Viral Vaccine-Preventable DiseasesDiseases
- what happens between the laboratory and the Sunday Telegraph?
Peter McIntyre
www.ncirs.usyd.edu.auwww.ncirs.usyd.edu.au
BackgroundBackground
Viral vaccines on the NIPViral vaccines on the NIPLaboratory testsTh tifi ti “ h i ”The notification “chain” Other data sources
Case studiesCase studies
A newly vaccine-preventable diseaseA newly vaccine preventable disease• Varicella
Eli i ti h t d it ?Elimination - what does it mean?• Measles
A re-emerging VPD• MumpsMumps
Viral Vaccines on the National Program
www.ncirs.usyd.edu.au
NIP then....... early 1990sNIP then....... early 1990s
Birth
2m Diphtheria, Tetanus, Pertussis, Polio
4 Di hth i T t P t i P li4m Diphtheria, Tetanus, Pertussis, Polio
6m Diphtheria, Tetanus, Pertussis, Polio
12m Measles Mumps Rubella12m Measles, Mumps, Rubella
18m
4yy
10-19y Diphtheria, Tetanus
19-26y
≥65y
NIP nowNIP ... now
Birth Hepatitis B
2m Diphtheria, Tetanus, Pertussis, Polio, Hib, Hep B, Pneumo, Rota
4m Diphtheria, Tetanus, Pertussis, Polio, Hib, Hep B, Pneumo, Rota
6m Diphtheria, Tetanus, Pertussis, Polio, Hib, Hep B, Pneumo,(Rota)
12m Measles Mumps Rubella Hib Men C (Hep B)12m Measles, Mumps, Rubella, Hib, Men C, (Hep B)
18m Varicella, Hepatitis A#, Pneumo#
4y Diphtheria, Tetanus, Pertussis, Polio, Measles, Mumps, Rubella
10-19y Diphtheria, Tetanus, Pertussis, Varicella (negs), Hep B, Meningococcus C, HPV, Influenz
19-26y HPV
15-49 Influenza#, Pneumo#
≥65y Influenza, Pneumo # Indigenous or high risk only, ages may vary
Long-standing “traditional” vaccinesLong standing traditional vaccines
PolioPolioMeaslesMMumpsRubellaHepatitis B
Disease Vaccine type Laboratory tests
Notifiable ?tests ?
Polio Inactivated (2005)
Culture/PCR Yes (2005)
Measles Live attenuated SerologyPCR
YesPCR
Mumps Live attenuated SerologyPCR
YesPCR
Rubella Live attenuated Serology YesPCR
Hepatitis B Subcomponent Serology YesHepatitis B Subcomponent Serology Yes
More recent viral vaccines and/or i bl tifi ti /l b t tvariable notification/lab status
HPV (2007)HPV (2007)Rotavirus (2007)Varicella (2005) Influenza (1999 - elderly) Hepatitis A (2007 - Indigenous children,
some jurisdictions only)some jurisdictions only)
Disease Vaccine type Laboratory tests Notifiable
HPV VLPs SerologyCytology
No
PCR Rotavirus Live attenuated ELISA - stool
PCRSomestatesPCR states
Varicella Live attenuated SerologyPCR
Some statesPCR
Influenza Inactivated SerologyC lt
YesCulture
PCR
Hepatitis A Inactivated Serology Yes
Surveillance of VPDs - some general principlesgeneral principles
www.ncirs.usyd.edu.au
Definition of surveillance
Information for public health actionp• systematic collection, analysis and interpretation • dissemination/feedback to those who need to know• use for disease prevention and control
VPD related surveillance
Immunisation coverageVaccine effectivenessVaccine effectivenessVaccine adverse events
Epidemiology of the disease• indirect
- serological surveys- serological surveys
• direct- numbers (notified cases, laboratory reports, GP visits)- morbidity (absenteeism, GP visits, hospitalisations) - mortality (deaths)
Evolving surveillance needsEvolving surveillance needs
Surveillance objectives & needs change over timeMore detailed information is required as
i i ti t• immunisation programs mature• disease incidence declines
Surveillance tailored to the phase of disease controlSurveillance tailored to the phase of disease control
Phases of a vaccination program
Pre-vaccination phase
Phases of a vaccination program
p• measure disease burden and identify at risk groups
Post program implementation phase• measure impact of program• immunisation coverage and adverse event monitoring
Established programs moving towards elimination• enhanced surveillance of each suspect case• rapidly detect and fully investigate all outbreaks
Detecting events in persons, place and timeAgeSexIndigenous statusResidential postcodeResidential postcodeConfirmation statusOutbreak linkOrganism details, genotypePl f i itiPlace of acquisitionVaccination statusVaccine typeDate(s) of vaccination(s)
incubation onset of symptoms consultation specimen lab result diagnosis notificationexposure
Date(s) of vaccination(s)
NotificationSpecimendate
Notificationdate
Notificationreceive
date
Onsetdate
Measles notifications and outbreaks
60
