October 2012, Volume 16, Issue 4
- Boys set to get HPV vaccine
- Report sheds light on STI rates
- GPs polled on chlamydia initiative
- STI and hepatitis on-line learning resources for health professionals
- New HIV case management guidelines
- 2012 Influenza season at a glance
- Mapping immunisation coverage data
Boys set to get HPV vaccine
Boys aged 12 and 13 years will be vaccinated against human papilloma virus (HPV) from next year under the National Immunisation Program (NIP).
This new initiative, announced by the Australian Government recently, includes ongoing vaccination in one cohort (year 7 as given to girls) and a 2-year catch up program for boys aged 14 and 15 years of age in year 9.
Australia was one of the first countries to implement a national HPV vaccination program for females in 2007. The HPV vaccine protects against the 4 strains of HPV that cause 70% of cervical cancers.
The benefits of offering the HPV vaccine to boys are likely to be substantial.
Since vaccination in females was introduced, the number of women in the vaccination age group presenting with cytologic lesions – potential precursors of cervical cancer – has declined.
There is considerable evidence that most men who get HPV (of any type) never develop symptoms or health problems. This is concerning because some types of HPV can cause genital warts. Other types can cause cancers of the penis, anus, or oropharynx (back of the throat, including base of the tongue and tonsils).
Transmission of anogenital HPV occurs primarily through sexual contact.
Some men are more likely to develop HPV-related diseases than others, for example, gay and bisexual men (who have sex with other men) are about 17 times more likely to develop anal cancer than men who have sex only with women.
Men who are immunocompromised, including those who have HIV, are more likely than other men to develop anal cancer. Men with HIV are also more likely to get severe cases of genital warts that are harder to treat.
Currently, there is no HPV test recommended for men. The only approved HPV tests on the market are designed to screen women for cervical cancer.
The HPV vaccine (Gardasil) works by preventing 4 common HPV types – 2 that cause most genital warts and 2 that cause cancers, including anal cancer. The vaccine protects against new HPV infections but does not cure existing HPV infections or disease (like genital warts). It is most effective when given before a person's first sexual contact.
The HPV vaccine is safe, effective and has no serious side effects. Soreness in the arm post vaccination, which resolves in a few days, is the most common side effect.
It is estimated that a quarter of all new HPV infections can be prevented by extending the vaccination program to boys. Thus, offering the HPV vaccine to boys in the school program offers the greatest long-term protection for both boys and girls (preventing cervical cancer in their female partners) as vaccination will eliminate the risks associated with HPV infection in older life and increase herd immunity.
- Australian Government Department of Health and Ageing National Health and Medical Research Council (NHMRC). Australian Immunisation Handbook 9th Edition 2008.
- Centres for Disease Control and Prevention HPV and Men-Fact Sheet
Report sheds light on STI rates
The recently published Report on Testing Data for Notifiable Sexually Transmissible Infections and Blood-borne Viruses in Western Australia showed that from 2009 to 2011, chlamydia and gonorrhoea test positivity rates increased more than the testing rates for these diseases. This indicates that increased chlamydia and gonorrhoea notification rates are due not just to increased testing but also to increased disease transmission and/or better targeted testing of groups with higher disease prevalence.
In Western Australia, chlamydia notification rates trebled between 2002 and 2011. Rates were highest among people aged 15 to 24 years, particularly those from remote regions (Goldfields, Kimberley and Pilbara). Since 2005, the Western Australian Department of Health has conducted annual mass media campaigns to raise young people's awareness of chlamydia, and promote chlamydia testing and condom use. In addition, sexual health teams were established in Western Australia's remote regions to increase testing and improve clinical and public health management of sexually transmitted infections (STIs).
De-identified laboratory testing data for chlamydia, other STIs and blood-borne viruses (BBVs) were obtained from 5 of the 7 WA pathology providers to assess the impact of disease control programs and assist in the interpretation of disease notification rates.
Between 2009 and 2011, the WA chlamydia testing rate increased by 6% (53 to 56/1000 population) while the test positivity rate increased by 22% (5.4 to 6.6%) and the notification rate by 26%. The testing rate in 15 to 24 year old females was 3 times that of the males; both increased only marginally over time: males by 8% (71 to 77/1,000) and females by 4% (223 to 231/1,000). However, notification rates in males and females increased by 23% and 31% respectively, and chlamydia test positivity also increased from 13% to 15% in males, and from 8% to 10% in females. Similar trends were observed for gonorrhoea.
Syphilis testing rates in WA increased marginally by 2% (34.8 to 35.5/1000 population) in WA between 2009 and 2011. Although the test positivity rate remained low, it increased significantly (1.0 to 1.4%) over this period. However, the notification rate increased 36%. Increases in testing rates and notification rates in males (but not in females) reflects the ongoing increase in transmission among men who have sex with men (MSM).
