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Volume 5 No 36; 9 September 2011

DH seasonal flu vaccine uptake reports 2010/11

Overall uptake of seasonal influenza vaccine during the 2010/11 season increased slightly in England - compared to 2009/10 - according to an HPA report published by the Department of Health [1].

Population groups eligible to receive the trivalent seasonal vaccine currently include all individuals aged 65 years or more, all pregnant women (for the first time), and those in a clinical risk group aged between six months and 65 years. In 2010/11, the national mean uptake level achieved among the over-65's showed a small increase (72.8% compared with 72.4% in 2009/10) but remained below the 75% target recommended by the WHO.

Vaccine uptake varies widely between regions of the country, and between disease groups and age groups. Geographical variations remain the most marked - the highest rates of uptake among the over-65s in 2010/11 were in the West Midlands and South East of England; whereas the lowest were in the London area.

At-risk groups

The report notes that, overall, the percentage of people vaccinated in each risk group had only marginally improved compared with the previous survey years. Almost 50% of those aged six months to under 65 years of age in an at-risk group remained unvaccinated.

Of the at-risk categories, those with diabetes showed the highest uptake (68.4%) while coverage among other groups, such as those with chronic degenerative neurological disease and chronic liver disease, was as low as 40%.

Pregnant women

Uptake levels among pregnant women were low in the early stages of the 2010/11 season but increased sharply with uptake reaching 38% by the end of the season.

Healthcare workers

Increasing seasonal influenza vaccine uptake amongst frontline HCWs is important to minimise their own risk of infection (HCWs may be at increased risk of exposure to influenza compared with the general population), and the risk to their vulnerable patients and to their families. Those directly involved in patient care are therefore encouraged to receive the trivalent seasonal influenza vaccine each year.

A second new HPA report on behalf of DH presents the results of a survey of seasonal influenza vaccine uptake among frontline HCWs involved in direct patient care from all 388 NHS Trusts (acute, mental health, ambulance, primary care, care, and foundation trusts) in England [2]. Data were collected: by staff grouping (doctors, qualified nurses, other professionally qualified clinical staff, and support to clinical staff), by Trust and by Strategic Health Authority (SHA).

The report indicates that seasonal influenza vaccine uptake was 34.7% overall among this group, the highest recorded uptake of seasonal influenza vaccine in this group since the programme began. Acute trusts achieved 29.5%. Nonetheless, the majority of frontline HCWs involved directly with patient care still remained unvaccinated during the period covered by the report.

References

1. Seasonal influenza vaccine uptake amongst GP patient groups in England: winter season 2010/11, Department of Health, 6 September 2011.

2. Seasonal influenza vaccine uptake amongst frontline healthcare workers (HCWs) in England: winter season 2010/11, Department of Health, 6 September 2011.

Lords select committee report on HIV and AIDS

The House of Lords Select Committee on HIV & AIDS in the UK, at which the HPA gave evidence, issued its report on 1 September [1]. The committee warned of the "potentially huge cost implications . of failing to deal effectively with the epidemic" and stressed that "the Government should ensure that HIV and AIDS is a key public health priority".  The report endorsed the HPA's recommendation for expanding HIV testing in areas with a high background HIV prevalence to those admitted to hospital and to all patients registering with a new general practitioner.

The committee, chaired by Lord Fowler, who as Health Secretary in 1986 launched the Don't Die of Ignorance campaign on AIDS, called for a greater priority to be given to HIV prevention, including the consideration of a new national campaign to inform the general public of the risks of HIV infection and to address prejudice and ignorance about the infection.  It criticised the current government approach to sex and relationships education in schools, which allows schools and parents to opt out and stated that schools should be legally obliged to provide sex and relationships education, including information on HIV, with teachers needing to be better trained to provide it.

Other recommendations of the report include: building stronger links with GPs, so that some elements of HIV care can be taken over by GPs; procurement of antiretroviral drugs to be conducted on a national basis; for people not currently entitled to free HIV treatment in the UK to receive free treatment; that priority be given into research to evaluate the impact of treatment on new infections in the UK; and that research into the use of pre-exposure prophylaxis with antiretroviral drugs to prevent infection in HIV-negative people should be a funding priority for the National Institute for Health Research and the Medical Research Council.

The release of the report coincided with the HPA's latest epidemiological data on the HIV epidemic in the UK summarised in the Health Protection Report [2]. During 2010 almost 70,000 persons accessed HIV-related care, an increase of 4,100 (6%) compared to 2009.

