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Volume 5 No 34; 26 August 2011

HPR Home | Archives | 2010 news

Measles cases in Europe: update to end-July 2011
Antenatal screening for infectious diseases in England: 2010 update

Measles cases in Europe: update to end-July 2011

In June, as part of an initiative to step up measles surveillance in Europe the European Centre for Disease Prevention and Prevention (ECDC) launched a monthly report, European monthly measles monitoring (EMMO) which includes timely updates on measles outbreaks and endemic transmission in Europe based on active surveillance reported from EU and EEA/EFTA countries [1].

In the second EMMO report for July 2011 an additional 5,000 new cases were confirmed across 30 reporting countries across Europe, bringing the total cases for the first seven months of 2011 to more than 26,000 [2]. France (14,040), Italy (4,000), Spain (2,407), Romania (2,072), and Germany (1,361) have reported the highest cumulative number of measles in 2011. The report warns that World Youth Day and other mass-gathering events in Europe during the summer months increase the risk of spreading measles in Europe and exportation of measles to other parts of the world. Those planning holidays or travelling to mass-gathering events in Europe during the summer should ensure they are protected against measles.

Confirmed measles cases in England and Wales

In England and Wales, 777 laboratory confirmed measles cases have been reported so far in 2011 to the end of July (table 1 and figure). One-hundred cases had onset in July compared to 133 in June and 176 in May, although the number for June is known to be an under-estimate as around 80 unvaccinated children with clinical measles associated with an outbreak in an anthroposophical school declined to be tested for measles infection. Outbreaks in schools and small family clusters are continuing to be reported in London (310 cases), while most of the recent cases in South East (207 cases) and South West (67 cases) are associated with schools attended by children of families known to oppose vaccination, with limited onward transmission to the wider community. Measles has been identified in a traveller community in London. This is likely to result in a spread in the wider traveller communities in coming months. As anticipated, there have also been a small number of cases linked to music festivals during the last two months [2,3]. Cases continue to be reported in unvaccinated individuals with more than 50% of cases in children and adolescents aged 5 to 19 years.

Table 1. Confirmed cases of measles by region and month of onset (England and Wales):
January-July 2011

Month	London	East Mids	East of England	North East	North West	South East	South West	West Mids	Wales	York & Humber	Total
Jan-11	7	1	-	-	2	10	9	1	-	1	31
Feb-11	6	-	1	-	1	17	1	2	-	4	32
Mar-11	40	5	2	-	10	35	8	6	-	31	137
Apr-11	64	-	3	2	12	47	13	14	-	13	168
May-11	81	2	11	2	7	44	13	2	8	6	176
Jun-11	53	1	8	5	4	28	20	7	6	1	133
July-11	59	1	5	-	-	26	3	1	5	-	100
Total to July 2011	310	10	30	9	36	207	67	33	19	56	777

Table 2. Number of confirmed cases of measles by region and age (England and Wales):
January-July 2011

Month	London	East Mids	East of England	North East	North West	South East	South West	West Mids	Wales	York & Humber	Total
Under 1 year	20	3	1	1	6	7	1	5	2	3	49
1-4 years	51	2	2	2	5	25	3	4	2	6	102
5-9 years	41	2	8	2	7	46	17	3	4	1	131
10-14 years	53	2	7	1	7	57	20	9	4	5	165
15-19 years	33	-	6	1	2	35	14	4	3	18	116
20-24 years	18	-	0	-	6	8	4	5	2	15	58
25-29 years	31	-	1	1	2	5	5	-	1	1	47
30-34 years	24	-	1	1	1	6	1	2	-	-	36
≥35 years	39	1	4	-	-	18	2	1	1	7	73
Total, all age groups	310	10	30	9	36	207	67	33	19	56	777

Number of confirmed measles cases by month of onset (England and Wales):
January 2006 to July 2011

References

1. European Centre for Disease Prevention and Control (ECDC). European measles monthly monitoring (EMMO), June 2011. Stockholm: ECDC; 2011. Available from: http://ecdc.europa.eu/en/publications/Publications/2011_June_measles_montly.pdf.

2. European Centre for Disease Prevention and Control (ECDC). European measles monthly monitoring (EMMO), July 2011. Stockholm: ECDC; 2011. Available from: http://www.ecdc.europa.eu/en/publications/Publications/2011_July_Measles_Monthly_Monitoring.pdf

3. HPA. Measles cases in Europe: update to end-June11 HPR 5(29): news. Available at: http://www.hpa.org.uk/hpr/archives/2011/news2911.htm#msls.

