Delivering a Healthy WA
Disease WAtch

May 2012, Volume 16, Issue 2

Full issue

Plan to boost preschool immunisation rates

Western Australia's departments of health and education are developing an immunisation reminder system that will encourage parents to check the immunisation status of their children before they start school.

The Australian Childhood Immunisation Register (ACIR) shows that for the past two years, preschoolers (4 year olds) have had the lowest immunisation completion rate in WA— 87% compared with 91% for two year olds.

Under the new system, parents will be given a reminder letter and information brochure as part of their child's school enrolment pack and be asked to provide the school with a copy of their child's 4 year old ACIR statement.

The new measures will enable schools to maintain a record of the immunisation status of all students, ensuring they are prepared in the event a child is diagnosed with a vaccine-preventable disease and exclusion from school needs to be considered for students not fully immunised.

The letter to parents will also stress the importance of protecting children from vaccine-preventable diseases when they start school, explain how they can check their child's immunisation status and advise on where immunisation can be accessed.

General practices have a role in helping to improve the immunisation rate of preschoolers by checking the immunisation status of all children who access their services and by recalling children between the ages of 3½ and 4 years, whose immunisation is incomplete.

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State extends vaccination program for new parents

Western Australia's pertussis vaccination program for parents and carers of newborns has been extended until the end of the year.

The State began funding the vaccination program—which aims to protect newborns against whooping cough—for new parents, grandparents and household carers on 1 January 2011.

The program had been scheduled to end next month but has been extended due to the continuing high level of whooping cough activity in the community. Although still elevated, the number of pertussis notifications has been falling since January 2012 and the Department of Health will continue to monitor pertussis notifications to help inform the decision as to whether the vaccination program continues beyond 2012.

The importance of pertussis immunisation was supported by an Australian Government campaign that was launched last November. It consisted of:

  • media alerts urging parents and people working or living with young children to check their immunisation status and to get immunised for pertussis if they had not been vaccinated against the disease within the previous 10 years
  • a letter to the parents of all newborns encouraging them to get their babies vaccinated at six weeks (rather than waiting until they were two months of age) and urging them to check the immunisation status of siblings, finalising vaccinations for any whose immunisation was incomplete
  • provision of educational material to all immunisation providers highlighting the importance of promoting pertussis immunisation and offering the vaccine to all infants at six weeks of age.

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Salmonella Typhimurium outbreak linked to chickens

Molecular typing has shown that a recent increase in notifications of Salmonella Typhimurium infection in humans is linked to particular chicken flocks and contaminated chicken meat.

Background

Salmonellosis was the second most commonly notified enteric infection in Western Australia in 2011, with 1323 cases. Salmonella Typhimurium (STM) was the most commonly notified Salmonella serotype, comprising 428 notifications, approximately 30% higher than the mean number for the previous 5 years. There were 5 identified food-borne or suspected food-borne outbreaks caused by STM in 2011, all associated with particular restaurants or caterers. Different subtypes of STM caused each outbreak, as determined by the pulsed field gel electrophoresis (PFGE) pattern of the organism.

STM PFGE 39 infections in humans

From the beginning of 2011 there has been a general increase in the number of notifications of gastroenteritis caused by another STM PFGE type, designated as type 39. There was an average of 2 cases per month of STM PFGE 39 notified from 2008 to 2010, but this increased to 6 per month in 2011, and has continued to be high in 2012 with an average of 8 per month (Figure 1). Other Australian states and territories have not reported an increase in this Salmonella type.

Graph showing the Number of Salmonella Typhimurium PFGE 39 notifications in WA from January 2008 to March 2012

Figure 1 – Number of Salmonella Typhimurium PFGE 39 notifications in WA, January 2008–March 2012

STM PFGE type 39 infections notified in WA appear to be more severe than other STM infections, with 26% of STM 39 cases hospitalised, compared to 21% of other STM cases over the same period. In December 2011, 1 case with STM PFGE 39 infection developed rhabdomyolysis, a serious and very rare complication of Salmonella infection, which resulted in acute renal failure.