70ACT NSW NT QLD SA TAS VIC WA
40
50
ons
30
40
Not
ifica
ti
10
20
0
1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12
2001 2002 2003 2004 2005 2006 2007 2008 2009
Y d th f di iYear and month of diagnosis
Source: NNDSS, 15 September 2009
Measles notifications, 2001-2009by year of birth and MCV eligibility
1968-77
140
160
by year of birth and MCV eligibility
1978-82
1983-90
2000-05100
120
ons
MCV MCV introduced introduced in 1969 for in 1969 for 1212--15 mth 15 mth old childrenold children1983-90
1991-951996-99
60
80
Not
ifica
tio old childrenold children
MCV 2 MCV 2 introducedintroducedMCV 2 MCV 2
1967 or earlier2006-08
0
20
40introduced introduced in 1993 for in 1993 for 1010--16 yr 16 yr oldsolds
changed to changed to 4 yr olds in 4 yr olds in 19981998
0
1-3 yrs 4-9 yrs 10-13 yrs 14-18 yrs 19-26 yrs 27-31 yrs 32-41 yrs 42+ yrs
1 dose MMR 2 doses MMR Eligible for 2doses MMR
One dose -very
susceptible
Eligible onedose -
susceptible
Naturalimmunity pre
vaccinep pintroduction
Current age cohort
Source: NNDSS, 15 September 2009
Australia - measles elimination ?Australia measles elimination ?
Measles notifications and vaccine coverage
1998 Measles Campaign - serosurveillance998 eas es Ca pa g se osu e a ce
Pre Campaign6-11 yo children
Rubella
Post Campaign
MumpsMumps
0 20 40 60 80 100
Measles
0 20 40 60 80 100Percent immune
Documenting elimination of indigenous measles t i i i A t li t tttransmission in Australia - genotype patterns
Vaccination coverage for 2 doses of rotavirus vaccine by 12 months of age, post-rota cohort, Australiaby 12 months of age, post rota cohort, Australia
Varicella in Australia – a “mild” disease?
Disease Varicella vaccineLi tt t d ( k t i )
~7 deaths/yr (most
adults)
Live attenuated (oka strain)
Varivax and Varilix
From 12 months of age
~ 1500 hospitalisations (most
children)
g
1 dose < age 14 yrs
2 doses ≥ age 14 yrs
> 200,000 cases
• School/child care costs
side effects low
protection >90% for severe
disease
• Non-immune adults
disease
Vaccine coverage and varicellaVaccine coverage and varicella
Estimated age-specific varicella f %incidence over time following 100%
coverage
12,000
14,000
6 000
8,000
10,000
Incidence per 100,000
45+19 to 445 to 18
2,000
4,000
6,000100,000 5 to 180 to 4
0
-5 3 11 19 27 35 43 51 59 67 75
year since vaccinationy
Estimated age-specific varicella i id f ll i 60%incidence following 60% coverage
12,000
14,000
6 000
8,000
10,000
Incidence per 100,000
45+19 to 445 to 18
2,000
4,000
6,000100,000 5 to 180 to 4
0
-5 3 11 19 27 35 43 51 59 67 75
year since vaccinationy
Varicella vaccine programVaricella vaccine program
Varicella vaccine @ 18 months +Varicella vaccine @ 18 months +• Schedule point available
Vaccine licensed from 12 moTrade-off between cases before 18 m and schedule • ~25% hospitalisations < 2yrs• ~20% of hosps <2yrs occur 12-18 months
Vaccine @ 10-13 years for those without a history (no blood tests) ( )Promote vaccination for persons >15y without a history, especially planning pregnancy (blood test required)q )
Varicella Breakthrough varicellavaricella
Challenges in varicella surveillance and it imonitoring
Lots of casesMost do not present to GP, few lab testsThose that are lab tested probably atypicalOnly SA had varicella notifiable pre vaccine programVaccine available in private market pre program
Conclusion - monitor hospitalisations Early data show decrease in hospitalisations in targetedEarly data show decrease in hospitalisations in targeted age group + older and younger children
Mumps in US - courtesy Jane SewardMumps in US courtesy Jane Seward
Mumps - other countriesMumps other countries
Mumps - two dose failuresMumps two dose failures
Lessons for Australia
Most of our mumps resurgent cases are in young adults p g y gwho have had one or no dosesWe need to maximise two dose coverage firstChallenges ahead with diagnosing two dose vaccine failures• Serology and PCR not useful• Serology and PCR not useful• Back to the “old days” of relying on clinical diagnosis
+ link to another clinical case
Summary and conclusions
Laboratory contribution vital but some VPDs have no ytests (eg HPV) and others interpretation a problemNeed to consider in the context of the vaccine program
t it dmaturity and coverageThere is always another challenge around the corner -eg mumpseg mumps