Welcome and Day 1 Recap

Stanley Plotkin, MDChairman

Plenary Session – Regional Reports

Regional AnalysisRegional AnalysisGroup 1Group 1

Estonia – Kuulo KutsarLithuania – Vytautas Usonis

Russia – Natalia Kurova, Leyla Namozova-Baranova, Galina Tseneva

Ukraine – Fedir Lapiy

Regional AnalysisRegional AnalysisEstonia, Lithuania, Russia, UkraineEstonia, Lithuania, Russia, Ukraine

(V.Usonis)

Surveillance SystemSurveillance System

Obligatory notification through National Surveillance system in all RegionExcept Ukraine, Sentinelle-like network available if needed– In Estonia, Lithuania Sentinelle established for Flu available– In Russia, Pediatricians network available various diseases

Standard Pertussis case definition CDC/ WHO based globally available– “WHO-like” for Russia > 2 weeks of cough– In Ukraine, no standard definition of "suspicious", "probable"

and "confirmed" cases of Pertussis

DiagnosisDiagnosis

Clinical diagnosis generally confirmed by laboratory – Laboratory diagnosis in 20% cases only in Ukraine– Mainly Culture prescribed– Serology and PCR available but expensive (private) – No PCR but capacities exists in Estonia, Lithuania

No National Reference appointed

Pertussis morbidity level in Russia Pertussis morbidity level in Russia (St. Petersburg) (St. Petersburg)

10

23.518.8 16.9

20.816.3

26.632.6

13.99.4

18.4 19.2 15.220.2

8.33.8

8.7 7.73.2 5.7 5.7 2.5 2.8

31.5

70.4

56

74.7 77.5

50.3

90.1

143.2

56.2

39.1

78.9

57.5

71.5 71.1

27.2

15.2

29.4 29.1

15.4

2922

8.2914.9

0

20

40

60

80

100

120

140

160

1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

per 1

00 0

00 p

eopl

e

0

10

20

30

40

50

60

70

80

90

100 %

Russia St.Petersburg vaccine coverage

Current researchCurrent researchAntibodies levels in children in St.PetersburgAntibodies levels in children in St.Petersburg

26.3

31.5

42.2

39.3

35.7

25

32

46

22

2-3 years 5-6 years 8-10 years

o low high

Epidemiology (Ukraine)Epidemiology (Ukraine)

morbidity in the last decade ranges from 2.3 to 13.3 per 100 thousand population; 1 to 5 deaths occur from Pertussis annuallythe average annual incidence rate for the last 5 years in different age groups:– 0-2 years - 64.7 per 100 thousand, it is 2.8 times

higher than the incidence rate among children from 3 to 6,

– It is 7.6 times higher than in children 7-14, – It is 18.5 times higher than in entire population

Epidemiology (Ukraine)Epidemiology (Ukraine)

The highest Pertussis morbidity in children population from 0 to14 years group is observed in (per 100 thousand child population)– Zaporizhzhya - 108.3 – Chernigov - 79.0 – Kharkiv - 51.1 – Odessa - 50.2– Kiev - 76.40.

2009 data / year

Current Immunization ProgramCurrent Immunization Program

Primary immunization– Primary vaccination at 3, 4, 5 by DTwP UA, RU– Primary vaccination at 2, 4, 6 by DTaP LT, ES– Booster at 18 months

• DTaP in Ukraine, Estonia, Lithuania• DTwP in Russia (DTaP available in private)

Estonia and Lithuania has DTaP pre-school boostNo adolescent and Adult pertussis immunization in the Region

Obstacles to ImmunizationObstacles to Immunization

Antivaccination lobbyConformers of medical community and general population regarding vaccine safetyDelay of vaccination in 1 year of age by children neurologist due to the lack of knowledge about Pertussis vaccine (UA) Lack of data on the prevalence of Pertussis among adolescents and adultsTdap vaccine still not widely available or approved

Current researchCurrent research

Not studies conducted in UkraineLow capacities available for research in EstoniaProject initiative on-going in LithuaniaStudies on-going in Russia : St Pertersburg, Moscow ..

