2015 School Nurse Conference

Infectious Diseases and School Health

Updates on Measles, Meningococcal and Pertussis Infections

& School Related Vaccine Topics

Questions or Rachel Cruz at Rcruz@skschools.net

CEU AccreditationThis continuing nursing education activity was approved by the Northeast Multi-State Division (NE-MSD), an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.

Credit Designation: The NE-MSD designates this live activity for a maximum of 3 CEU Credits™..

Disclaimer:This educational program is designed to present scientific information and opinion to health professionals, to stimulate thought, and further investigation.

Disclaimer

Faculty Disclosure

The speakers indicated that they have no relevant financial relationships to disclose:

Nicole Alexander-Scott, MD, MPHUtpala Bandy, MD, MPH Ailis Clyne, MD, MPH

Gregory Fox, MDTricia Washburn, BS

Learning Objectives

At the conclusion of this session, attendees should be able to:

At the end of the conference, participants should be able to: 1).Describe the symptoms and treatment for pertussis, measles and meningococcal infections 2) Describe elements of managing outbreaks of measles and meningococcal infections 3) Describe changes to the Rhode Island School Health Regulations related to vaccine requirements for 2015 school entry 4) Describe the process for documenting medical and religious exemptions from school entry vaccine requirements 5) Understand common themes in vaccine hesitancy and strategies for addressing vaccine concerns

Target Audience

• School Nurses• Healthcare Providers

Please complete evaluation to receive your CEU certificate.

CEU Questions?Rachel Cruz

rcruz@skschools.net

CME Questions?Ailis Clyne MD

Ailis.Clyne@health.ri.gov

Thank You for Participating

Meningococcal Disease

Neisseria Meningitides: Serogroup A B C Y W• Nasopharyngeal carriage

– Asymptomatic

• Invasive disease rarely occurs

• Spread through close contact– Respiratory or oral secretions

– Patients or asymptomatic carriers

• Spectrum of Invasive Disease

Bacteremia with or without Meningitis

Pneumonia

Focal sepsis (epiglottitis, arthritis etc.)

Rapid progression of illness. Toxin mediated shock.10-15% Mortality

• Acute onset of fever, headache (“worst headache of my life”), altered mental status

• Meningismus: Stiff neck• Rash in 50-75% of meningococcal

meningitis cases – Mostly on extremities– Early: erythematous, macular (flat), blanching– Evolves into petechia (non-blanching)– Severe (meningococcemia): purpura fulminans

• Nausea/vomiting, seizures

Meningococcal Meningitis: Clinical Presentation

Meningococcal Disease

-------------------------------------------------------------------

ENVIRONMENThousehold exposure, dorm

residence, crowding, demographics, active and passive smoking,

concurrent upper respiratory tract infections

Pathogen virulence factorsCapsule, adhesins, endotoxin release, nutrient acquisition factors

Immunity (general-local-acquired)Asplenia, terminal component of complement missing,AgeSexNutritionGeneticsBehaviorsUnderlying disease

Epidemiological Triad of Risk Factors

AGENT HOST

Incidence by Serogroup and Vaccine Coverage, US 1993-2012

Cases and Outbreaks of Meningococcal Disease in Rhode Island 1993-2015

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

0

5

10

15

20

25

30

Nu

mb

er

of

Ca

se

s

Data as of 5/6/2015

Woonsocket: Oct ‘96 3 cases in 3 months (clonal Serogroup C) 17,000 vaccinatedStatewide: Nov ‘97 to Feb ‘98, 12 cases (3 pedi deaths) (250,000 vaccinated)W

Incidence of Meningococcal Disease by Age and Serogroup, US 2005-2012

Coverage for ≥1 Dose of Meningococcal Vaccine among Teens 13-17 years of age R.I. and U.S., 2008-2013

Source: CDC, National Immunization Survey (NIS-Teen), 2008-2013 http://www.cdc.gov/vaccines/imz-managers/coverage/nis/teen/index.html

Serogroup B Meningococcal Disease

Meningitis conjugate vaccine does not protect against serogroup B• Serogroup B capsule antigen is poorly immunogenic

Most common cause of meningococcal disease in persons aged 16 to 21 years

Serogroup B outbreaks:• Serogroup B caused 4 university outbreaks during last 2 years