Despite the Royal Australian College of General Practitioners' recommendation that annual chlamydia testing be offered to all 15 to 24 year olds, testing rates in this group were lower than expected, even in remote regions serviced by dedicated STI teams. Improved strategies are needed to encourage chlamydia testing among young people.
GPs polled on chlamydia initiative
Chlamydia notifications have been increasing in both Western Australia and the catchment area covered by the South Metropolitan Area Health Service (SMAHS).
In 2010, 3,686 cases of chlamydia were notified in the SMAHS catchment, an increase of 20% from 2009 and accounting for 44% of all notifiable diseases. Crude notification rates in the SMAHS catchment (438 per 100,000 population) and WA (442 per 100,000) were higher than national rates (352 per 100,000). Notification rates were highest among young people, with 2,001 per 100,000 in the 20 to 24 years age group and 1,841.4 per 100,000 in the 15 to 19 years group.1
The South Metropolitan Public Health Unit (SMPHU) chlamydia protocol previously targeted all notifications in people under 16 years and older cases in high-risk populations, with phone calls to notifying doctors and follow up as required.2 However, there was no intervention for 16 to 21 year olds, for whom chlamydia notification rates were the highest. In 2010, the SMPHU commenced an initiative to target this age group through correspondence with their notiifying general practitioner. The following is an evaluation of that initiative.
This intervention was targeted at GPs in SMAHS who notified a case of chlamydia in a person aged 16 to 21 years. Doctors excluded from the intervention were those who specialised in sexual health (such as sexual health and family planning clinics) and those whose patient had already been identified and followed up as a high-risk case (such as an antenatal patient or somebody with a co-infection).
The intervention was in the form of an SMPHU mail-out which included a letter that could be filed in the patient’s notes that provided information on treatment of chlamydia and other sexually transmitted infections (STIs) and STI screening and contact tracing. A standard treatment protocol for STIs was also included.
The survey was designed to seek feedback from GPs on the usefulness of this intervention. A random sample of GPs was taken from chlamydia notifications to the Western Australia Notifiable Infectious Disease Database (WANIDD) for patients in the SMAHS catchment for a 3-month period from the week beginning 4 July 2011 to the week ending 2 October 2011. A standardised questionnaire was used for all GPs. Questionnaires were delivered by fax or email along with copies of the chlamydia correspondence as a memory prompt.
GPs who did not respond within 2 weeks were contacted by telephone. Cases where a practitioner had not engaged in the survey after 3 attempts, were deemed non responses.
From a total of 264 GPs in the target group, a sample of 150 GPs were selected to survey. Of those, 8 were no longer working at the practice or were on extended leave, 20 declined to participate and 15 were not followed up according to protocol (i.e. the questionnaire was faxed to the surgery but no attempt was made to follow up with a telephone call). These GPs were excluded from the analysis, leaving 107 GPs or 71% of the 150 selected for the survey.
Most GPs surveyed (89%) were aware of the chlamydia mail out sent by the SMPHU upon notification of a case and 72% found the correspondence useful. Participants found the STI standard treatment protocol to be the most useful resource (66%), followed by the STI testing advice (52%). Some GPs also requested that patient information be sent along with GP information.
Half the GPs said the information assisted with the recall and treatment of the patient and half felt it helped with patient education and counselling. Only a third, however, reported that the letters helped them with contact tracing.
Feedback from many GPs indicated that they assumed the Department of Health followed up with contact tracing for all chlamydia cases.
The majority of GPs (70%) said they would like to continue to receive SMPHU correspondence regarding chlamydia. A number said the initial information was useful but that they would like to receive further letters only if there were new developments in the management of chlamydia or STIs. A number also indicated they would like further information on other notifiable diseases.
As a result of the survey it was recommended that:
- communication with GPs around their role in chlamydia contact tracing be improved
- GPs be referred to the WA Department of Health website for further information on notifiable diseases
- GPs be given the option to decline further correspondence through phone or fax back
- the targeted intervention continue.
- Internal document of Disease Control Section, South Metropolitan Public Heath Unit (SMPHU), WA DOH. July 2011. Review of Notifiable Diseases in the South Metropolitan Area Health Service – 2010.
- Internal document of Disease Control Section, South Metropolitan Public Heath Unit (SMPHU), WA DOH. July 2011.Chlamydia Follow-up Prioritisation Protocol.
STI and hepatitis on-line learning resources for health professionals
Edith Cowan University and the Department of Health WA have developed free online learning programs for managing sexually transmitted infections (STIs), hepatitis B and hepatitis C.