Hypothesis-generating interviews of cases conducted between January and March 2011 found that the most commonly consumed foods were eggs (88% of cases), chicken (82%) and pasteurised milk (82%). Historically, Salmonella cases have had a similar frequency of chicken and milk consumption (80% and 83% respectively), but egg consumption has been lower (73%). As pasteurised milk is subject to heat treatment and is an unlikely source, further investigations focused on chicken and egg consumption. Interviews with additional cases in the period January to March 2012 found that within their likely incubation periods, 81% of cases had eaten chicken and 38% had eaten eggs, providing stronger evidence of a link to chicken.

STM PFGE 39 in chickens and chicken meat

In late 2011, STM PFGE 39 was detected in a number of poultry livestock samples that were submitted to PathWest Laboratory Medicine WA through a veterinary laboratory. These samples were submitted in accordance with WA quarantine requirements, as there was a higher than normal mortality rate in some grower flocks. The Department of Health's Food Unit has been investigating possible environmental causes of the STM PFGE 39 contamination, including links with a fertile egg-producing flock.

To assist investigations, the Food Unit implemented a chicken meat sampling program in October 2011 and from March to May 2012. In October 2011, 7 of 8 samples from selected chicken processors collected at retail outlets were positive for STM PFGE 39. In 2012, 1 of 12 samples from the same processors was positive for this type. The October 2011 results showed that there was a significantly higher proportion of samples positive for Salmonella, when compared to a poultry survey conducted in 2007 and 2008, which found that only 12.5% of carcasses were positive.

Discussion

Raw chicken products are frequently contaminated with Salmonella and other organisms, such as Campylobacter, due to environmental factors associated with livestock production and growing. It is thought that a significant proportion of cases of WA-acquired infections with S. Typhimurium are associated with consumption of chicken meat or eggs. While defined outbreaks linked to contaminated food served at specific food premises or functions are identified occasionally, most STM cases appear to be sporadic, representing a range of STM PFGE types, and are generally ascribed to cross-contamination during food preparation or inadequate cooking at home.

The contemporaneous identification of infections due to STM type 39 in humans and livestock chickens, along with detection of the same organism in retail chicken meat samples that were linked to the affected poultry flocks, provides unusually strong evidence that increased levels of contamination of chicken meat by some Salmonella sub-species can lead to increased human illness. It is possible that this organism was associated with a higher than usual bacterial load in livestock chickens, that was more difficult to control during processing and/or was able to withstand consumer hygiene practices. The mortality rate in livestock chickens, and the higher hospitalisation rate in humans with STM type 39 infection, also suggests that this organism may have higher virulence than other STM types.

The identification of this outbreak demonstrates the utility of enhanced surveillance of enteric diseases using molecular typing methods, and of linkage of data on human infections with results from food sampling and potential animal sources. The Department of Health will continue to liaise with poultry companies to thoroughly examine all potential sources of contamination, while monitoring whether notifications of STM PFGE 39 infections in humans return to their former lower levels.

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Providers urged to help cut wastage

Immunisation providers are being urged to help reduce vaccine wastage by considering the high costs of vaccines when storing and stocking up on vaccines provided free under the National Immunisation Program (NIP).

The WA Department of Health (DoH) is concerned that some providers may be unaware of the costs of individual vaccines, which are significant when the vaccines routinely stored in a practice refrigerator are added up.

A single .5ml dose of Gardasil for example—used in the prevention of human papilloma virus (HPV)—costs around $100 and girls require three doses to be fully protected against the most common strains of HPV. Similarly, Infanrix Hexa, given to children at 2, 4 and 6 months of age, is priced around $65 a dose.

To help reduce vaccine wastage the DoH is encouraging providers to:

  • consider existing stock and their practice’s demand for immunisation when reordering vaccines, reducing the risk of vaccines reaching their expiry dates without being used
  • avoid overstocking fridges. Overstocking can reduce airflow, placing a strain on fridges that can lead to fridge malfunction and cold chain breaches
  • check fridges regularly to ensure vaccines are being stored within the recommended 2–8 °C temperature range.