• Outbreak definition*:o ≥2 unrelated cases in organization with <5000 personso ≥3 unrelated cases in organization with ≥5000 persons

*Interim Guidance for Control of Serogroup B Meningococcal Disease in Organizational Settings.

ccccc

Nov 2014

Cases of Serogroup B Meningococcal Disease at P.C., Rhode Island, 2015

Case of serogroup B meningococcal disease

January

Rhode Island Department of Health notified

Case 1: 19-year-old undergraduate Case 2: 20-year-old undergraduate (no links to case1) Novel strain type: ST9096 71 close contacts given prophylaxis 2 cases in ~4,500 students Attack rate = 44 cases per 100,000 students

• 489-fold higher than the national incidence in persons aged 17-22 years

Serogroup B Meningococcal (MenB) Vaccines

2 vaccines recently licensed in U.S. for persons aged 10-25 years

• Oct 2014 – Trumenba, 3 dose series (Wyeth Pharmaceuticals, Inc., a subsidiary of Pfizer Inc.)

• Jan 2015 – Bexsero, 2 dose series (Novartis Vaccines and Diagnostics)

Licensed on immunogenicity data Serogroup B capsule antigen poorly immunogenic MenB vaccines instead based on outer membrane proteins (H binding proteins). 30-40% show a 4 fold titer response after 1 dose No post licensure safety data and understanding of impact on carriage is limited

Eligible students:• all undergraduate students

• graduate students who:o live or work on campus OR o are in an intimate relationship with an undergraduate OR o are asplenic or immunocompromised

Students were directed to report to the vaccination clinic • If declined vaccination, required to sign opt-out form

Vaccine offered at no cost to eligible participants Dose 1: Feb 2015 Dose 2: April 2015 Dose 3: September 2015

P.C. Mass Vaccination Campaign

P.C. Outbreak and Response, Round 1

Mass MenB vaccination campaign

Trumenba• Feb 8 and 11

• 96% of 3,800 eligible students vaccinated with first dose

Serogroup B meningococcal disease. Both Novel strain type ST9096

Rhode Island Department of Health notified

January

Vaccination clinics

Novel strain type: ST9096

Mass Vaccination POD

Advisory Committee on Immunization Practices (ACIP) vote: February 2015

A serogroup B meningococcal (MenB) vaccine series should be administered to persons aged ≥10 years at increased risk for meningococcal disease. (Category A) This includes:• Persons with persistent complement component deficiencies1

• Persons with anatomic or functional asplenia2

• Microbiologists routinely exposed to isolates of Neisseria meningitidis

• Persons identified to be at increased risk because of a serogroup B meningococcal disease outbreak

MMWR Policy Note coming soon June 2015: May consider expanded recommendation

for MenB

What do we know about meningococcal carriage?

UK: ~30% among university students US:

• 3.2% among Georgia and Maryland high school students (2006-7)1

• 7.5% among social network of a case in Minnesota (included some university students; 2008)2

MenB vaccine impact on carriage• No data for Trumenba (3 doses)

• Bexsero (2 doses)o Associated with lower carriage prevalence in children 1-7 years3

o Associated with decreased carriage by 3 months after 2nd dose4

Sources:

1. Harrison et al. JID 2014. (US)

2. Wu et al. NEJM 2009. (US)

3. Delbos et al. Vaccine 2013. (France)

4. Read et al. Lancet 2014. (UK)

CDC Meningococcal Carriage Evaluation

Objectives:1. Determine baseline prevalence of nasopharyngeal carriage of

N. meningitidis

2. Assess impact of MenB vaccination on carriage

Methods:• Questionnaire & oropharyngeal swab

• Specimen evaluation via bacterial culture, real-time PCR, and molecular testing

Case of serogroup B meningococcal disease

January

Vaccination clinics Carriage evaluation

Rhode Island Department of Health notified

Questionnaire (1)

1. Sex: □ Male □ Female

2. How old are you? _________ years

3. What type of student are you?

□ Freshman □ Sophomore □ Junior □ Senior □ Graduate student

4. Did you receive the serogroup B meningococcal vaccine (Trumenba®) during the recent vaccine campaign in response to the outbreak?

□ Yes: If so, what date? ____/____/________ □ No □ Don’t Know

5. Did you receive a quadrivalent serogroup ACWY meningococcal vaccine (Menveo® or Menactra®)? This meningitis vaccine is recommended for adolescents at ages 11 and 16, or before heading off to college.

