March 2013, Volume 17, Issue 1
- Evaluation of the Backpackers Project
- Influenza vaccination in pregnancy
- New and emerging treatments for hepatitis C
- Boys focus of 2013 HPV Campaign
- Mumps outbreak in Perth
- New resources for Aboriginal communities
- Forums focus on STIs and BBVs
- 2012 Western Australian Vaccine Safety Surveillance Annual Report
Evaluation of the Backpackers Project
On 1 May 2012, WA Health launched a safe sex project aimed specifically at backpackers. The message was "Could I be getting more than I came for? (PDF 285KB)" linking with the ongoing WA Health Chlamydia campaign "Could I have it?"
The Backpackers Sexual Health Project encouraged young travellers to:
- practise safe sex
- get tested for STIs if they had had unprotected sex.
The project is underpinned by research that shows nearly three-quarters of backpackers had sex during their stay in Australia, with many reporting inconsistent condom use and unprotected sex with multiple partners.1 These behaviours, as well as heavy alcohol consumption and illicit drug use, are associated with a higher risk of sexually transmitted infection (STI) among backpackers. 1
The Sexual Health and Blood-borne Virus Program (SHBBVP) developed an additional webpage to the WA Health chlamydia campaign, Could I Have It. The webpage contained information for backpackers regarding risk and where they could access testing. It also included specific information about health and travel insurance. The Online Chlamydia Self-Risk Assessment (OLC) was also updated to include a question about travel status, to capture the number of travellers using the service.
Guided by a reference group of youth-travel industry representatives, promotional posters and condom wallets were distributed to 18 backpacker hostels across WA, and 4 Perth-based GP clinics frequented by travellers. Condom wallets were also available in 500 rental vehicles.
The SHBBVP also provided condom-vending machines to high-volume backpacker hostels in Margaret River and Perth. The vending machines, fitted in the male and female restrooms, provided 24-hour access to condoms.
The Backpackers webpage received regular visits during the promotional period (29 May to 30 September 2012), averaging 150 visits per month. The majority of visitors were referred by Google searches for terms such as “backpacker STI” and “can backpackers get tested in Australia”.
During the promotional period, travellers were responsible for 25% of OLC forms downloaded and 7% of positive OLC tests. Among people tested at the B2 Clinic (not referred by the OLC), 27% of total positive chlamydia notifications were in travellers. The majority of these were from England (25%) and Ireland (25%). Additionally, one positive syphilis notification for a traveller (England) was recorded, out of 5 total notifications at the B2 Clinic.
The outcomes of this small campaign reinforce published evidence that backpackers are a high-risk group who should be encouraged to practise safe sex and get tested. General practitioners are encouraged to offer STI testing to all travellers and backpackers aged 16-25 years of age.
For more information visit the Could I have it (external site) website.
- Hughes, K, Downing, J, Bellis, M A, Dillon, P, & Copeland, J (2009). The sexual behaviour of British backpackers in Australia. Sexually Transmitted Infections 85: 477–482.
Influenza vaccination in pregnancy
Experience with prior annual seasonal influenza epidemics and the pandemic in 2009 have demonstrated clearly that pregnant women are at increased risk of morbidity and mortality from influenza.1 2 3
Last year, under the National Immunisation Program, free seasonal influenza vaccine was offered to all pregnant women throughout Australia. Despite this, a recent WA Department of Health survey found that only 25% of all pregnant women in Western Australia were vaccinated against flu while they were pregnant and just 38% said they were advised by their antenatal health care provider to be vaccinated.
We have to do better—influenza vaccination of pregnant women is ‘standard of care’ in Australia. The National Health and Medical Research Council (NHMRC) recommends that the influenza vaccine be offered to all pregnant women who will be in the second or third trimester during the influenza season, including those in the first trimester at the time of vaccination.7
Why pregnant women should receive seasonal influenza vaccine
- Influenza vaccination of pregnant women reduces illness in both the mother and newborn. A randomised controlled trial in which pregnant women were vaccinated against influenza, demonstrated a 29% reduction in respiratory illness with fever in the pregnant women. It also showed that infants born to vaccinated women had a 63% reduction in laboratory-confirmed influenza illness during their first 6 months of life.4
- Influenza vaccination of pregnant women reduces hospitalisations. Influenza vaccination is estimated to prevent 1 to 2 hospitalisations per 1000 women vaccinated during the second or third trimester.5
- Caregivers of newborns are potential sources of transmission of influenza. Vaccinating everyone who lives with—or cares for—infants less than 6 months of age (who are too young to receive the vaccine themselves) is the best way to prevent these children from getting influenza.6
- The influenza vaccine is safe for pregnant women. There is no evidence of congenital defects or adverse effects on the fetus of women who are vaccinated against influenza in pregnancy.6 8 Seasonal influenza vaccines can be given to pregnant women in any trimester.
