Delivering a Healthy WA
Disease WAtch

May 2014, Volume 18, issue 1

Full issue

Measles cases linked to Philippines outbreak

Over the past decade, the number of measles cases reported globally has decreased significantly, following a push to eliminate this infection by increasing immunisation rates. There are, however, still regions of the world, such as Asia and Africa, where measles is endemic and where large outbreaks occur.

Although Australia is one of 10 countries that have formally declared elimination of measles, cases continue to occur, particularly in returning unvaccinated travellers and, subsequently, their susceptible contacts. The follow-up of each measles case requires considerable public health resources.

In Western Australia, the annual number of measles cases has remained low, with 6 to 17 notifications per year from 2008 to 2013 (Figure 1).The majority of cases each year have been acquired overseas with the exception of 2010, when there was a local outbreak of measles mostly among healthcare workers following an importation. Of 42 overseas-acquired cases in the period 2008-2013, 69% were acquired in Southeast Asia, mostly from Indonesia and Thailand.

In the first quarter of 2014 alone, 17 measles cases have been notified, equivalent to the total number of cases in 2012. Cases were aged from 7 to 40 years old (median age 26 years) and were predominantly male (82%).Twelve of the cases (71%) were acquired overseas, 4 were locally acquired and one was acquired in the Northern Territory. All the imported cases were acquired in Southeast Asia, with the majority acquired in the Philippines (8) reflecting a widespread outbreak in that country, followed by Indonesia (3) and Singapore (1). Prior to 2014, only one measles case had been imported from the Philippines, in 2011.

Of the 17 measles cases, only 3 cases had documented evidence of having received one dose of measles-containing vaccine, the remaining cases either did not know their vaccination status (8) or were not vaccinated (6) – 3 of the unvaccinated cases were siblings whose parents were vaccine refusers.

This highlights the need for general practitioners to ensure that people planning to travel be encouraged to be appropriately vaccinated prior to departure. Children or adults born during or since 1966, who do not have evidence of measles infection or documented evidence of having received two doses of a measles-containing vaccine, are considered to be susceptible to measles and should be strongly encouraged to be vaccinated appropriately. Adults born before 1966 are assumed to have natural immunity.

Measles-containing vaccines are safe, very effective and provide lifelong protection following 2 doses of vaccine. The current recommendations for measles vaccination are shown in the table below.

Table 1 – Recommendations for measles vaccination
  Schedule point (age) Vaccine
Children
(from July 2013)
12 months
MMR
18 months * MMR-V
Adults   MMR-2 doses, at least 4 weeks apart

MMR = trivalent measles-mumps-rubella vaccine
MMR-V = quadrivalent measles-mumps-rubella-varicella vaccine
* Prior to July 2013, children were recommended a second dose of MMR at 4 years

Figure 1 - Measles notifications by place of acquisition, year and quarter, WA, 2008 to March 2014
Figure 1 – Measles notifications by place of acquisition, year and quarter, WA, 2008 to March 2014

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Avian influenza A(H7N9) virus in China

Avian influenza viruses normally circulate among birds. Human infections with these viruses are rare and occur mostly after people have been in contact with infected birds.

The first human case infected with avian influenza A(H7N9) virus was reported in China in February 2013. Genetically similar influenza A(H7N9) viruses have been detected in infected humans and pigeon and poultry samples collected at live animal markets in Shanghai. Unlike highly pathogenic avian influenza strains, such as influenza A(H5N1), H7N9 is a low-pathogenic strain that is difficult to detect in poultry and other birds because it causes little or no signs of disease.

Sequence analysis indicates the virus has properties that facilitate infection of mammalian cells. Therefore, although sustained person-to-person transmission of H7N9 influenza virus has not been reported to date, the potential for such transmission exists and further close monitoring and investigation is required.

Non-sustained person-to-person spread of other avian influenza viruses is thought to have occurred in the past, most notably with avian influenza A (H5N1) viruses. Almost all of these cases occurred during unprotected, close and prolonged contact between a caregiver (mostly blood-related family members) and a very ill patient.

Of concern is the pandemic potential of this H7N9 virus, which might either adapt to enable efficient transmission among humans, or reassort gene segments with human influenza viruses during the co-infection of a single host, resulting in a novel virus that would be transmissible from person to person, such as occurred with the H1N1(2009) pandemic strain.