□ Yes □ No □ Don’t Know

If yes, what date? ____/____/________ □ I can’t remember

6. Have you taken any antibiotics for any reason in the past 30 days? Examples of antibiotics include cipro, Z-Pak (azithromycin), penicillin, etc.

□ Yes □ No □ Don’t Know

Questionnaire (2)

7. During the last two weeks, did you have any upper respiratory infection symptoms such as cough, runny nose, or sore throat? □ Yes □ No

8. What are your current living arrangements?□ Dorm with roommate(s) □ Apartment/house with roommate(s)

□ Dorm alone □ Apartment/house with family □ Apartment/house alone

7. In the past 30 days, did you smoke tobacco (cigarettes, cigars, hookah) or marijuana?

□Yes, every day □Yes, some days □No, not at all

8. In the past 30 days, were you exposed to secondhand smoke?□Yes, every day □Yes, some days □No, not at all

9. In a typical week, how often do you join activities that have been identified as "risk factors" for meningococcal meningitis, such as visiting bars or nightclubs or attending parties?

□ Less than once a week or never □ 2-3 times a week

□ Once a week □ 4 or more times a week

Note: percentages refer to the proportion of the 717 participants with serogroup-specific nasopharyngeal carriage

(None ST9096)

Meningococcal Carriage Evaluation Results, P.C., Rhode Island, February 2015

Characteristic Total N N. meningitidis carriage, N (%)

Prevalence Ratio

p-value

All students 717 176 (25) --- ---

Male 247 78 (32) 1.5 (1.2-2.0)

0.001

Female 470 98 (21) 1.0

School Year

Freshman 191 38 (20) 1.0

Sophomore 283 86 (30) 1.5 (1.1-2.1)

0.013

Junior 118 30 (25) 1.3 (0.8-1.9)

0.253

Senior 122 21 (17) 0.9 (0.5-1.4)

0.556

Graduate student 3 1 (33) 1.7 (0.3-8.5)

0.534

Meningococcal Carriage Evaluation Results, P.C. , Rhode Island, February 2015

Characteristic Total N N. meningitidis carriage, N (%)

Prevalence Ratio

p-value

Recent antibiotic use1 106 12 (11) 0.4 (0.2-0.7)

0.002

Smoke1 154 51 (33) 1.5 (1.1-2.0)

0.004

Live on campus 655 160 (24) 0.9 (0.6-1.5)

0.808

Recent upper respiratory infection symptoms2

397 105 (26) 1.2 (0.9-1.6)

0.190

Second-hand smoke1 260 74 (28) 1.3 (1.0-1.7)

0.064

Received first dose MenB vaccine

701 170 (24) 0.6 (0.3-1.2)

0.186

Received ACWY vaccine 682 166 (24) 0.9 (0.5-1.5)

0.5611In the past 30 days2In the past 2 weeks

Meningococcal Carriage Evaluation Results, P.C., Rhode Island, February 2015

MEASLES

Measles Clinical Facts

• Febrile rash illness caused by the measles virus

• Airborne transmission via fine particle aerosols through the air, droplets and direct contact with infected respiratory secretions.

• Contagious from 4 days before to 4 days after rash onset.

• Incubation period: 7-21 days (average 14 days)

• Complications : diarrhea, pneumonia and other bacterial infections, blindness, brain damage and death.

Comparison of Contagiousness

• Prodrome (2-4 days)

-Fever (upto 105 F)

-Cough, Coryza, Conjunctivitis

-Koplik’s spots (enanthem)

• Rash

-maculopapular

-spreads from head to trunk to extremities

(centrifugal)

- may become confluent

- fades in order of appearance in 5-6 days

-as rash appears fever disappears

Clinical Features

• 1963 - First live measles vaccine licensed• 1968 - Improved live measles vaccine

licensed• 1971 - MMR vaccine introduced• 1989 - 18,193 cases of measles

– Measles outbreaks tied to low vaccination rates

• 1990 - 27,786 cases – Second MMR vaccination added to

immunization schedule.