The WA Department of Health receives approximately $33 million worth of vaccines each year to immunise children against a wide range of diseases including; hepatitis B, pneumococcal, rotavirus, diphtheria, tetanus, pertussis, poliomyelitis, hemophilus influenzae type B, meningococcal C, measles, mumps, rubella, varicella (chickenpox) and hepatitis A.

The vaccines are used according to the National Immunisation Program schedule and supplied to the Department by the Commonwealth under the National Partnership Agreement for Essential Vaccines (NPAEV).

The WA Department of Health is accountable for all vaccines bought via the Commonwealth and reports quarterly on vaccine usage and wastage.

Each year significant amounts of vaccines are discarded in Western Australia due to cold chain breaches whereby the vaccine is exposed to temperatures outside the recommended 2-8 °C. These breaches occur primarily through power outages or refrigerator failure.

Providers are required to report all vaccine loss to their local Public Health Unit—regardless of whether such loss is as a result of refrigerator failure, power failure, cold chain breaches, breakage or vaccines passing their use-by dates.

In the event of a cold chain breach providers should:

  • mark the vaccines ‘do not use’
  • isolate them in an alternative 2–8 °C environment
  • contact their local public health unit.

Providers should not dispose of any vaccines until their viability has been discussed with the regional immunisation coordinator.

For a more in-depth look at vaccine efficacy and cold chain breach protocols, please refer to the article on ‘Protecting vaccine potency’ in the October 2011 edition of DiseaseWAtch.

Simple system for ordering online

Ordering vaccines available under the National Immunisation Program schedule is a simple process.

Immunisation providers across the metropolitan area can order NIP-funded vaccines via the online vaccine ordering website. The website is accessed using a unique username and password, both of which are issued by the Communicable Disease Control Directorate.

Practices or clinics that do not already have access to the online ordering system should email the vaccine team or telephone 9388 4835. Those without internet access can fax vaccine orders to CDCD on 9388 4877. Orders placed by fax may take an additional 24 hours to process.

Providers in the Wheatbelt and Goldfields came online recently. The roll out of the online ordering system across regional WA is expected to be completed within the next few months. Regional providers not yet using the online system should order vaccines through their Regional Pharmacy.

Using the system

The process of ordering vaccines online is simple and efficient and orders can be placed weekly.

Most vaccines are available in single doses or packs of 10. Some vaccines have maximum limits (eg Year 7 vaccines are limited to 5 vaccines per order). Most, however, are not limited.

Once an order is placed:

  • a 10-digit purchase order number will be generated. This number should be recorded and quoted in any subsequent communications regarding the order, including vaccine delivery
  • the order will be viewed and approved by CDCD staff
  • approved orders will be sent to the CSL warehouse, the contracted state distribution centre
  • CSL will collect, pack and ship the vaccines to metropolitan immunisation providers and to the state’s eight Regional Pharmacies, which act as regional distribution centres.

The current turn around time for deliveries in the metropolitan area is 3 to 4 business days. Regional deliveries take longer because vaccines are repackaged and forwarded on from regional distribution centres.

An instruction manual can be accessed from the ordering site.

The WA Department of Health oversees the on-line ordering system and approves all vaccine orders. CSL is contracted by the Department of Health to pack and deliver the vaccines. Queries relating to vaccine delivery should therefore be directed to the CSL warehouse (telephone 9328 7322) or to the relevant Regional Pharmacy.

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Get the Facts gets all new look

The Department of Health's youth website Get the Facts has a fresh new look and feel.

Get the Facts’ makeover follows an evaluation of the site early last year by young people.

Targeted at 14 to 17 year olds, the site provides information, resources, advice and referrals on sexual health, blood-borne viruses and other related sexual and relationship issues.

The site was developed in 2009 after consultation with young people on how they accessed information on these subjects.

Results from an online survey found that 50% of site visitors to Get the Facts were aged 14 to 16, followed by 10 to 13 year olds (20%), people aged 20 and over (13%) and 17 to 19 year olds (11%).

The survey revealed that a large number of people who visited the site were doing so for the first time.

Feedback from the evaluation was positive regarding the site’s navigability and content, with site-testing respondents and focus group participants describing its categories as easy to follow and its information as credible, relevant and easy to understand.