GPI RecommendationsGPI Recommendations

Pre-school– Under discussion in Ukraine, Russia– Regional immunization program in Russia– Unmeet needs demonstrated in Russia with recent data available in

childrenAdolescents– No Adolescent program in the Region

Healthcare workers– No current recommendations

Adults– No current recommendations

Cocoon vaccination– Implementation feasibility discussed for Russia, provided vaccine

and recommendation available (Pediatric centers)

SummarySummary

Pertussis is a disease with obligatory notification, however the burden of pertussis is underestimatedThere are national criteriae for the diagnosis of pertussisPCR capacities are available but not implemented yetThere are high coverage levels with Pa vaccines in Lithuania and EstoniaThere are still no Pa containing vaccines available for adolescents and adults vaccinationKnowledge of vaccination for Adolescent and Adult must be enhanced

Regional AnalysisRegional AnalysisGroup 2Group 2

Ivory Coast – Flore Amon-Tanoh-DickJordan – Samir Faouri

Lebanon – Ghassan DbaiboSaudi Arabia – Haysam Tufenkeji, Kanan Balkhy

South Africa – Stephen PondeTunisia – Amel Kechrid

SurveillanceSurveillanceJordan. Pertussis notifiable report each month. Many GPs do not notify. Hospital cases treated as ‘pertussis-like’, as no definite diagnosisSouth Africa. Notifiable, but not mandatory. Lebanon. Passive surveillance system. Diagnosis mostly clinical. Law to report all pertussis,– But how compliant? – How well do physicians recognise pertussis?

Saudi Arabia. Diagnosis mainly clinical. Official figures vastly underestimate true prevalence. National reporting needed. Can form part of wider surveillance programme (Meningococcal etc). Tunisia: NoneUnder-reporting in all countries– Often older cases only detected from an index case

Often a split between private and public sector (South Africa, Lebanon)

Laboratory FacilitiesLaboratory FacilitiesPCR possible in many countries, but primers are expensive ($3000 for 100 samples) – Who pays? – PCR often done only by private institutions (Jordan, Lebanon).– PCR available, but primers not bought (Saudi Arabia)– Need to convince fundholders.

Culture. Often available, but not requested frequently. Samples taken incorrectly, or arrive too late (Saudi Arabia) Real time PCR and culture available in South Africa. The National Institute for Communicable Diseases (NICD) is the reference lab. Also private labs and government central lab. Tunisia struggled to get positive samples from culture and PCR– now improved with help from Institute Pasteur.Seroprevalence. Not done in most countries

Educational InitiativesEducational Initiatives

Jordan. GPs need educating that pertussis is still a problem.Saudi Arabia. Education initiatives important.South Africa. Outbreak last year increased awareness and interest.Publishing of adolescent vaccination schedules can be helpful

Vaccine CoverageVaccine CoverageIvory Coast. 50%-90% DTP3 coverage, depending on region. 6, 10, 14 week schedule. 5 year booster. Vaccine free for first 9 monthsSouth Africa. 90% primary series coverage. Combination vaccines used , with a sanofi pentavalent vaccine with acellular pertussis used at 6 weeks. Private sector does both, pentavalent and hexavalent.Jordan. Pentavalent (IPV hepatitis). 3 doses. 60, 90, 120 days. At 6-7 years of age, dT is given. Lebanon. Coverage is good in some parts of country, and not in others. Health ministry is working hard to increase coverage, part of the WHO Iniative.Saudi Arabia. Mixture of acellular and whole cell vaccines. Vaccination at 2,4,6 months of age. 70% ministry of health, 30% private. Government vaccines are free. ID cards issued to 1yr olds, but only if vaccine coverage is good. Tunisia. Whole cell vaccine, good infant coverage. No vaccination after 18 months.

Ongoing ResearchOngoing Research

Ivory Coast. Proposed project, supported by Pasteur Institute, investigating B pertussis prevalence in respiratory tract of children. And to monitor the effectiveness of the vaccine. Lebanon. Research on surveillance system across the country. Eg pneumococcus. Funding required for these studiesSouth Africa have 5 or 6 institutions capable of carrying out research programmes. Respiratory pathogens unit, studying a cohort since 1996. So far concentrated on pneumococcus etc, but could expand to pertussis. No adolescent of adult program.

Implementation of cocoonImplementation of cocoon

New parents likely to do alot to protect their new bornFunding is difficult. May be of interest in private markets– Eg in South Africa, likely that families with health care

insurance, or independent ability to pay, would be very interested. Likely to cost around €18 per dose.

Difficult to vaccinate all contacts, but if you vaccinate parents, grandparents and siblings, you may have covered 75% of exposure.Implementing the Cocoon strategy may be possible in Saudi Arabia, particularly for military personnel.

Healthcare WorkersHealthcare Workers

Should be strongly considered, particular those working with infants.Medical workers, often have low uptake. Eg Only 15% uptake for influenzaStronger language by CDC and WHO would make it easier to implement heathcare vaccination locally.Heathcare workers who work with infants and young children really have a duty of care to get vaccinated.Stronger policies could include vaccination requirements to enter employment in heathcare settings.