Measles Vaccine Timeline

•

•Measles Cases, United States, 1962-2014*

•600,000

•500,000

•1963 Vaccine Licensed •30,000

•1989-1991 Resurgence

•25,000

•Number of cases

•400,000 •20,000

•15,000 •300,000 •10,000

1993 Vaccines for

Children Program

•200,000 •5,000

•0

2000•Elimination

Declared

•1985 1990 1995 2000 2005 2010 •100,000

•1989 – 2nd Dose Recommended

•0 •1960 1970 1980 1990 2000 2010

•Year •*2014 case count preliminary as of June

Kindergarten Vaccine Exemptions RI 2013-14 School Year

Number of Kindergarten Students Who Have an Exemption

Public (n*=10,194)

Private (n*=1,227)

Total (n*=11,421)

Medical 29 4 33 (.28%)

Religious 65 (.6%) 15 (1.2%) 80 (.7%)

Total 94 19 113 (.98%)

* n: number of students assessedSource: RI Immunization Program, School Immunization Assessments, 2013-2014 school year

• 1998 – Study by Dr. Andrew Wakefield, suggests relationship between MMR and autism

• 2006 - Jenny McCarthy begins promoting anti-vaccine beliefs

• 2010- Dr. Wakefield’s study was found to be fraudulent. The research paper was retracted from the scientific journal and he was stripped of his medical license.

• 2014- A study by Taylor et al. in the journal Vaccine examined data on 1,000,000+ children who received MMR. The study found no evidence between the vaccine and autism.

Vaccine Controversy

Measles, United States, 1996-2014* (Importations indicated by red bar, available since 2001)

700

600

500 No of Cases

400

300

200

100

0

*2014 case count preliminary as of June 20

Measles Outbreak, France, 2008-2011 (n>20,000, 10 deaths)

Antona, et al. EID 2013;19:357-364.

Measles Epidemiology US, 20101-2014

 

Imported cases

Cases(mean 277)

Outbreaks

2001- 2010

33/yr (1RI) 60 case (median)

4 small

2011 80 200 14 (3-21 cases)

2012 21 (1RI) 55 4 (3-14 cases)

2013 54 189 11 (3-58 cases)

2014 60 644 23 (3-383 cases)

65% Unvaccinated-25% Hospitalized

Global Incidence of Measles

•

•Distribution of measles genotypes •from Dec-2013 to Nov-2014 (12M period)

•Countries with Genotype data available

•.

•

Vaccination Recommendations

• Children & Students: 2 doses of MMR:

–1st dose at 12-15 months

–2nd dose at 4-6 years (at least 28 days after 1st dose)

• Adults:–Those born during or after 1957 without evidence of immunity should get at least one dose of MMR

• International Travelers:Before travel:

–Infants 6-11 months: 1 dose of MMR

–Children ≥12 months: 2 doses of MMR

–Teenagers, or adults born during or after 1957

without evidence of immunity: 2 doses of MMR

Measles PH Response

One report of a suspect or confirmed measles case triggers a full outbreak response.

• Case investigation

(case defn, lab testing)• Contact investigation• Prophylaxis rapid response

Contact Investigation

• Identify all non-immune susceptible people who the case came in contact with during infectious period– Determine exposure dates and locations– Assess immunization status and risk level

• Priority groups:– Close contacts– Health care facilities– Schools/congregate settings

• Press release for general

public

Post-exposure Prophylaxis (PEP) for Those Without Proof of Immunity

• Vaccinate with MMR within 72 hours• Provide immunoglobulin (IG) within 6 days

of exposure to those high-risk individuals who cannot receive MMR– Infants <12 months– Pregnant women – Severely immunocompromised individuals

• Individuals given PEP should still be monitored for symptoms for one incubation period (21 days)

• Acceptable presumptive evidence of measles immunity includes at least one of the following:1. Written documentation of adequate vaccination:

• One or more doses of MMR: administered on or after the first birthday for preschool-age children and adults not at high risk

• Two doses of MMR: for school-age children and adults at high risk for exposure transmission (i.e., health care personnel, international travelers, and students at post-high school educational institutions)

2. Laboratory evidence of immunity (IgG titer)

3. Laboratory confirmation of disease (IgM titer or PCR)

4. Birth before 1957

Persons who do not meet the above criteria are considered susceptible and should be vaccinated unless

contraindicated.

Evidence of Immunity

• Vaccinated contacts:– No exclusions, do not need PEP and can continue

regular activities.

