Closing MR Immunity Gaps Experiences from the Regions Italy...(2010-2015) Year SPES Sentinel...

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: RegionalHealth Authorities

146 Local Health Units

Total population: 60,626,442

Italy: Country information

Ministry of Health, Directorate General for Health Prevention


Italian National Health System

Italian Ministry of Health

• Definition of objectives to reach in order to improvepopulation health status

• National health planning

• Determination of EssentialLevels of Assistance to be provided to any citizen, uniformly throughout the whole national territory

The Regions

• Autonomous in operatingstrategies

• Ability to legislate on healthissues, respecting the general principles

• Determination of furtherLevels 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 HealthSystem

Local Health Unit

Local HealthUnit

Local HealthUnit

Local HealthUnit

Departmentof Prevention

Department of Prevention



Organization of the vaccinations: where and who?

VaccinationService

VaccinationService

VaccinationService

VaccinationService

VaccinationService

VaccinationService

VaccinationService

Vaccination Service


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

HPVHPV 6

(3 doses)

FluFlu

VaricellaVar 7

(2 dosi)


N. of

cases

cases Vaccination coverage (%)

Vaccin

ati

on

co

verag

eat

24

mon

ths

(%

)

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)

Monovalentvaccine available

MMR

MMR in nationalimmunization

schedule

First eliminationplan (2003-2007)

Second elimination plan

(2010-2015)

Year

SPES SentinelSurveillance


N. of

cases

Vaccin

ati

on

co

verag

eat

24

mon

ths

(%

)

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

Italy, 1970-2015.



MMR

MMR in nationalimmunization

schedule

First eliminationplan (2003-2007)

Second elimination plan

(2010-2015)

SPES SentinelSurveillance

cases Vaccination coverage (%)

Year


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. Pediatricsentinel surveillance of vaccine-preventable diseases in Italy. Pediatr Infect Dis J 2002; 21: 763-8


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


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


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


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 – 9.910.0 – 19.920.0 – 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 2014Incidence: 27.6Number cases: n = 1,389 (59.1% lab-conf.)

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

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

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

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

How did you diagnose that older teenager/adult

susceptibility is (was) an issue in your country?


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

Italy, 2008-2014

13

24

58

40

19 19

57

41

12

22

60

5

0

12

24

58

6

0

13

18

60

7

1

1115

66

8

0

13

18

58

11

00

10

20

30

40

50

60

70

80

90

100

00

-04

05

-14

15

-39

40

-64

65

+

00

-04

05

-14

15

-39

40

-64

65

+

00

-04

05

-14

15

-39

40

-64

65

+

00

-04

05

-14

15

-39

40

-64

65

+

00

-04

05

-14

15

-39

40

-64

65

+

00

-04

05

-14

15

-39

40

-64

65

+

00

-04

05

-14

15

-39

40

-64

65

+

2008 2009 2010 2011 2012 2013 2014

%

Year 2008median age

17 yrs

Year 2009median age

17 yrs

Year 2010median age

18 yrs

Year 2012median age

21 yrs

Year 2014median age

23 yrs

Year 2013median age

22 yrs

Year 2011median age

18 yrs


Measles incidence (x million), by agegroup, Italy 2013 - 2014

88,8

58,8

85,8

8,7

0,3

78,6

51,756,0

8,7 0,30

10

20

30

40

50

60

70

80

90

100

00-04 05-14 15-39 40-64 65+

Me

asle

s in

cid

en

ce (

pe

r m

illio

n)

Age group

2013 2014


Distribution of reported measles cases by age group, median age of cases, and incidence (x 100,000) by age

group, Italy 2015 - 2016

%

In

cid

en

ce

(p

er 1

00

,00

0)

Age group

%

In

cid

en

ce

(p

er 1

00

,00

0)

Age group

2015median age = 23 y

2016median age = 23 y


Measles complications (n=1,389) among 3,931 reported cases, Italy 2013-2014

- 23% of cases had at least 1 complication (N=919)

- 29% of cases was hospitalised (N=1,030)

- No deaths reported

0

0

3

4

3

5

7

11

11

13

11

31

0 5 10 15 20 25 30 35

Encephalitis

Convulsions

Thrombocytopenia

Laringotracheobronchitis

Respiratory insufficiency

Hepatitis

Otitis media

Keratoconjunctivitis

Pneumonia

Other

Stomatitis

Diarrhea

% of total number of complications


Measles complications (n=68) among 251 reported cases, Italy 2015

- 27.1% of cases had at least 1 complication (N=68)

- 42.6% of cases was hospitalised (N=107)

- 14.7% of cases requested a visit by the First Aid (N=37)

0

0

3

4

3

5

7

11

11

13

11

31

0 5 10 15 20 25 30 35

Encephalitis

Convulsions

Thrombocytopenia

Laringotracheobronchitis

Respiratory insufficiency

Hepatitis

Otitis media

Keratoconjunctivitis

Pneumonia

Other

Stomatitis

Diarrhea

% of total number of complications


Distribution of complicated measles cases by agegroup.

Italy, 2016

45% of cases (99/ 220) had at least 1 complication26 cases < 5ys


Vaccination status of reported measles cases, Italy 2013-2014

0

10

20

30

40

50

60

70

80

90

100

Not vaccinated 1 dose 2 doses vaccinated, uknown n. ofdoses

% o

f m

easl

es c

ase

s

Vaccination status


Who is susceptible to measles and rubellain 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 iscontroindicated

5) Children (95% VC not achieved yet)

6) Children who are immunized late

7) Children not immunized due to parents choice


How did you design a specific approach or strategy for

closing immunity gaps, if any?

Main facilitators and barriers for action


Vaccination coverage for 1st dose of measles vaccine, in 24-month-old children, by Region.

Italy: 2000, 2007 and 2013

56.0

67.6

86.2 90.5

91.

8

90.4

78.5

84.4

80.0

71.059.9

90.0

70.0

74.0

53.

0 58.9

57.0

Italy: 74.1%

Source: Italian Ministry of Health

< 85%

> 90%

85% - 90%

Not available

88.0

90.6

90.6 91.7

90.6

93.5

92.2

93.4

91.2

92.097.3

92.2

87.7

86.6

86.889.4

67.7

93.1

86.4

91.5

88.

9

83.9

92.1

92.6 90.0

87.8

91.3

90.1

93.1

87.4

88.592.4

87.6

90.6

91.1

86.3

85.8

86.891.3

87

.6

68.9

Italy: 89.6% Italy: 88.3%

2000 2007 2013


Vaccination coverage for 1st dose of measles vaccine, in 24-month-old children, by Region.

Italy, 2015

National VC=86.7%


Vaccination coverage for 2nd dose of measlesvaccine, in 7 year-old children, by Region.

Italy, 2014

National VC=82.7%

< 85%

> 90%

85% - 90%

Not available


Approach and challenges on which we are thinking

What have we doneWhat are we going to doWhat we should do (likely)


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

28Ministry of Health, Directorate General for Health Prevention

I hope

that I did

not

reduce

you so!


“Knowing is not enough; we must apply.

Willing is not enough; we must do.”

Goethe


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