4. HPA. Frequently asked questions (FAQs) about measles. June 2011. Available at: http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1296687918015.

5. NaTHNaC: http://www.nathnac.org/pro/index.htm.

Antenatal screening for infectious diseases in England: 2010 update

This article presents an overview of the trends in uptake of screening for hepatitis B, HIV, syphilis and rubella susceptibility during the period 2006 to 2010. Key points are that:

the uptake of antenatal screening for all four infections has increased over the period 2006-2010: from 94% to 96% for hepatitis B; 91% to 96% for HIV; 94% to 97% for syphilis; and 95% to 97% for rubella susceptibility;
the 90% screening uptake target for HIV was met by all regions in 2008 and high uptake has been sustained since, although further vigilance is essential to prevent mother-to-child transmission;
there has been an increase in rubella susceptibility from 2.9% in 2006 to 4.5% in 2010;
the proportion of women who tested positive for hepatitis B, HIV and syphilis has remained relatively stable over the past five years;
where information was reported, just under half of hepatitis B cases and over one third of HIV cases identified through antenatal screening in 2010 were new diagnoses.

Background

As part of the NHS Infectious Diseases in Pregnancy Screening (IDPS) Programme, all women in England are offered screening for hepatitis B, HIV, syphilis infection and rubella susceptibility. Screening aims to ensure that women with hepatitis B, HIV and syphilis are identified so that strategies can be put in place to prevent mother-to-child transmission of these conditions and to benefit the woman's own health. Screening also aims to identify women who are susceptible to rubella, and for whom postnatal MMR vaccination could protect future pregnancies.

In September 2010 the new IDPS Programme Standards and Laboratory Handbook were published, which clearly set out the UK National Screening Committee's expectations around the local delivery and quality of the programme. The new standards can be found on the IDPS website [1].

The 2003 Department of Health's Screening for Infectious Diseases in Pregnancy Standards set a target of 90% for the uptake of antenatal screening for HIV [2]. This was the only infection with such a target until the 2010 revised Standards retained this 90% uptake target as a reference point for all four infections.

In 2009 the UK National Screening Committee agreed on a set of Key Performance Indicators (KPIs) as part of a strategy for the collation and return of Quality Assurance and performance data [3]. Two of these indicators are related to infectious diseases screening in pregnancy: HIV coverage and timely referral of hepatitis B positive women for specialist assessment. The introduction of these KPIs along with the implementation of the 2010 screening standards is expected to greatly improve the quality of screening monitoring data over the coming years.

Data collection and analysis

In 2004, the National Antenatal Infections Screening Monitoring (NAISM) Programme began monitoring the uptake and test results of antenatal screening for the four infections in England. Information is requested at maternity unit or trust level on the number of pregnant women attending for antenatal care, the number previously diagnosed with hepatitis B and HIV, the number screened for each of the four infections, and the results of the screening tests.

There has been great improvement in the quality of data collected since 2004; however, problems still remain, particularly in relation to the number of women booking for antenatal care. Data therefore need to be interpreted with care. Limitations to data quality have been detailed in previous reports [4], and the data analysis methodology can be found on the NAISM website: http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1245581538007.

Reported uptake of antenatal screening

Uptake of antenatal screening is calculated as the proportion of women booked for antenatal care, as reported by maternity services, who have a screening test. If maternity unit booking data are not available, a proxy is often used for bookings, such as the number of laboratory tests for syphilis or rubella under the assumption that all booked women are screened for these infections. The use of these proxy data could lead to an over-estimate of the uptake of screening. As part of the data processing, some data exclusions and adjustments are made, mainly when the denominator, numerator or both are not available, or when the screening uptake for a particular infection is over 100%.

Screening uptake increased for all four infections from 2006 to 2010 (figure 1), with the greatest increase in screening seen for HIV, from 91% (571,262/627,253) to 96% (657,479/684,835). The 90% uptake target for HIV was met for the first time in 2006 at a national level and all regions achieved the target in 2008. Even though uptake is now above the national target, vigilance is still paramount in order to continue the prevention of mother-to-child transmission of HIV.

The screening uptake between 2006 and 2010 for hepatitis B increased from 94% (546,377/582,989) to 96% (672,800/697,461), for syphilis from 94% (531,680/564,622) to 97% (664,053/687,095) and for rubella susceptibility from 95% (528,869/558,390) to 97% (659,849/683,349). The drop in screening uptake in 2009 for all infections is likely not a true decrease but is rather due to an improvement in data quality, with more maternity units providing booking data rather than relying on numbers of laboratory tests as a proxy for bookings.