Encouraging pregnant women to get the seasonal influenza vaccine can help to protect them and their newborns from influenza. Health providers play a crucial role in addressing concerns pregnant women may have about influenza vaccination. Preventing influenza among pregnant women can save lives.
- Irving WL, James DK, Stephenson T, et al. Influenza virus infection in the second and third trimesters of pregnancy: a clinical and seroepidemiological study. BJOG: An International Journal of Obstetrics & Gynaecology 2000;107:1282–9.
- McNeil SA, Dodds L, Allen VM, Scott J, Halperin B, MacDonald N. Influenza vaccine programs and pregnancy: new Canadian evidence for immunization. J Obstet Gynaecol Can. 2007 Aug;29(8):674–6.
- World Health Organization. Pandemic Influenza in Pregnant Women. Available at the World Health Organization website (external site) .
- Zaman K, Roy E, Arifeen SE, Rahman M, Raqib R, Wilson E, Omer SB, Shahid NS, Breiman RF, Steinhoff MC. Effectiveness of maternal influenza immunization in mothers and infants. (external site) N Engl J Med. 2008 Oct 9;359(15):1555–64. Epub 2008 Sep 17. 1.
- Neuzil KM, Reed GW, Mitchel EF, Simonsen L, Griffin MR. Impact of influenza on acute cardiopulmonary hospitalizations in pregnant women. American Journal of Epidemiology 1998;148:1094–102.
- CDC. Prevention and Control of Seasonal Influenza with Vaccines. Recommendations of the Advisory Committee on Immunization Practices (ACIP), July 31, 2009 / 58(RR08);1–52. Available at the US Centers for Disease Control and Prevention website (external site).
- The Australian Immunisation Handbook 9th Edition 2008, National Health and Medical Research Council. Available at the Immunise Australia Program website (external site).
- Letter from Professor Jim Bishop, Chief Medical Officer, Australia, 2 November 2009.
New and emerging treatments for hepatitis C
Invited contribution by:
Dr Wendy Cheng
Head, Liver Service, Royal Perth Hospital
Adjunct Professor, Curtin Health Innovation Research Institute
The standard of care for chronic hepatitis C (HCV) is constantly evolving with the development of more efficacious drugs, shortened duration of therapy and optimisation of dosages. Using a combination of pegylated interferon and ribavirin, a sustained virological response (SVR) can be achieved in only about 50% of cases with 48 weeks of treatment.
The recent introduction of direct antiviral drugs (DAAs)—and future drugs that work on different parts of the virus' complex life cycle (or combinations of these newer drugs or these newer drugs and DAAs), and interferon-free regimens—is likely to revolutionise the treatment of chronic hepatitis C, with higher SVR and reduced toxicity. The interferon-based regimen may still be required for difficult-to-treat patient populations, such as previous non-responders to interferon-based regimens.
Direct Antiviral Agents
In mid 2011, approval in the USA and European Union of the first generation DAAs—telaprevir and boceprevir (protease inhibitors)—resulted in an increased willingness of patients with HCV genotype 1 to undertake treatment. The DAAs, in combination with pegylated interferon and ribavirin (triple therapy) has increased SVR from 50% to over 70% in treatment-naïve HCV genotype 1 patients, and with a shorter duration of treatment.1, 2 Patients who failed previous therapy have variable responses, with highest SVR in patients who relapsed (75–88%), and poorest response in patients who did not achieve an initial adequate response (30–34%).3, 4 These drugs are effective in genotype 1 patients only.