Current situation

As of 14 April 2014, the World Health Organization has reported 420 human infections, including 122 deaths, with onset since February 2013. There are still no signs of ongoing, efficient, or sustained human transmission of this virus. To date, all laboratory-confirmed human infections appear to have been acquired in mainland China – mostly in eastern provinces, in particular, Zhejiang, Jiangsu and Shanghai.

Avian influenza A(H7N9) infections in humans have been reported in Hong Kong (10 cases), Taiwan (2 cases) and Malaysia (1 case). All cases reported recent travel to China and most reported visits to live bird markets. The travel-related cases highlight the need to consider influenza A(H7N9) in human cases of severe acute respiratory illness with a history of recent travel to eastern China.

As there is no evidence of sustained person-to-person spread of H7N9 at this time, there has been no recommendation to restrict travel to China. However, travellers are advised to avoid poultry farms, live bird markets, or entering areas where poultry may be slaughtered, or contact with any surfaces that appear to be contaminated with faeces from poultry or other animals. Travellers should also wash their hands frequently with soap and water. Information for clinicians and laboratories can be found on the WA Health website.

Figure 1 – Epi-curve of avian influenza A(H7N9) cases and deaths by date of onset, as of 14 April 2014
Figure 1 – Epi-curve of avian influenza A(H7N9) cases and deaths by date of onset, as of 14 April 2014
Source: Provincial CDC (China), National China CDC, WHO, and news reports (external site)

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WA lifts uptake in antenatal influenza vaccination

Although the World Health Organization singles out pregnant women as the most important risk group for seasonal influenza vaccination and free influenza vaccine has been available to pregnant Australians since 2009, uptake has been poor.

In response to the low influenza vaccine uptake by pregnant women in WA in 2012, the WA Health Department focused on promoting the vaccine to pregnant women and their antenatal care providers in 2013. The department worked with one public maternity hospital (hospital A) to observe the impact on uptake of routinely offering the influenza vaccine at the time of antenatal care. It also worked with a group of private maternity hospitals (health service B) to examine the impact on uptake of mandatory documentation of antenatal influenza vaccination status. The department also studied the safety of antenatal influenza vaccine by surveying pregnant women who received an influenza vaccination in the 2013 season.

In December 2013, 831 randomly selected women – who were pregnant during the 2013 influenza vaccination season – were interviewed by telephone. Self-reported vaccination status was confirmed by medical record review. A total of 3,173 pregnant women (92.1%) who had agreed to post-vaccination follow-up were contacted by SMS or telephone. These women were asked whether they experienced any adverse events in the week following their vaccination.

In 2013, influenza vaccination uptake in WA pregnant women was 40.9%, a 60% increase on 2012 figures (25.6%). Pregnant women whose antenatal care providers advised them to have the influenza vaccine were 10.6 times more likely to be vaccinated. Women who received most of their antenatal care from a private obstetrician and had a post-graduate university education were also more likely to have been vaccinated.

A total of 11.7% of women self-reported a reaction to the influenza vaccine in 2013. The most commonly reported reaction was swelling or pain at the injection site (3.5%); 3.0% reported a headache, 1.9% reported fatigue, 2.0% reported fever, and 2.6% reported a cough or congestion. All other symptoms (e.g. rash, rigors, myalgia) were reported by fewer than 1% of women. No serious vaccine-related events were reported.

Antenatal influenza vaccine uptake is increasing and general practitioners play an important role in protecting pregnant women. Antenatal care providers in WA should inform pregnant mothers of the vaccine's excellent safety profile when routinely offering vaccination during the influenza vaccination season.

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Regional teams working to 'Close the Gap' in sexually transmitted infections

The Western Australian Aboriginal Sexual Health and Blood-borne Virus Strategy provides a framework for reducing sexually transmitted infection (STI) and blood-borne virus (BBV) transmission in Aboriginal people in Western Australia. Regional sexual health teams were established in 2004 in the Midwest, Pilbara, Kimberley and Goldfields regions to assist with implementing comprehensive STI and BBV control programs.