Figure 1. National reported uptake of antenatal screening by infection in England: 2006-2010

Proportion of pregnant women screening positive or susceptible

The proportion of women who undertook screening and tested positive for hepatitis B, HIV, and syphilis remained relatively stable from 2006-2010 (figure 2). There was regional variation with the highest positivity rates in London for each infection. Nationally in 2010, 0.43% (3,140/723,978) of pregnant women screened positive for hepatitis B, 0.17% (1,167/705,825) for HIV and 0.15% (1,083/710,127) for syphilis (see table).

Over the five year period, there was a significant increase in the proportion of women screened susceptible to rubella infection (see figure 2). In 2010, 4.5% (31,057/696,137) of women screened were susceptible to rubella, compared to 2.9% (17,304/598,243) in 2006. However, this increase should be interpreted with caution due to the variation in laboratory testing protocols and cut-off values to determine susceptibility.

Figure 2. Proportion of pregnant women screening positive for hepatitis B, HIV and syphilis and susceptible to rubella infection in England: 2006-2010*

Women previously diagnosed with hepatitis B or HIV

The 2010 IDPS Programme Standards and Laboratory Handbook [1], which came into effect in April 2011, states that there may be no need for initial screening if the woman is known to be hepatitis B or HIV positive, where this is documented and known to the healthcare professional. Prior to these standards, in 2009 and 2010, data were collected on the number of women previously diagnosed, and of these, how many were retested as part of the screening programme in the current pregnancy. The proportion of women newly diagnosed with hepatitis B or HIV and the total proportion of women positive for these infections were then calculated (see table). From 2011, data are being collected on the number of women not screened as a result of prior diagnosis.

Some maternity units could not supply information on previously diagnosed women and therefore these data were excluded from the newly diagnosed proportion.

For diagnoses where all information was available, in 2010, 49% (1,309/2,678) of diagnosed hepatitis B infected women and 36% (366/1,019) of diagnosed HIV-positive women were identified through antenatal screening in the current pregnancy. These are pregnant women who would not have been diagnosed in the absence of routine screening. The screening programme aims to ensure that both newly and previously diagnosed women are referred for specialist care to reduce the risk of mother-to-child transmission.

Proportion of pregnant women screening positive for hepatitis B, HIV or syphilis or susceptible to rubella infection in England: 2010

		Hepatitis B		HIV			Syphilis		Rubella susceptibility
	Tests	% positive*	% newly diagnosed**	Tests	% positive*	% newly diagnosed**	Tests	% positive***	Tests	% susceptible
East Midlands	51203	0.28	0.14	48323	0.18	0.07	50358	0.15	42980	3.09
East of England	76157	0.29	0.16	75715	0.15	0.08	75239	0.06	76809	3.43
London	149805	0.99	0.47	144681	0.32	0.12	149475	0.35	138629	4.79
North East	32182	0.25	0.19	30876	0.14	0.08	31192	0.12	32525	5.84
North West	85883	0.28	0.18	84972	0.07	0.03	80132	0.07	79878	3.71
South East	113230	0.28	0.13	111817	0.13	0.03	112169	0.08	113320	5.03
South West	64234	0.18	0.11	63867	0.05	0.01	64549	0.08	63155	3.39
West Midlands	81325	0.39	0.10	78113	0.17	0.04	78563	0.17	80669	4.24
Yorkshire & Humber	69959	0.33	0.14	67461	0.13	0.02	68450	0.10	68172	6.34
National	723978	0.43	0.20	705924	0.17	0.06	710127	0.15	696137	4.46

Copies of the most recent annual report are available electronically at: http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1245581538007.

References

1. UK National Screening Committee. Infectious Diseases in Pregnancy Screening Programme Standards and Laboratory Handbook, 2010. Available at: http://infectiousdiseases.screening.nhs.uk/standards.

2. Department of Health. Screening for infectious diseases in pregnancy: Standards to support the UK antenatal screening programme, 2003. Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance
/DH_4050934.

3. UK National Screening Committee. Key Performance Indicators for Screening, 2010-11 (version 1.6). Available at: http://www.screening.nhs.uk/kpi.

4. UK National Screening Committee. Infectious Diseases in Pregnancy Screening Programme 2008-2009 Annual Report, 2010. Available at: http://infectiousdiseases.screening.nhs.uk/publications.