Treatment regimens for DAAs are complex, with different treatment durations and cessation rules. Boceprevir and telaprevir need to be taken 3 times per day resulting in a heavy pill-burden, although a recent study suggests that telaprevir may be taken twice daily. Patients who have failed previous therapies require treatment for 48 weeks. Treatment monitoring is more intensive due to increased toxicity—boceprevir is associated with anaemia and dysgeusia (unpleasant taste) and telaprevir with rash and bone marrow suppression. The use of DAAs in patients with cirrhosis and portal hypertension is associated with increased risk of infection and mortality. Both telaprevir and boceprevir were approved (external site) in 2012 by the Therapeutic Goods Administration (TGA) for the treatment of genotype 1, and in February 2013 they were approved for Pharmaceutical Benefits Scheme (PBS) listing.
Several second generation DAAs that are effective across all genotypes are currently under investigation. These are taken once daily, are more efficacious than their predecessors and are associated with less toxicity. In a recent small study of difficult-to-treat patients (previous null-responders), SVR of 100% was achieved with the use of two DAAs (declastavir and asunaprevir) in combination with pegylated interferon and ribavirin (quadruple therapy).5
Pegylated interferon Lambda
Pegylated interferon Lambda (PEG-IFN λ) is not associated with systemic toxicity, including bone marrow suppression (low platelet, white and red cell counts), seen in conventional interferon therapy. This is due to the interferon-λ receptor being restricted to hepatocytes (liver cells) and not widely distributed in other organs. In preliminary studies, when PEG-IFN λ is used in combination with ribavirin, it is also associated with higher SVR in patients with HCV genotype 1 patients. Patients who had previously not responded (null responders) may still require interferon-based regimens and PEG-IFN λ may have an important role to play.
Preliminary data with Sobosfuvir (GS-7977 ) used in combination with ribavirin showed SVR of 100% in genotype 3 and 90% in genotype 1 patients. A recent press release confirmed SVR of 90% (295/327) in genotype 1, 4, 5 and 6 patients but only 67% (170/250) in genotype 2 and 3 patients. Treatment duration in all groups was 12 weeks and side effects were less frequently observed compared with pegylated interferon and ribavirin.
Studies examining the effects of a combination of DAAs or combinations of drugs which work on other sites of the virus' life cycle—with or without pegylated interferon or ribavirin—are in progress. Several combinations have shown encouraging results.
It is likely that with multiple drugs being used in future treatment regimens, increased toxicity may limit their use in clinical practice.
Combination therapy using pegylated interferon and ribavirin remains an integral part of the current treatment in Australia but may be superseded by interferon-free regimens in the future. It is likely that the majority of patients with HCV will be able to achieve a ‘cure’ in the near future, with regimens associated with shorter duration of therapy and minimal toxicity.
- Jacobson IM, McHutchison JG, Dusheiko G, et al. Telaprevir for Previously Untreated Chronic Hepatitis C Virus Infection. N Engl J Med 2011; 364:2405–2416.
- Poordad F, McCone J, Bacon BR, et al. Boceprevir for Untreated Chronic HCV Genotype 1 Infection. N Engl J Med 2011; 364:1195–1206.
- Zeuzem S, Andreone P, Pol S, et al. Telaprevir for Retreatment of HCV Infection. N Engl J Med 2011; 364:2417–2428.
- Bacon BR, Gordon SC, Lawitz E, et al. Boceprevir for Previously Treated Chronic HCV Genotype 1 Infection. N Engl J Med 2011; 364:1207–1217.
- Lok AS, Gardiner DF, Lawitz E, et al. Preliminary Study of Two Antiviral Agents for Hepatitis C Genotype 1. N Engl J Med 2012; 366:216–224.
Boys focus of 2013 HPV Campaign
The Australian Government is promoting a national, school-based vaccination program for males in Year 8 to 10 protect them against HPV-related cancer and disease.
The school-based program will be provided primarily at high schools throughout Western Australia . If a student misses a vaccination at school however, he can get vaccinated at a general practice, local council, or Aboriginal Medical Service in the 2013 school year.
In the event that a school-based vaccine is provided in general practice to an eligible student, the health provider should ensure the Report form for GP use of government-procured vaccine (PDF 185KB) is completed and faxed to CDCD on 08 9388 4877.
In Western Australia, the 2013 school-based HPV program for Year 8 boys will be delivered simultaneously with a catch-up program for male students in Years 9 and 10.
The standard school immunisation program will recommence in 2014 when both female and male students in Year 8 will receive the routine school vaccinations. No student will miss out on the opportunity to receive school-based vaccinations.
