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