Mobile and Temporary PopulationsMobile and Temporary Populations

Many countries have mobile and temporary populations which (potentially) have not and will not receive adequate vaccination coverage– Eg. Philippino workers in Jordan– Healthcare workers in Saudi Arabia

Next StepsNext Steps

Jordan. Better diagnostic facilities (introducing PCR). Valuable for surveillance, diagnosis and raising awareness among GPs. Add acellular for 1st year of life and booster. dT -> dTP for booster. Lebanon. Set up reference lab. Increase coverage in children, and add pre-adolescent booster.Tunisia. Obtain epidemiological data using PCR.Ivory Coast. Research program with Institute Pasteur.Saudi Arabia. Introduce PCR and do seroprevalence study. Emphasise preschool boosters.South Africa. Seroprevalence study (Juno Thomas).

Regional AnalysisRegional AnalysisGroup 3Group 3

Czech Republic – Roman Chlibek, Roman PrymulaHungary – Marta Melles, Zsofia Meszner

Poland – Pawel StefanoffSlovakia – Maria Avdicova,

Slovenia – Marta Vitek

Case definitionsCase definitions

Clinical, epidemiological, laboratory criteria used since 2005– General agreement– However, needs detailed checking that information

compiled on the database is accurate (definition of cases variable) and resource not available generally

– Serology in Poland but one titre can be used to define a case

– PCR used everywhere but cost issues– Culture rarely done (reference lab)

Surveillance SystemSurveillance System

Reporting only happens where there is an index of suspicion of pertussis– Very few cases of pertussis reported in Poland but

believe that the incidence is much higher– In Slovenia, incidence in <1 year remained high

even when rate very low during the 1990s –paediatricians are aware of pertussis and report it

– 9/100,000 highest incidence in Poland; however, during epidemic in Slovenia was 35/100,000

– Surveillance easier in smaller countries?

Can surveillance be improved?Can surveillance be improved?

Poland: need to be aware that sentinel surveillance never reflects real lifeCzech: would be interesting to compare serology with epidemiology Hungary: work with perinatal society to survey children admitted with RSV; similar study with pertussis would be easy (except need to do PCR and nasopharyngeal swabs,,,,)Can run sentinel surveillance – easier to collate data but can it be extrapolated? Use hospital data only? But is this accurate enough?

EpidemiologyEpidemiology

Slovenia: article from 2008, similar picture as elsewhere. Low in 1990s and then increased. PCR used since 2005, could this be related to increase in incidence? Real-time PCR being introduced now

Slovakia: age-specific incidence similar to other countries; case numbers increased since 2005 but more dramatic since 2007. 2009 saw 288 cases characterized by “mild” course

Epidemiology (cont)Epidemiology (cont)

Czech Republic : Age-specific incidence as seen in other countries. Is change from wcP to acP responsible for increase in incidence ? Might be related to use of local vaccine derived from B. pertussis strain circulating in local area. GPs still don’t recognize pertussis as an adult disease

Epidemiology (cont)Epidemiology (cont)

Poland: different strains that need to be monitored, but logistical considerations (e.g. media available in hospitals and transport costs); also pertussis seen as a paed condition in Poland, no hospitalization in adultsIn Hungary, high pre-term rate believed to be related to low vaccination coverage. 40,000 dite-forte vaccines used. Pre-term rate higher in gipsy or underprivileged population – cocoon should focus here but will be difficult.

Current Infant Immunization ProgramCurrent Infant Immunization Program

Infant vaccination:– All countries implement high coverage with infant

vaccination– Potential to start earlier (at 2 months) in Czech

Republic, need to move BCG immunization (BCG reaction due to HepB component)

PrePre--school boosterschool booster

In some countries, some vaccines only licensed up to 3 years of age, with a gap in availability up to 7 years of ageFear of adverse reactions so dTap preferred in GermanyAvailability of licensed vaccines to be reviewed and supporting data to be made available

AdolescentAdolescent

Working well in Czech, may lower age of administration to 9 yearsSlovenia: booster at age 8 (DP changed to DTP) instead of pre-school / adolescent (final P vaccination); DT administered again at age 16Hungary (infant plus pre-school at age 6 in schools or at GP, plus adolescent) Slovakia: as Hungary, planning adolescent boosterPoland: adolescent under discussion (perhaps age 14? Last tetanus given at 18 years)

Adult vaccinationAdult vaccination

Adult universal programme: very challenging as even flu coverage is difficult; perhaps more interest in pertussis if seen as a serious diseaseThe already accepted tetanus vaccine could be replaced by dTapDistrust of government recommendations (e.g. Flu)Challenge is to communicate need for vaccination; challenge to communicate via media (celebs as public “opinion leaders”)

Implementation of cocoonImplementation of cocoon

Czech Republic Cocoon can be recommended to authorities ; perhaps will depend on funding, possible private market for some families who will pay; need local Czech data to support the suggestionPoland: Cocoon feasible with good communication including “prevention is better than cure” message to physicians and to general public (particularly parents will push for vaccine)

