This quarterly report presents laboratory-confirmed cases of vaccine preventable diseases measles, mumps and rubella for the quarter, ending week 48 2016. Vaccine uptake figures for the childhood immunisation programme for the quarter ending 30 September 2016 and HPV vaccine uptake for the school year 2015/16 are also presented.
This will be the last immunisation report published in the current format. From 2017, quarterly data will be published directly on the HPS web pages for measles, mumps and rubella. The pertussis web pages have been updated with the latest surveillance data for quarter 4.
There have been 26 laboratory-confirmed cases of measles in this quarter, compared with no cases during the same period in 2015, ten in 2014 and 51 in 2013 (Table 1). All 26 cases have been imported or import-related, 24 of which have been part of three clusters. Of the 26 cases, nine were unvaccinated and six were partially or fully vaccinated with a measles-containing vaccine. Vaccination status remains unclear for 11 cases.
The increase in measles cases in this quarter is due to an outbreak in Edinburgh which began following the importation of the virus from abroad. In total, there have been 18 laboratory-confirmed cases associated with this outbreak. The majority of the cases had links to either the University of Edinburgh or a social gathering attended by the index case. There was one family cluster during the outbreak which led to vaccine being offered at a high school but otherwise there was no further spread outwith the above groups.1 The median age of cases was 22 years (range <1 to >40 years) and the majority were unvaccinated or partially vaccinated. NHS Lothian set up vaccination clinics at the University of Edinburgh and in the affected high school in response to the outbreak resulting in MMR vaccination of over 1000 people.2
Since October 2016, two measles outbreaks have been reported in Europe: the one in Edinburgh and one in Romania which has been ongoing since the beginning of 2016.3 Measles cases are under scrutiny in Europe, as measles is targeted for elimination by the World Health Organisation (WHO). The The European Centre for Disease Prevention and Control (ECDC) publishes a monthly summary of measles activity,4 for which Health Protection Scotland submits national data.
There have been 211 laboratory-confirmed cases of mumps up to week 48 of 2016, a considerable decrease compared to 806 cases in the same period of 2015 (Table 1). The high number of laboratory-confirmed mumps cases in 2015 was associated with a national outbreak which predominantly affected students.
Since 2004 there has been an ongoing widespread outbreak of mumps which has affected all areas of the UK. Although cases have decreased overall since the peak in 2005, mumps cases continue to occur steadily in Scotland with smaller outbreaks occurring in 2009, 2012, 2014 and 2015.
There were no laboratory-confirmed cases of rubella in the first 48 weeks of 2016 as was the situation in the same period in 2015. The last laboratory-confirmed case of rubella in Scotland was an imported case reported in April 2013 and therefore this meets the WHO definition for elimination (no cases of rubella for a 12-month period or more).
Rubella cases are under scrutiny in Europe, as rubella is targeted for elimination by WHO. Poland accounts for the majority of rubella cases in Europe following a large outbreak that peaked in 2013. No rubella outbreaks have been detected since the last ECDC monthly summary for which Health Protection Scotland submits national data.5
Childhood vaccines uptake
Vaccine uptake remains generally high in Scotland. Quarterly uptake figures for children reaching ages 12 months, 24 months and five years by 30 September 2016 are shown in Tables 2, 3 and 4 respectively. These are prepared by National Services Scotland Information Services Division (NSS-ISD) and were released on 13 December 2016.6 There is further commentary on these uptake figures in the ISD statistics publication.