Improvements in STI and BBV control in Aboriginal people in WA over the past decade include:

  • acknowledgement by Aboriginal communities and state and national governments that the gap in STI and BBV roles between Aboriginal and non-Aboriginal people needs to be closed. This has been followed up with a significant investment of resources and political support towards STI and BBV control
  • improved workforce capacity through the provision of clinical guidelines and the establishment of monthly teleconferences and twice yearly face-to-face updates supported by the Sexual Health and Blood-borne Virus Program
  • improved availability of health promotion resources, school-based education resources and small grants to support regional teams
  • the routine provision of quarterly data, including laboratory testing data, by the Communicable Disease Control Directorate
  • improvements in laboratory diagnostic tests for chlamydia and gonorrhea that have improved their sensitivity and rendered them less affected by transport delays
  • improved partnership building through regional planning (although not consistent throughout all regions)
  • the creation of an enabling, evidence-based policy environment with the development of the Second WA Aboriginal STI and BBV Strategy 2010-2014
  • achievement of good control of syphilis, hepatitis B and C, and HIV, shown by stable or falling notification rates.

Despite these achievements, considerable disparities remain between Aboriginal and non-Aboriginal people in relation to STI and BBV control.

Epidemiological trends, 2003 to 2012

Over the past decade, chlamydia notifications for all West Australians have tripled. This is considered to be the result of improved sensitivity of diagnostic tests and increased transmission in the community. Although the number of notifications for non-Aboriginal people was consistently higher than for Aboriginal people, the chlamydia age-standardised rates (ASRs) in Aboriginal people was higher than in non-Aboriginal people. Notifications are increasing in both groups, but more rapidly in the non-Aboriginal group, hence a decrease in Aboriginal to non-Aboriginal ASR ratios between 2003 (16:1) and 2011 (4:1) (Figure 1).

Figure 1 – Age-standardised rate of chlamydia notifications by Aboriginality and Aboriginal:non-Aboriginal rate ratio, WA, 2003 to 2012
Figure 1 – Age-standardised rate of chlamydia notifications by Aboriginality and Aboriginal:non-Aboriginal rate ratio, WA, 2003 to 2012

Aboriginal people have consistently had higher gonorrhea notification rates than non-Aboriginal people. Although the Aboriginal to non-Aboriginal rate ratio has been decreasing since 2010, it remains very high (28:1 in 2012) and is due to notification rates increasing more rapidly in the non-Aboriginal group, rather than any significant gains being made in the Aboriginal population (Figure 2).

Figure 2 – Age-standardised rate of gonorrhoea notifications by Aboriginality and Aboriginal:non-Aboriginal rate ratio, WA, 2003 to 2012
Figure 2 – Age-standardised rate of gonorrhoea notifications by Aboriginality and Aboriginal:non-Aboriginal rate ratio, WA, 2003 to 2012

Aboriginal infectious syphilis rates have remained low and stable since 2010 following an outbreak in 2008 among Aboriginal people in the Pilbara (Figure 3). This outbreak was rapidly brought under control and by 2009 infectious syphilis notifications among Aboriginal people had returned to baseline low levels.

Figure 3 – Age-standardised rate of infectious syphilis notifications by Aboriginality and Aboriginal:non-Aboriginal rate ratio, WA, 2003 to 2012
Figure 3 – Age-standardised rate of infectious syphilis notifications by Aboriginality and Aboriginal:non-Aboriginal rate ratio, WA, 2003 to 2012

Aboriginal people have consistently had higher hepatitis C ASRs than non-Aboriginal people. The majority of hepatitis C cases among Aboriginal people were detected through routine voluntary blood-borne virus testing in correctional facilities. High rates of imprisonment and access to needle and syringe programs are significant barriers to hepatitis C control in Aboriginal populations. Hepatitis C treatment uptake is also poor among Aboriginal people.

View the public health publication The Epidemiology of Notifiable Sexually Transmitted Infections and Blood-Borne Viruses in Western Australia 2012 (PDF 1.27MB) for more detailed information.

Where to from here?

In late 2014, the Communicable Disease Control Directorate will host a statewide forum on Aboriginal sexual health and BBVs to mark the regional sexual health teams' tenth anniversary and start the development of the next WA Aboriginal Sexual Health and Blood-borne Virus Strategy due in 2015.

Aboriginal leaders, Aboriginal community-controlled health organisations and representatives from the departments of Health, Child Protection and Corrective Services will be invited to review the successes and challenges of the past 10 years and discuss ways of taking a collaborative approach for the coming decade in reducing STI and BBV infections in WA Aboriginal people.