The UK is seeing the greatest uptake of antiretroviral therapy to date, with 82% (56,071/68,683) of individuals seen for HIV care prescribed ART in 2010 compared with 69% (14,051/20,373) in 2000.  The proportion of patients whose CD4 cell count was <350 cells/µl and who were prescribed ART has increased from 76% (12,759/16,875) in 2007 to 87% (12,675/14,638) in 2010. Previous analyses have shown that 60% of patients not receiving ART, despite being eligible (ie CD4 <350 cells/µl), are treated by the next survey period; if these individuals are included, an estimated 90% were being treated as indicated under the current national guidelines in 2010.

References

1. "No vaccine, no cure: HIV and AIDS in the United Kingdom", House of Lords select committee on HIV and AIDs in the United Kingdom - first report, www.parliament.uk/.

2. Diagnosed HIV infection in the UK: 2010 update. HPR 5(35), http://www.hpa.org.uk/hpr/archives/2011/news3511.htm#hiv.

Interim data from the current national survey of abnormal prion prevalence in archived appendix specimens

Interim data from the unlinked anonymous survey of the prevalence of abnormal prion protein using archived appendix tissue show that four samples have tested positive for disease-associated prion protein (PrPCJD) out of 13,878 suitable specimens examined (288 per million - 95% Confidence Interval (CI): 79 to 738 per million) (table 1).  Using the information collected by the National CJD Research and Surveillance Unit on the 175 variant Creutzfeldt-Jakob Disease (vCJD) cases to date, it is possible to conclude that all four appendices found positive in this survey have not come from known vCJD cases. Codon 129 analysis of the four positive specimens is underway at the MRC Prion Unit. Excluding a small survey of tonsils reported in 2004 [1], available data on the prevalence of PrPCJD in Britain is summarised in table 2 [2-4].

Table 1. Number of appendix samples tested for disease-associated prion protein (PrPCJD) in England by birth cohorts, gender and area as at July 2011 (Positive/total, rate per million with 95% confidence intervals)*†

 Broad geographic area

 Individuals born between 1941 and 1960

 Individuals born between 1961 and 1985

 Total from both birth cohorts

Female
Male
Total including unknown gender
Female
Male
Total including unknown gender

North East and North West

0/334

1/317

1/860

0/107

0/1176

0/3015

1/3875

South East Coast and South West

1/917

0/748

1/2062

0/3026

2/2841

2/7067

3/9129

West Midlands

0/109

0/89

0/198

0/318

0/357

0/676

0/874

Total

  1/1360

1/1154

2/3120

  0/4415

2/4374

2/10758

4/13878

Rate per million (95% confidence intervals)

 

 

641
(78-2314)

 

 

186
(23-671)

288
(79-738)

* The Appendix Study is an unlinked anonymous survey coordinated by the Health Protection Agency with immunohistochemical testing being conducted at two collaborating laboratories: the Department of Neurodegenerative Diseases at the UCL Institute of Neurology and the Animal Health and Veterinary Laboratories Agency. Approximately 20,000 samples will be from individuals born between 1961 and 1985 and 10,000 from those born between 1941 and 1960.
†  Archived specimens from appendectomies which took place between 2000 and the present day are being included in the study. The previous IHC screening study of samples taken between 1995 and 1999 gave a prevalence estimate of 3 in 12,674 tested (237 infections per million population –- 95% CI 49-692) [4].
‡  Using the information collected by the National CJD Research and Surveillance Unit on the 175 vCJD cases to date, it is possible to conclude that the four appendices found positive in the current survey have NOT come from known vCJD cases.

The ACDP TSE Risk Assessment Sub-Group has considered the interim data from the current appendix survey and concluded that the results for the 1961 to 1985 birth cohort 'essentially reproduce' the results for the earlier survey published in 2004 [5].  Also, two of the four positives to date in the survey that is underway were in the 1941 to 1960 birth cohort (641 infections per million population - 95% CI 78-2314), so it is possible prevalence could be higher in the 1941 to 1960 birth cohort compared to the 1961 to 1985 birth cohort (186 infections per million population - 95% CI 23-671).  The Sub-Group concluded that: 'the precautionary (and maybe most likely) scenario is that all those with signs of infection in tissue would have infective blood.  So although the contrary assumption could help explain the small number of blood-borne cases to date, relying on this would be problematic.  Unless there is evidence to the contrary, abnormal prion protein in tissues can be regarded as a proxy measure for infectivity in blood.' [5].