Uptake rates of diphtheria, tetanus, pertussis, polio and Haemophilus influenzae type b (Hib)(DTP/Pol/Hib), meningococcal serogroup C (Men C), pneumococcal conjugate vaccine (PCV) and rotavirus at 12 months of age in the third quarter of 2016 are high and stable between 93% and 97.6%. A new vaccine, to help protect against some strains of meningococcal group B bacteria, was added into the routine immunisations offered to babies born from 1 May 2015. The Men B vaccine is given at the 2, 4 and 12 months visits and uptake of the two primary doses at 12 months is high at 94.5%. The uptake in the catch-up cohorts, those born in May and June 2015, was lower at 85.4% for dose one and 73.8% for dose two respectively.6
For the same period, the uptake rate by 24 months of age for completing the primary course of diphtheria, tetanus, pertussis, polio and Haemophilus influenzae type b (Hib) was 97.7% compared to 97.9% in quarter two of 2016. Uptake of one dose of measles, mumps and rubella vaccine (MMR) by 24 months was 94.8% which is a slight decrease from 95.1% in the preceding quarter. Uptake rates for the two booster vaccines by 24 months (Hib/MenC and PCV given at 12 and 13 months of age) were 95.3% and 95.1% for the Hib/MenC booster and the PCV booster respectively (95.6% and 95.4% respectively for the preceding quarter) (Tables 2 and 3 and Figure 1).
For those reaching five years of age, uptake of at least one dose of MMR (MMR1) was 97.1% (compared with 97.2% in the previous quarter) and remains above the 95% target for children receiving at least one dose by the age of five (i.e. around school starting age) (Table 4 and Figure 2). Uptake of two doses of MMR (MMR2) increased slightly from 92.8% in quarter two of 2016 to 93.3% in quarter three of 2016 and is just below the 95% uptake target. In those reaching six years of age, uptake was under the 95% target at 94.7%.
HPV vaccine uptake
HPV immunisation was introduced in Scotland in 2008 as part of the routine childhood schedule, to help protect girls against developing cervical cancer in later life. HPV is now known to cause a number of other cancers including vulvovaginal, penile, anal and a subset of head and neck cancers. The HPV vaccine protects against four types of HPV: types 16 and 18 which cause more than 70% of cervical cancers and types 6 and 11 which cause genital warts. Historic immunisation involved three doses of vaccine delivered over a six-month period and was routinely given in school to 12-13 year old girls (school year S2). Since September 2014, the immunisation programme has moved to a two-dose schedule over a six- to 24-month period. HPV vaccine uptake rates are prepared annually by NSS ISD and were published on 8 November 2016.6
HPV vaccine uptake for the routine S2 school year in 2015-16 is shown in Table 5. Uptake for dose one was 93% and for dose two was 82.7%. Vaccine uptake figures for the previous year were 91.4% for one dose and 82.7% for two doses. The fall in uptake for dose two reflects that doses are missed during the school year which cannot be caught up in that school year due to scheduling of visits to school. Figure 3 shows how uptake of the final dose of vaccine has increased in the year following school year (when the girls move into S3) as missed doses are caught up. For S2 girls vaccinated in 2014-15, uptake of two doses of vaccine was 82.7% in the September of 2014, but had increased to 86.5% one year later. This is a decrease from previous uptake figures at one-year follow-up, which have remained above 90% since the immunisation programme was introduced. The decrease in uptake of the second dose in 2015/16 is likely to be due to the change in the HPV immunisation schedule in the UK from September 2014 and subsequent changes in the timing when NHS boards offer the vaccine. This meant S3 girls in 2015/16 will have had fewer opportunities to receive the second dose than previous cohorts. Girls who may have missed a dose will be re-offered the HPV vaccine next year so uptake in this cohort is expected to increase.
- NHS Lothian website. Press releases: confirmed measles cases in Lothian: http://www.nhslothian.scot.nhs.uk/MediaCentre/PressReleases/2016/Pages/Measles-cases-confirmed-in-Lothian.aspx.
- The University of Edinburgh website. News: Measles: http://www.ed.ac.uk/health-safety/news/measles.
- Communicable disease threats report, week 47, 20-26 November 2016: http://ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx?List=4f55ad51-4aed-4d32-b960-af70113dbb90&ID=1606.
- ECDC measles surveillance data: http://ecdc.europa.eu/en/healthtopics/measles/epidemiological_data/pages/annual_epidemiological_reports.aspx.
- ECDC rubella surveillance data: http://ecdc.europa.eu/en/healthtopics/rubella/epidemiological-data/Pages/epidemiological_data.aspx.
- NSS ISD website. Child health web page with link to all vaccine uptake data: http://www.isdscotland.org/Health-Topics/Child-Health/Publications/index.asp.