The programs have been designed to enhance the knowledge and skills of medical practitioners, nurses and other health professionals in Western Australia.
The STI, hepatitis B and hepatitis C programs all include 2 modules, each of which ends with a test and certificate of completion.
The programs have been approved for continuing professional development by the Royal Australian College of General Practitioners and the Royal College of Nursing, Australia. The hepatitis B and hepatitis C modules are also accredited by Paramedics Australia and the Pharmaceutical Society of Western Australia.
The hepatitis C course includes a third module on advanced management of hepatitis C, including antiviral therapy. General practitioners who successfully complete this module may apply to the Department of Health to become a S100 antiviral treatment prescriber.
New HIV case management guidelines
New case guidelines have been approved for managing HIV positive clients who knowingly place others at risk of infection.
The new guidelines, now on the Public Health and Clinical Services webpage, bring Western Australia into line with national guidelines as far as WA legislation will allow.
The Guidelines contain an updated 5-level process for managing clients of the WA HIV Case Management Program.
2012 Influenza season at a glance
The 2012 influenza season commenced earlier and was more intense than anticipated but appears to have peaked in mid-July (week 27) and is now declining.
Notification and laboratory surveillance data
Between 1 January and 26 August 2012, the Communicable Disease Control Directorate (CDCD) received 4315 notifications of laboratory-confirmed influenza, more than double the number received for the full year in both 2011 (1887 notifications) and 2010 (1633 notifications) (Figure 1).The early start to the season and sharp rise in notifications was reminiscent of the 2009 pandemic year. Notably, the Department of Health has also been notified of more outbreaks of influenza in residential aged-care facilities in 2012 than in any previous year.
Figure 1: Influenza notifications by date of onset, 2010 to 26 August 2012.
This year's large increase in notifications has been associated with a marked decline in the number of detections of the 2009 A/H1N1 pandemic strain – which had continued to be the dominant strain in both 2010 and 2011 – and a concomitant increase in detections of both influenza A/H3N2 and B viruses (Figure 2). Up to 19 August 2012, PathWest has subtyped 2059 influenza isolates, comprising 63.4% A/H3N2, 35.4% B, 0.8% A/H1N1 and 0.4% mixed influenza virus infections.
Figure 2: Influenza notification subtypes, 2010 to 26 August 2012.
Surveillance in the northern hemisphere over the 2011–12 winter demonstrated a declining match between circulating A/H3 and B influenza virus strains and the strains included in both the 2011–12 northern hemisphere and the 2012 southern hemisphere influenza vaccine formulations (namely, an A/California/7/2009 (H1N1)-like virus; an A/Perth/16/2009 (H3N2)-like virus; and a B/Brisbane/60/2008-like virus). Not surprisingly, the same drift strains (an A/Victoria/361/2011 (H3N2)-like virus; and a B/Wisconsin/1/2010-like virus) have predominated in Australia this winter and it is likely that relatively reduced levels of immunity against these strains have contributed to the intensity of the 2012 influenza season.
The 2012 season has also differed from the 2 previous seasons in terms of a pronounced geographical division of influenza subtype activity. Influenza subtype A/H3N2 has been the predominant cause of influenza in the Perth metropolitan area and southern part of WA, whereas influenza B was the predominant circulating strain in the Kimberley and Midwest regions during the inter-seasonal period from January through to May, causing 72% and 73% of influenza infections in these areas, respectively. Interestingly, influenza B virus was responsible for only 25% of infections in the Pilbara region during the same period.
Sentinel GP and ED influenza-like illness surveillance
Hospital emergency departments in Perth experienced high demand in early winter associated with the sharp increase in influenza activity. More than 1000 patients presented with influenza-like illness (ILI) symptoms at the peak in week 27, and presentations remained high in the following 2 weeks (Figure 3). However, the number of ILI presentations has since fallen to levels similar to those experienced at the same time in 2011 and 2010.
Figure 3: Influenza-like illness presentations to Perth hospital emergency departments, 2010 to 26 August 2012.
Similarly, reflecting the burden of respiratory disease in the community, data collected at GP practices participating in the Sentinel Practitioners Network of Western Australia also demonstrated a peak in ILI consultations (29.6 per 1000 consults) in week 27 (Figure 4). ILI consultations have since declined and are now lower than the peak levels reached in 2011 and 2010. Between 1 January and 26 August 2012, sentinel practitioners submitted a total of 1263 ILI samples to the PathWest laboratory. Of these, 43.8% (553) tested positive for influenza virus.
Figure 4: Influenza-like illness presentations to WA sentinel GP practices, 2010 to 26 August 2012.