Accessible primary heath care remains a central element to the public health response to STIs and BBVs in Aboriginal communities. Health literacy, hepatitis B and HPV vaccination, adult heath checks, STI and BBV testing and treatment, a skilled workforce and overcoming the stigma and discrimination associated with STIs and BBVs underpin CDCD's programs.

WA Health offers a range of resources and training opportunities to assist general practitioners, practice nurses and Aboriginal health workers working in Aboriginal sexual health and BBV control including:

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Bold new direction for 2014 chlamydia campaign

In the past year, the Sexual Health and Blood-borne Virus Program has undertaken a review of activities surrounding its annual chlamydia campaign and will take a new strategic approach during 2014 and beyond.

A renewed focus on Aboriginal communities outside the metropolitan area and the construction of a new campaign website are two exciting new developments planned for 2014.

Partnership with Mary G and renewed focus on Aboriginal communities

In response to high chlamydia notification rates for Aboriginal young people, particularly in regional and remote Western Australia, an exciting new partnership has been forged with NAIDOC Person of the Year and West Australian of the Year, Mark Bin Bakar, otherwise known as Mary G. Mary G, a strong advocate on the needs of WA's Aboriginal communities, will be the star of the 2014 Chlamydia Campaign which will use radio and online media to raise awareness of the importance of maintaining good sexual health.

New social media portal website

In today's ever-changing media landscape, the attention of young people – the most important demographic for WA chlamydia prevention – has shifted more and more from traditional outlets such as radio and newspapers, to online, digital and social media. To keep pace with these changes the chlamydia campaign's online presence is being completely restructured with its main website being rebuilt to act as a portal for innovative chlamydia prevention content. The new website will be built with interactivity and social media in mind and will be adaptive to future shifts in technology.

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Rising immunisation rates a win for regional WA

The percentage of children in regional WA who are fully immunised has increased over the past year to a level where immunisation rates in regional WA have now surpassed the national average (Figure 1).

In recent years, regional Public Health Units (PHUs) have prioritised immunisation and introduced a variety of strategies that have been successful in raising immunisation rates. Examples of these are:

  • conducting programs, in many of the regional PHUs, that involve monthly follow up of every family with a child who is overdue for immunisation
  • regional PHUs providing regular immunisation updates – one region provides a quarterly summary report to all immunisation providers that includes postcode level information on numbers of overdue children and allows comparison between different areas. Other regions run immunisation information days for providers
  • regional PHUs introducing more flexibility around immunisation provision, such as immunisation delivery by school health nurses, in after-school clinics and delivery of immunisations in a variety of settings, including the home.

Immunisation rates in the Perth metropolitan area remain approximately 2% below the national average (Figure 2). Coordinated strategies to prioritise and address low immunisation coverage in the metropolitan area are critical. As 81% of metropolitan overdue children received their most recent vaccination from a general practitioner (compared to 45% of children in regional areas), regular follow-up by general practices of children overdue for immunisation is essential to improve immunisation rates in the metropolitan area. Systematic recall of overdue children through appointment letters, telephone calls or SMS is strongly recommended.

Figure 1 - Rates of children fully immunised, regional WA
Figure 1 – Child immunisation, regional WA

Figure 2 -  Rates of children full immunised, metropolitan WA
Figure 2 – Child immunisation, metropolitan WA

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Community alliance helping to promote immunisation

The recent media coverage of the work of the Immunisation Alliance organisation has highlighted the important role that community groups can play in promoting immunisation to parents and the community.

Background

The Immunisation Alliance WA (IAWA) was launched in 2009 in recognition of effective community coalition models being used internationally for promoting immunisation.

In 2010, the IAWA, an Australian not-for-profit organisation, became an independent organisation incorporated in WA. The IAWA is made up of a number of representatives from community associations and interested individuals, with the purpose of improving the health of Western Australians through immunisation.

The role of the alliance

Members of the IAWA support the organisation's strategic direction and vision through:

  • working towards increasing public trust in immunisation
  • helping to eliminate myths associated with immunisation programs and vaccines
  • providing the public with factual information about immunisation
  • developing approaches to increase community support for immunisation programs.

Several projects have already been accomplished, including development of a range of immunisation posters targeting undecided parents, public information sessions and the development of an early childhood book on immunisation.

Providers of immunisation services are encouraged to view the IAWA website (external site) and refer parents to it for information on the benefits of immunisation.

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