Implementation of cocoon (cont)Implementation of cocoon (cont)Hungary: how to immunise mothers if 50% of pregnancies unplanned ; easier to implement though as family are motivated; where couples planning pregnancy (usually educated classes), good opportunity when checking rubella status etcSlovenia: Cocoon should be recommended

Healthcare WorkersHealthcare Workers

Should be considered, particularly starting with neonatal unitsCommunication can be combined with the cocoon strategySlovenia: recommended particularly in HCW who deal with children; discussion around who should pay! Liaison with occupational healthHungary: employers responsible for vaccination of employees

Obstacles to ImmunizationObstacles to Immunization

Need good nursing support – vaccine administration and also for nasopharyngeal swabsPoor understanding among lay population of the value of vaccinationYoung parents more of an issue in SlovakiaGPs refuse to undertake vaccination in some countries (e.g. Czech); may only achieve 30% coverage. Similar issue seen even with tetanus. Recall systems not widespread – often rely on workplace initiatives.

Health economicsHealth economics

Need health economic arguments to show cost benefit of pertussis vaccination programmes compared to cost of pertussis treatment (X-rays, pulmonology visits, diagnostics, drug treatment….)Has HE data been provided for previous vaccination programmes? Was required for HPV. In Poland, don’t accept data from other countriesWhatever is possible is not always feasible

Regional AnalysisRegional AnalysisGroup 4Group 4

Bulgaria – Nadezhda VladimirovaCroatia – Marija Radonic

Montenegro – Dragan LausevicRomania – Maria Damian, Vasilica Ungureanu

Serbia – Vladimir PetrovicTurkey – Zafer Kurugol

Vaccination ScheduleVaccination Schedule

Bulgaria Croatia Montenegro Romania Serbia Turkey

Primary Schedule

2, 4, 6, 16 months (acP)

2, 4, 6, 12 months(acP)

2, 4, 5, 18/24 months(wcP)

2, 4, 6, 12 months(acP)

2, 3/4, 5/6, 24 months(acP)

2, 4, 6, 18 months(acP)

Booster 6 Years 3 years No 4 years No 6 years

SurveillanceSurveillance

Bulgaria Croatia Montenegro Romania Serbia Turkey

- Highest morbidity in < 1 year- Single cases in ados and adults

-Most cases in ados-a few cases in adults

- Last 10 years, 16 cases lab confirmed, 90% non immunized- No cases in > 14 years

-2008: 266 suspected cases, 51 laboratory confirmed-2009: 59 suspected cases, 6 lab confirmed

-no active surveillance

Lab DiagnosisLab Diagnosis

Bulgaria Croatia Montenegro Romania Serbia TurkeyLaboratory diagnosis

Paid by patients

needed expensive Culture and serology

PCR

Deaths?Deaths?

Bulgaria Croatia Montenegro Romania Serbia Turkey2 deaths in 2009

None in 2009, 1 in 2008

No No No ?

ConclusionsConclusions

WHO recommendations to follow, particularly for monitoring epi dataLaboratory diagnosis: heterogeneous availability of PCR in countries, expensive, sometimes paid by patientSurveillance in adolescents and adults is necessary Elderly is also an age group where pertussis disease is present (to take into account in the surveillance)Cocoon strategy seems difficult to implement

Plenary Session – Regional Endorsement of GPI Recommendations

Discussion pointsDiscussion points

Surveillance– Monitoring of childhood disease– Regional surveillance– Reference laboratory and PCR requirements– Surveillance of adolescents and adults– Tracking and evolution of bacterial strains

Diagnosis– Clinical definition of pertussis– PCR availability (including primers)– Serology

GPI immunization strategy GPI immunization strategy recommendationsrecommendations

Reinforce and/or improve current infant and toddler immunization strategiesFourth or fifth dose for all preschool children (4–6 years of age) Cocoon Strategy - selective immunization of new mothers, and family and close contacts of newbornsSelective immunization of healthcare workers Selective immunization of childcare workers Universal immunization of adolescents Universal immunization of adults

Obstacles to immunizationObstacles to immunization

Need for data, evidence and argumentation– Need for health economic data

Public health policyFundingReaching target populations

Practicalities of implementation of Practicalities of implementation of immunization strategiesimmunization strategies

FundingIdentification and targeting of the population– Tracking of mobile populations (seasonal workers,

gipsy populations...)Location of vaccination (eg GP office, hospitals

maternity unit, schools)Awareness and communication– Physicians– General public

Vaccine uptake and surveillance

Break

Plenary Session – Regional Endorsement of GPI Recommendations

(continued)

Regional Summary

Stanley Plotkin, MDChairman

Wrap-up and Close

Stanley Plotkin, MDChairman

Thank you for coming!