The combined evidence from influenza notifications to the Department of Health, laboratory data, and sentinel GP and hospital emergency department indicators of community influenza-like illness, suggests that influenza activity is gradually declining in Western Australia, after an unusually early and abrupt period of high activity, peaking in mid-July. Other respiratory viruses, particularly respiratory syncytial virus, as well as the tail-end of the 2011–12 pertussis epidemic, have also contributed to the burden of respiratory illness over winter. The early influenza season followed higher than normal levels of inter-seasonal influenza activity during the summer and autumn months, especially in the north of the state.
The virtual disappearance of the A/H1N1 2009 pandemic influenza virus, and the relative rise in A/H3N2 and B viruses worldwide over the past 12 months – including in Australia – would appear to reflect the after effects of the rapid ecological ascendancy of the A/H1N1 2009 virus associated with pandemic spread in 2009, and its subsequent decline due to a high levels of herd immunity gained through natural infection and/or vaccination since 2009, and the fact that there has been little antigenic drift in the virus.
The intensity of the 2012 influenza season in Western Australia and other parts of Australia was not expected, given relatively mild activity during the preceding northern hemisphere winter.
Mapping immunisation coverage data
As part of the National Partnership Agreement on Essential Vaccines there are a number of performance benchmarks that have to be reached by the Department of Health in order for it to receive full funding.
One of the performance benchmarks is “Maintaining or increasing coverage in agreed areas of low immunisation coverage”. To help identify, monitor and improve areas of low immunisation coverage throughout Western Australia (WA), the Communicable Disease Control Directorate (CDCD) has begun mapping Australian Childhood Immunisation Register (ACIR) immunisation coverage data by Local Government Area on a quarterly basis.
Below are a selection of the maps showing immunisation coverage of 3 different cohorts of children, 12-<15 months, 24-<27 months and 60-<63 months. Traffic light colours have been used with green indicating areas that have achieved high immunisation coverage (≥90%), red indicating areas that have low immunisation coverage (≤80%) and different shades of amber in between. All maps are produced by the Geographical Information System (GIS), Epidemiology Branch, System Policy and Planning Directorate, Department of Health, WA.
Please note: Local Government Areas with small numbers of children are prone to large fluctuations in immunisation coverage rates and maps should be viewed alongside the ACIR coverage data.
Figure 1: Percentage of children aged 12-<15 months in Western Australia fully immunised, by Local Government Area (LGA), taken from the quarterly Australian Childhood Immunisation Register (ACIR) data extracted on the 30 June 2012.
Overall, the total WA immunisation coverage of 12-<15 months for the latest quarter is 90.1%. Public Health Unit regions with immunisation coverage exceeding 90% include Kimberley (91.1%), North Metropolitan (90.9%), Midwest (91.0%) and the Wheatbelt (94.1%).
Figure 2: Percentage of children aged 12-<15 months in metropolitan Perth fully immunised, by Local Government Area (LGA), taken from the quarterly Australian Childhood Immunisation Register (ACIR) data extracted on the 30 June 2012.
Large areas of green in both North and South metropolitan Perth represent LGAs that have immunisation coverage ≥90%. The lowest immunisation coverage is seen in Claremont, Fremantle and Waroona.
Figure 3: Percentage of children aged 24-<27 months in Western Australia fully immunised, by Local Government Area (LGA), taken from the quarterly Australian Childhood Immunisation Register (ACIR) data extracted on the 30 June 2012.
Overall, the total WA immunisation coverage of 24-<27 months for the second quarter in 2012 is 90.1%. Public Health Unit regions with immunisation coverage exceeding 90% include Great Southern (91.5%), Kimberley (97.4%), Midwest (92.5%), South West (90.4%) and the Wheatbelt (94.1%).
Figure 4: Percentage of children aged 24-<27 months in metropolitan Perth fully immunised, by Local Government Area (LGA), taken from the quarterly Australian Childhood Immunisation Register (ACIR) data extracted on the 30 June 2012.
Immunisation coverage for North Metropolitan and South Metropolitan fell just shy of 90%, with 89.7% and 89.9%, respectively.
Figure 5: Percentage of children aged 60-<63 months in metropolitan Perth fully immunised, by Local Government Area (LGA), taken from the quarterly Australian Childhood Immunisation Register data extracted on the 30 June 2012.
More areas are highlighted in red and orange in this map than in the previous 2 state-wide maps, with the overall immunisation coverage for children aged 60-<63 months falling to 87.6%.
Figure 6: Percentage of children aged 60-<63 months in metropolitan Perth fully immunised, by Local Government Area (LGA), taken from the quarterly Australian Childhood Immunisation Register (ACIR) data extracted on the 30 June 2012.
Few areas of green are shaded in the map above reflecting the immunisation coverage rates of North and South Metropolitan Health Services that both fall below 90%, 86.8% and 86.6%, respectively.