flu

Varicella Var 7

(2 dosi)

Ministry of Health, Directorate General for Health Prevention

N . o f

c a s e s

cases Vaccination coverage (%)

V a c c in

a ti

o n

c o

v e r a g

e a t

2 4

m o n

th s

( %

)

N. of reported measles cases and measles vaccination coverage (in 24 month-old children), by year.

Italy, 1970-2014. Source: MOH, statutory notification system (1970-2007)

Source: ISS, enhanced measles surveillance (2008-2012)

Source: ISS, integrated measles-rubella surveillance (2013 – 2015)

Monovalent vaccine available

MMR

MMR in national immunization

schedule

First elimination plan (2003-2007)

Second elimination plan

(2010-2015)

Year

SPES Sentinel Surveillance

Ministry of Health, Directorate General for Health Prevention

N . o f

c a s e s

V a c c in

a ti

o n

c o

v e r a g

e a t

2 4

m o n

th s

( %

)

N. of reported rubella cases and rubella vaccination coverage (in 24 month-old children), by year.

Italy, 1970-2015.

Monovalent vaccine available

Monovalent vaccine available

MMR

MMR in national immunization

schedule

First elimination plan (2003-2007)

Second elimination plan

(2010-2015)

SPES Sentinel Surveillance

cases Vaccination coverage (%)

Year

Ministry of Health, Directorate General for Health Prevention

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 2003. Euro Surveill. 2003;7(27):pii=2253 - 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=1933 - 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

Ministry of Health, Directorate General for Health Prevention

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 post-

exposure 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

Ministry of Health, Directorate General for Health Prevention

Integrated measles-rubella surveillance system

-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 web-

based reporting (7 Regions)

Collect clinical information on suspected case (measles or

rubella); report to local health authorities (LHA)

within 12 hrs

of diagnosis

WEB-BASED PLATFORM (managed by ISS)

Regional health authorities

Physicians

Local health authorities

Monthly reporting of individual cases to ECDC/WHO via TESSy

Report individual cases to national level by web-based

platform

National

reference

lab

Regional

reference

lab

Ministry of Health

Local lab

Ministry of Health, Directorate General for Health Prevention

N. of reported measles cases, by month of rash onset, Italy 2013-2016

Source: Bella A, Filia A, Del Manso M, Declich S, Nicoletti L, Magurano F, Rota MC. Morbillo & Rosolia News, Gennaio

2015. Available online at: www.iss.it/site/rmi/morbillo

Total cases (conf., prob., poss.) Confirmed cases only

Ministry of Health, Directorate General for Health Prevention

http://www.iss.it/site/rmi/morbillo

39.1

148.6

71.7 5.1

8.2

22.8

25.2

1.1

31.1

9.6

6.9

9.4

152.1

5.2

8.7

210.0

127.2

1.5

5.6

1.8

< 1.0 (WHO elimination target) 1.0 – 9.9 10.0 – 19.9 20.0 – 49.9 > 49.9

Not available

7.8

119.0

14.6 12.6

16.3

46.8

16.0

1.1

25.1

3.2

17.8

11.2

123.7

2.2

0.0

21.3

13.5

6.1

1.0

60.1

30.5

Italy: year 2014 Incidence: 27.6 Number cases: n = 1,389 (59.1% lab-conf.)

Measles incidence (x million) by region. Italy: 2013 - 2016

Italy: year 2013 Incidence: 40.7 Number cases: n = 2,251 (53.2% lab-conf)

Italy: year 2015 Incidence: 4.0 Number cases: n = 251 (60.6% lab-conf)

Italy: year 2016 Incidence: 4.0 Number cases: n = 220 (67.3% lab-conf)

How did you diagnose that older teenager/adult

susceptibility is (was) an issue in your country?

Ministry of Health, Directorate General for Health Prevention

Distribution of reported measles cases by age group, and median age of cases, by year.

Italy, 2008-2014

13

24

58

4 0

19 19

57

4 1

12

22

60

5

0

12

24

58

6

0

13

18

60

7

1

11 15

66

8

0