Mumps outbreak in Perth
The Perth metropolitan area is experiencing an outbreak of mumps, with 23 confirmed cases notified with illness onset between 25 December and mid-February, compared to 2 cases in the same period last year. No mumps cases have been notified in Western Australian residents outside Perth for more than 12 months.
With one exception, all the recent cases appear to have acquired their infections locally (see Figure 1). Direct linkages to a source have been identified for only 4 cases, suggesting that there could be many other cases in the community not being detected. This is supported by anecdotal reports of undiagnosed cases, and knowledge that around one third of people infected with mumps do not have obvious symptoms.
Two thirds of the notified cases live in the northern suburbs and most are older teenagers or young adults aged in their 20s and early 30s. Around one third of the cases have documented evidence of being partially (1 dose) or fully (2 doses) vaccinated against mumps, while one third have not been vaccinated, and there is no information for the remainder. Three cases (13%) have been hospitalised, including one with meningitis and another with orchitis.
Figure 1 – Mumps notifications in Western Australia, January 2012 to 25 February 2013, by likely place of acquisition.
Mumps became a notifiable disease in Western Australia in 1993, and excepting a large and localised outbreak in the Kimberley region in 2007–2008, the annual number of notified cases has fluctuated between a low of 7 cases in 1994 and a high of 40 cases in 2000. On a statewide basis, in the 4 years 2009–2012, an average of 1.4 cases were notified per month, around 50% of whom acquired infection overseas. Hence, the upsurge in cases since late December 2012—primarily locally acquired—is unusual.
The 2007–08 Kimberley outbreak was also very unusual in that there was clearly intense and sustained local transmission, primarily in Aboriginal residents of that region aged between 5 and 29 years, a high proportion of whom were partially or fully vaccinated.1 While 148 cases were notified in Kimberley residents between July 2007 and September 2008, only 2 cases have been reported from the Kimberley since then. The Kimberley outbreak was caused by a genotype J mumps virus, and it is thought that the mumps vaccine, which is of genotype A lineage, may not offer good protection against all strains.
Similarly, the United States, Canada and several European countries have also experienced outbreaks of mumps in recent years, characterised by high incidence in older teenagers and young adults, a high proportion of whom have been vaccinated. 1–5 Several of these outbreaks have been due to genotype G5 mumps virus, which has been identified in all three of the recent WA cases for whom typing has thus far been performed.
Resurgent mumps in the United States and Europe has been attributed to several factors, including waning immunity in young adults who were vaccinated in childhood, lack of boosting of immunity due to significantly decreased circulation of wild-type virus, and diminished serologic cross-protection due to antigenic differences between the Jeryl Lynn (genotype A) mumps vaccine strain and circulating strains, including genotype G5.1–4Mumps vaccine was introduced to the childhood immunization schedule in WA in 1981 as a single dose given at age 12 months. A second dose—as part of the combined measles-mumps-rubella (MMR) vaccine—was added to the schedule in 1994, initially at age 12 years and from 1998 at age 4–5 years. Estimates of effectiveness for 2 doses of mumps vaccine range from around 88% to 95%.1,2 Hence, even with reasonably high MMR vaccine coverage—estimated in WA for the latest quarter (September 2012) as 93% and 90% in children aged 2 years and 5 years, respectively—herd immunity may not be sufficiently high to prevent outbreaks. This would particularly affect older age groups where vaccine coverage is expected to be lower, immunity has waned and where social circumstances may facilitate transmission, such as close contact in tertiary education settings, over-crowded houses and nightclubs.2
Preferred tests and specimen collection
All persons with illnesses compatible with mumps—fever, swelling and tenderness of one or more salivary glands—should preferably be tested to verify the diagnosis, at least where there is no known linkage to a case that has already been laboratory-confirmed. Serology alone is unreliable for diagnosing mumps in people who have been previously vaccinated as many have IgG but do not mount an IgM response. Also, both IgG and IgM may be absent in very early infection in unvaccinated individuals.
Hence, it is recommended that all suspect cases have both serology (IgG and IgM) and, if parotitis is still present, that specimens are also collected for virus detection by isolation/PCR. Virus can be isolated from previously unvaccinated cases from 6 days prior to—and up to 9 days after—symptom onset but in previously vaccinated cases the PCR is usually negative after 3 days of symptoms. Specimens for PCR and/or isolation should be referred to PathWest at the QEII Medical Centre for testing.