• Unvaccinated contacts given PEP :– MMR (first for the naïve, second for those with one

dose): can return to child care, school, or work immediately

– IG: case-by-case basis depending on setting and individual’s health status

• Unvaccinated contacts not given PEP in time:– Exclude/monitor for 21 days

• Contacts with medical/religious exemptions:– Exclude/monitor for 21 days

Control MeasuresDaycares, schools, educational settings

• All persons who work in healthcare facilities should have evidence of immunity to measles

– This information should be documented and readily available (ideally through electronic medical records) at the work location

• Evidence of immunity includes any of the following:

1. Written documentation of vaccination with 2 doses of live measles or MMR vaccine administered at least 28 days apart

2. Laboratory evidence of immunity,

3. Laboratory confirmation of disease, or

4. Birth before 1957

• Note: For unvaccinated healthcare workers born before 1957 without evidence of immunity, healthcare facilities should consider vaccinating these individuals with two doses of MMR at the appropriate interval.

Evidence of ImmunityHealthcare Workers

• Unvaccinated healthcare workers

without evidence of immunity:

– Should be given PEP immediately

– Even if given PEP in time, cannot return

to work until 21 days have passed since

exposure to case

Control MeasuresHealthcare workers

PERTUSSIS

Pertussis Clinical Facts

• Whole cell DPT(<7yrs)…1930’s-40’s

70/90% effective 5 doses, waned over 5 to 10 yrs.

BUT Reactogenic

• Acellular DTaP (<7yrs): 1992 for 4th and 5th dose, 1997 for all doses. DTap: Recent studies demonstrate that immunity wanes rapidly after 5th dose (2-4 yrs). Fastest in children born after 1998 and later who had only acellular vaccine.

• Tdap (>11yrs)…2005. Less effective/less reactogenic. 53%-64% effective. Recent Kaiser study CA.

• Tdap for EACH pregnancy to be given in third trimester

to prevent infant disease/deaths. PRIORITY

Pertussis Vaccines

2010 2011 2012 2013 20140

20

40

60

80

100

120

140

160

180

0

2

4

6

8

10

12

14

16

18

44

62

113

160

108

Number of Cases Rate per 100,000

Year

Num

ber o

f Cas

es

Rate

per

100

,000

Reported Cases of Pertussis RI 2010-2014

<1 1-4 5-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 ≥800.0

10.0

20.0

30.0

40.0

50.0

60.0

45.6

15.1

29.8

47.3

0.7 2.4 0.6 1.3 1.0 1.7 1.9

Age Group

Rate

per

100

,000

Rate of Pertussis by Age Group RI 2014

Public Health Response

Interview index case Assure isolation and treatment, identify contacts

• Face to face contact with symptomatic pt during infectious period of index case• Direct contact with respiratory secretions• Shared confined space for prolonged period (at least 1hr) with symptomatic pt during infectious period of index case

Counsel contacts: Assure prophylaxis and watch for symptoms

Notify contacts in congregate settings (e.g. school). Standard letter TARGETED PROPHYLAXIS

Recommend vaccination with DTaP <7yrs, or Tdap>7yrsIf un- or under-vaccinated.

Clinician GuidanceTARGETED PROPHYLAXIS

Reason for visit: Patient is a CONTACT in a congregate setting when index case name is not known (school, day care, sports team, dance class etc.). Parent knows this because they got a letter.

IF NO SYMPTOMS: Give prophylactic antibiotics ONLY if the patient is themselves or a household member is • Immunocompromised/severe chronic illness • Infant<1 yr, • Pregnant in 3rd trimester Otherwise send home and advise return if and when symptoms develop.

IF SYMPTOMS: Cough illness {3 weeks caveat} with paroxysms, whoop or post-tussive vomiting OR no other plausible diagnosis: SWAB---TREAT---ISOLATE---REPORT to HEALTH---VACCINATE.

• Increased incidence is the new normal for pertussis• No new vaccines currently in the pipeline• Prevention efforts should focus on preventing

severe disease and death among infants• Prenatal providers key in influencing patients• Acellular vaccines greatly reduce the incidence,

despite limitations. Prevaccine era rates were 6 times higher than the CA 2010 outbreak

• Outside of public health control over household contacts, TARGETED PROPHYLAXIS is the intervention of choice (NOT MASS PROPHYLAXIS and NOT MASS VACCINATION)

Summary of Pertussis PREVENTION & CONTROL

THE END

THE END!