However, the evaluation also highlighted the view of young respondents that the site would benefit from a more modern and vibrant look.

The revamped site includes many interactive animations and features, such as:

  • “Find a Service” – where users can search for sexual health clinics and youth-friendly GPs in WA
  • “Ask a Question” – where users can have a sexual health query answered by a health professional
  • Online chlamydia testing – which enables people aged 16 years and over to complete a risk self-assessment for the disease and, where necessary, access a free chlamydia test by presenting to a PathWest collection centre.

From 1 February 2010 through to 31 January 2011, Get the Facts had a total of 69,793 visits.

The website is promoted through schools, youth services, Department of Health sexual health and blood-borne viruses publications, and non-government organisations.

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Support sought to boost immunisation catch-up

The support of immunisation providers and GPs is being sought to promote a program that strengthens young children's resistance to pneumococcal disease.

The call for support comes as the program passes its halfway mark.

The program offers a single dose of the vaccine Prevenar 13 free to children aged between 12 and 35 months who have completed primary vaccination with the vaccine's predecessor, Prevenar.

The catch-up program, which ends September 30, was introduced last year after Prevenar 13 replaced Prevenar on the National Immunisation Program. Prevenar provided protection against 7 serotypes that caused invasive pneumococcal disease. Prevenar 13 guards against an additional 6 serotypes.

Children who have already received one or more doses of Prevenar 13 or the 10-valent pneumococcal conjugate vaccine (10vPCV, Synflorix) are ineligible for the free supplementary dose.

Immunisation providers are being encouraged to:

  • check the immunisation history of potential program candidates and offer the vaccine to those who meet its eligibility criteria
  • send reminder letters to patients who have children eligible for the supplementary dose
  • access promotional material offered by Pfizer to support the program.

In cases where a child is being considered for both Prevenar 13 and influenza vaccination, the Australian Technical Advisory Group on Immunisation recommends there be at least 3 days between the administration of Prevenar 13 and the influenza vaccine.

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Policy on hepatitis C testing revised

Hepatitis C infection is a major public health problem in Australia.

It is estimated that more than 280,000 people have been exposed to the hepatitis C virus (HCV) since testing began in 1990 and that a further 10,000 acquire the infection each year.

Influenced by multiple factors, infection persists in between 55% and 85% of those infected. Cirrhosis develops within 20 years in 5% to 10% of this group (usually associated with other co-morbidities such as co-infection with human immunodeficiency virus (HIV) or hepatitis B virus (HBV), obesity, insulin resistance, alcohol intake > 40gm/day) and in a further 10%–15% after 40 years.

Hepatocellular carcinoma will develop in 3% to 5% of people per annum who develop cirrhosis. Preventative and therapeutic interventions have proven effective in lowering HCV transmission and improving quality of life and clinical outcomes for people with HCV.

HCV testing provides people with information about their contact with the virus. Appropriate testing indicates whether they have cleared the virus spontaneously or with antiviral therapy, or have an ongoing (active) chronic infection.

The benefits of reliable, timely testing are numerous, both for the patient and public health. Detection of HCV infection followed by appropriate education can:

  • reduce onward transmission by empowering people with HCV to modify their behaviour
  • modify progression of the disease through earlier referral for advice and/or treatment
  • protect blood, tissue and organ donation supplies.

Despite the public health and individual benefits of testing, a significant but as yet undocumented number of infected people in Australia remain undiagnosed.

It is therefore crucial that clinicians who obtain informed consent and provide hepatitis C test results have the skills and knowledge to fully communicate the significance of each of the available tests to the person being tested.

A revised national policy on HCV (external site) was released recently and contains significant differences from the previous 2007 policy including:

  • a change in terminology from pre-test discussion to informed consent
  • a change in the way HCV-negative test results are communicated to patients
  • web-based provision of policy allowing for regular revision to provide consistent management of emerging technologies such as Point of Care testing and viral resistance testing
  • access to related resources such as related policies, operational guidelines and evidence of best practice.

Training on caring for patients with hepatitis C and B (external site) is available free online.

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