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

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  • 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

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