The current appendix survey is being conducted by a collaboration of the HPA, the Department of Neurodegenerative Diseases at the UCL Institute of Neurology and the Animal Health and Veterinary Laboratories Agency. The survey is collecting and archiving sufficient (up to 40,000) appendix samples from participating pathology departments throughout England so that 30,000 suitable specimens from operations since 2000 can be examined. These anonymous samples are being unlinked from any patient identifiable information and tested by immunohistochemistry (IHC) for the presence of PrPCJD. A specimen unsuitability rate of approximately 18% has been observed in both testing laboratories which compares favourably against the expected rate of 25%.

The earlier study of appendix and some tonsil tissue, from operations conducted between 1995 and 1999, found three positive samples out of 12,674 tested for PrPCJD using the IHC method [4]. The prevalence estimate calculated from this study was 237 per million (95% CI: 49-692 per million) - or 380 per million (95% CI=80-1120 per million) in 20-30 year olds, since all the PrPCJD positive individuals were in this age group (table 2).

Table 2. Prevalence of disease-associated prion protein (PrPCJD) in Britain by birth cohort and overall: data to July 2011 (Positive/total, rate per million with 95% confidence intervals*)

Birth Cohort

Current (2004-July 2011) national
tissue surveys

Earlier (1995-1999) national tissue survey [4]

Tonsils (EIA) [2]

Tonsils (IHC) [3]

Appendices

Appendices

Tonsils

Pre-1940

0/51

0/225

1941-1960

0/648

2/3120
641 (78-2314)

0/573

0/266

1961-1985

0/17786
0 (0-207)

1/9160
109 (3-608)

2/10758
186 (23-671)

3/10278
292 (60-853)

0/694

1986-1990

0/12799
0 (0-288)

0/135

0/396

0/119

1991-1995

0/15147
0 (0-244)

0/83

0/106

1996 and later

0/47518

0/294

0/17

Total

0/93949
0 (0-39)

1/9672
103 (3-576)

4/13878
288 (79-738)

3/11247
267 (55-779)

0/1427
0 (0-2582)

* 95% CI only calculated when denominator exceeds 1000.


In April 2008, the Spongiform Encephalopathy Advisory Committee (SEAC) considered available data from the National Anonymous Tonsil Archive (NATA) [6]. At that time no PrPCJD positive samples had been found in nearly 55,000 samples, analysed by a high throughput enzyme immunoassay technique, including about 11,000 samples from the 1961 to 1985 birth cohort [1]. Statistical analysis of the data from the completed appendix survey and NATA showed that, because of the wide confidence intervals around both prevalence estimates, the data sets were statistically consistent with each other. However, should the lack of PrPCJD positive samples from NATA continue as more samples are collected and analysed, the two data sets will at some stage become discrepant. Subsequently, through applying the immunohistochemistry technique to the tonsils from the 1961 to 1985 birth cohort, one specimen with a single strongly positive follicle was found, leading to the conclusion that there was 'no or one v-CJD positive individual' in this group (table 2) [2].

In the face of continued uncertainty over possible discrepant results between both prevalence surveys, together with the urgency to resolve this uncertainty as quickly as possible, SEAC advised that, provided appendix samples were collected from the appropriate birth cohort (1941 to 1960 and 1961 to 1985), and these samples were tested using the same immunohistochemistry technique as used in the previous appendix tissue study, the data from such a study could be combined with the previous study [6]. This would allow further refinement of the current estimates for the prevalence of subclinical infections.

References

1. Frosh A, Smith LC, Jackson CJ, Linehan JM, Brandner S, Wadsworth JDF, et al. Analysis of 2000 consecutive UK tonsillectomy specimens for disease-related prion protein. Lancet 2004; 364: 1260-2.

2. Clewley J, Kelly CM, Andrews N, Vogliqi K, Mallinson G, Kaisar M, et al. Prevalence of disease related prion protein in anonymous tonsil specimens in Britain: cross sectional opportunistic survey. BMJ 2009; 338: b1442.

3. de Marco MF, Linehan J, Gill ON, Clewley JP, Brander S. Large scale immunohistochemical examination for lymphoreticular prion protein in tonsil specimens collected in Britain. J Pathol 2010; 222: 380-7.

4. Hilton DA, Ghani AC, Conyers L, Edwards P, McCardle L, Ritchie D, et al. Prevalence of lymphoreticular prion protein accumulation in UK tissue samples. J Pathol 2004; 203: 733-9.

5. Advisory Committee on Dangerous Pathogens TSE Risk Assessment SubGroup. Minutes July 14th 2011: http://www.dh.gov.uk/ab/ACDP/TSEguidance/DH_125868.

6. Spongiform Encephalopathy Advisory Committee (SEAC). Position Statement. Prevalence of subclinical variant Creutzfeldt-Jakob Disease infections. August 2008. SEAC position statement.