Since PCR is not positive in all cases, those with a negative PCR should have a convalescent serum sample sent to look for a rising IgG titre. The common mumps IgG tests used by most laboratories cannot detect rising IgG, so these specimens should be referred to PathWest at the QEII Medical Centre.
Preferred specimens for PCR/isolation are buccal swabs (and/or throat swabs) collected using a sterile dry cotton-tipped swab placed into a sterile vial containing viral transport medium (VTM) (see Figure 2), as this allows testing by both PCR and culture. If VTM is not available and cannot be obtained quickly, dry swabs should be sent as these can still be used for PCR. Swabs are recommended for anyone with ongoing parotitis, but preferably within 5 days of onset.
Virus detection can also be undertaken on clean-catch urine specimens in a sterile screw-top jar, collected up to around 14 days after symptom onset. Swabs and urine specimens should be kept at refrigerator temperature (4–8 ºC), but not frozen.
Figure 2 – How to collect a buccal swab for mumps virus testing
Step 1: Massage the parotid gland (area between the cheek and teeth below the ear) for 30 seconds prior to the collection of buccal secretions. The parotid duct drains into this space near the upper rear molars.
Step 2: Swab the buccal cavity near the upper rear molars between the cheek and teeth. Using a sterile dry cotton tipped swab (plastic or metal shaft, as pictured in step 3), place between the molars and cheek and leave in place for 10 to 15 seconds.
Note: Charcoal and Gel based swabs are inappropriate for PCR and viral culture.
Step 3: Place the swab immediately into a sterile vial containing 3 mL of viral transport medium (yellow-lidded vial pictured). Break or cut shaft and seal in the vial and label with patient's name, date of collection and specimen site. Keep sample cold. Do NOT freeze.
If viral transport medium is unavailable, place dry swab back into tubing, seal and label with patient's name, date of collection and specimen site.
|Adapted from information developed by Seattle and King County Public Health (USA) (external site)|
Notification and public health response
Cases should be excluded from school, other educational settings, work, and public places where other susceptible people may be present, for 9 days after the onset of symptoms. Incompletely vaccinated close contacts should be offered MMR vaccine, although post-exposure vaccination will not always prevent infection.
All suspected or confirmed cases should be notified to the Communicable Disease Control Directorate (CDCD - Perth) or the appropriate Public Health Unit (regional areas), preferably by telephone or fax, using the standard notification form. Public Health Units will follow-up cases to investigate exposure history, facilitate testing where appropriate in liaison with the diagnosing clinician, and identify contacts who may benefit from advice or other action.
At a community-wide level, it is important that all children receive their MMR vaccinations on time, at 12 months of age and at 4 years, prior to commencing pre-school. Vaccination should also be offered opportunistically to older children and young adults who do not have documentation of having received two doses of MMR vaccine, especially prior to overseas travel. Measles, rubella and mumps viruses continue to be imported into WA by returning travellers or incoming visitors who are infected in overseas countries where these diseases remain endemic.
In the meantime, CDCD will maintain close surveillance. Any wider response, such as promoting a third dose of MMR vaccine among adolescents and young adults, either generally or in more focused settings, will be determined by how the outbreak evolves.
- Bangor-Jones RD, Dowse GK, Giele CM, van Buynder PG, Hodge MM, Whitty MM. A prolonged mumps outbreak among highly vaccinated Aboriginal people in the Kimberley region of Western Australia. MJA 2009; 191: 398–401.
- Dayan GH, Quinlisk MP, Parker AA, et al. Recent resurgence of mumps in the United States. N Engl J Med 2008; 358:1580–1589.
- Otto W, Mankertz A, Santibanez S, et al. Ongoing outbreak of mumps affecting adolescents and young adults in Bavaria, Germany, August to October 2010. Euro Surveill. 2010;15(50):pii=19748. View on the Eurosurveillance website (external site) .
- Whelan J, van Binnendijk R, Greenland K, et al. Ongoing mumps outbreak in a student population with high vaccination coverage, Netherlands, 2010. Euro Surveill. 2010;15(17):pii=19554. View on the Eurosurveillance website (external site).
- Walker J, Huc S, Sinka K, Tissington A, Oates K. Ongoing outbreak of mumps infection in Oban, Scotland, November 2010 to January 2011. Euro Surveill. 2011;16(8):pii=19803. View on the Eurosurveillance website (external site).
New resources for Aboriginal communities
The Sexual Health and Blood-borne Virus Program (SHBBVP) has an updated range of sexual health and blood-borne virus resources to support health professionals working with Aboriginal communities.
The 6 new resources now available are:
- Chlamydia and Gonorrhoea (PDF 560KB)
- Hepatitis (PDF 620KB)
- HIV (PDF 693KB)
- Herpes (PDF 562KB)
- Syphilis (PDF 565KB)
- Sexually Transmitted Infections (PDF 748KB)
THE SHBBVP resources can be accessed and ordered at the online publication ordering (external site) website.
Forums focus on STIs and BBVs
Every three months the WA Department of Health's Sexual Health and Blood-borne Virus Program facilitates a forum on sexual health, sexually transmitted infections [STIs] and blood-borne viruses [BBVs].
The quarterly forums draw participants from a wide range of government, non-government and private organisations working in a variety of roles including health promotion, disease control, education, research and clinical roles.
The forums are designed to provide STI and BBV updates, as well as professional development and networking opportunities.
Dates for the remaining 2013 forums are:
- Wednesday, 5 June
- Wednesday, 4 September
- Wednesday, 4 December
Videoconferencing is available for regional sites. For more information and to download the agenda and presentations, visit the STI and BBV quarterly forum update (external site) website.
2012 Western Australian Vaccine Safety Surveillance Annual Report
The Western Australian Vaccine Safety Surveillance (WAVSS) system has been operating since March 2011. Reports of suspected adverse events following immunisation (AEFI) are accepted from health providers and the public. The WA Health Department monitors these reports to ensure anybody who experiences a significant AEFI receives appropriate clinical follow-up.
Significant AEFIs are rare and adverse events after immunisation are not necessarily caused by the vaccine. Factors such as medical history, diagnostic tests, and other medication given near the time of vaccination must be considered when determining the cause of an adverse event.
The following is a summary of AEFIs reported to WAVSS following a vaccination given in 2012.
- A total of 290 individual AEFI reports were received by WAVSS for persons vaccinated in 2012, compared with 323 in 2011, (Table 1) and 1,075 in 2010.
- The reports described a total of 566 possible adverse events (a vaccine recipient may describe multiple AEFI reactions). A total of 370 met established case definitions.
- The AEFI reports involved the administration of 473 vaccines, with a median number of 1 vaccine per person reported (range 1–5 vaccines per person).
- A comparison of the number of reports received by month vaccinated in 2012 to 2011 is seen in Figure 1 below. The months with the highest number of AEFI reports were March and April 2012, coinciding with the influenza vaccination program launch and roll-out of more than 340,000 doses of influenza vaccine. The reactions reported in these months are seen mainly in adults aged 18 years and over.
- Trivalent influenza vaccine was administered in 24% (70) of the AEFI reports—either singularly or in combination with other vaccines—compared with 21% (67/323) in 2011 and 89% (795/1075) of reports in 2010.
- Of all AEFI reports, 45% (130) were reported in children aged less than 5 years, compared with 42% (135/323) in 2011 and 78% (839/1075) in 2010. In 2012, more than 750,000 doses of National Immunisation Program childhood vaccines were distributed in Western Australia.
- Healthcare providers made 74% of the reports.
- Fax was used to report 42% of cases, 37% were received online, 14% by phone and 8% by regular post.
- Further clinical evaluation was recommended for 22 cases.
Table 1 – Characteristics of adverse events following immunisation reported to WAVSS, by year of vaccination, 2011 vs 2012
Total reports received
Age: <5 years
Reporter type: Health provider
Reported by: Fax
Reports admitted to hospital
Figure 1 – Reports of adverse events following immunisation, Western Australia, 2011-2012, by month of vaccination.
An adverse event following immunisation can be reported to WAVVS:
- online (external site)
- by telephone: (08) 9321 1312 (between 8.30am and 4.30pm)
- by completing a WAVSS reporting form and returning it by:
- Fax: (08) 9426 9408
- Post: Central Immunisation Clinic, PO Box 8172, Perth Business Centre WA 6849.