No 50 - 2015

Free HPV vaccination for women born in the 1993-1997 period will be discontinued as from end of 2015
Measles postexposure prophylaxis
Booster vaccination against polio - updated recommendations for travel to certain countries
New publication from the Danish Health and medicines authority on the handling of sexually transmitted infections
European training programme to become a field epidemiologist (epiet) or a field microboilogist (euphem)

Free HPV vaccination for women born in the 1993-1997 period will be discontinued as from end of 2015

On 1 January 2014, the age limitations were changed on the existing offer of free HPV vaccination under the Danish childhood vaccination programme, EPI-NEWS 1-2/14. The offer was broadened allowing vaccinations to be given to young women until they turn 18 years old (as opposed to 15 years previously).

Furthermore, a temporary free offer of HPV vaccination was introduced for women from the 1993-1997 birth cohorts who were previously covered by an offer of free vaccination. Birth cohorts 1993-95 had been offered vaccination as part of a catch-up programme in 2008-2010, and cohorts 1996-97 had been offered vaccination under the childhood vaccination programme, EPI-NEWS 35/08. This repeated offer to the 1993-97 cohorts will be discontinued as from the end of 2015.
(Department of Infectious Disease Epidemiology)

Measles postexposure prophylaxis

Based on a literature review and in accordance with the most recent international recommendations, Statens Serum Institut and Copenhagen University Hospital (Rigshospitalet) have jointly changed the recommendations on the use of MMR vaccine and human normal immunoglobulin following exposure to measles infection.

With a view to avoiding or weakening measles symptoms, MMR vaccination may be given to persons who have been exposed to measles infection within the past 3 days. In case of an outbreak, the vaccination may be given as from 6 months of age, EPI-NEWS 20-21/15. According to the summary of product characteristics, the MMR vaccine may be used as from 9 months of age in exceptional cases, but several international studies have documented that the majority of children of vaccinated mothers do not have measurable levels of measles antibodies as from 6 months of age, and therefore the vaccine may possibly be used off-label already from this age. If the MMR vaccination is given before 12 months of age, the vaccination shall be repeated when the child reaches the age at which the first dose of MMR vaccine is normally given (15 months).

Human normal immunoglobulin (Ig) may be used as prophylaxis or to weaken the disease in susceptible patients who have been exposed within 6 days.

The below overview may be used to select post-exposure prophylaxis:

Premature infants
All premature infants born before 32 weeks of gestation shall be offered Ig until the age of 6 months irrespective of the mother's immune status.

Infants under 3 months of age
In children who are under 3 months of age who have been exposed to measles, the mother's measles status shall be checked anamnestically. Mature children <3 months of age are offered Ig unless the mother has previously had measles. Thus, Ig is offered to children of vaccinated mothers.

Children aged 3-15 months
We recommend that all children aged 3-5 months of age be given Ig in case of exposure to measles. Children aged 6-15 months (including any previously premature infants) are given MMR vaccination if less than 3 days have passed since the exposure, and provided the exposure did not occur within the family. Ig is given if 3-6 days have passed since the exposure, or if the person affected by measles is a family member.

Children older than 15 months of age
All non-vaccinated children above 15 months of age and children whose vaccination status is uncertain shall be given Ig or MMR vaccination following the principles used in children aged 3-15 months of age.

Pregnant women with no verifiable immunity
Due to an increased risk of complications in case of disease and due to the contraindication against administration of live attenuated vaccine, unprotected pregnant women shall be offered Ig rather than MMR vaccination. In case of an uncertain vaccination status, measurement of antibodies should precede Ig. Nevertheless, Ig treatment should not be postponed until the immune status result arrives.

Adult immunocompetent persons
The majority of adults will either be naturally immune of have received MMR vaccination. If the exposed is a known non-immune person, MMR vaccination may be given within 3 days and Ig within 6 days.

Immunosuppressed persons
Immunosuppressed persons may not receive MMR vaccination and shall receive Ig (intramuscularly or intravenously, see below) irrespective of their vaccination status. This applies to cancer patients, patients who have received a bone marrow transplant, patients with immunodeficiency and HIV-positive patients. Ig therapy shall not be postponed until the result on the immune status test arrives. Rather, the therapy shall be initiated quickly, preferably within 3 days and always within 6 days. We recommend that treatment of immunosuppressed patients be conferred with the treating specialist. Ig shall be given again in case of renewed exposure to measles after 21 days. In case of late acknowledgement of infection, Ig treatment may be indicated for up to 18 days after infection, but this shall be conferred with specialists, e.g. an infection specialist or a paediatrician.

Immunoglobulin dosage
The previously applicable Ig dosage guidelines have been adjusted to ensure alignment with the concentration in the products that are available (currently Beriglobin for intramuscular use and Privigen for intravenous use).
The following dosage recommendations have been prepared as a joint effort including the Department of Paediatrics and Adolescent Medicine and the Departments of Clinical Microbiology (Copenhagen University Hospital) and Statens Serum Institut based on the latest international guidelines:

Ig for intramuscular use: 0.6 ml/kg (160 mg/ml), max. 5 ml for children < 15 months, max. 15 ml for children > 15 months.

Ig for intravenous use: 0.4 g/kg (4ml/kg, 100 mg/ml).

Ig for pregnant women, for intramuscular use: 15 ml (160 mg/ml), irrespective of weight.

Ig for non-immune adults, for intramuscular use: 15 ml (160 mg/ml), irrespective of weight.

Ig treatment for intravenous use is primarily given to immunosuppressed persons and in some cases to other admitted persons, e.g. children with pre-established IV access, as the high doses that can be administered IV provide superior protection. MMR vaccination is performed no earlier than 6 months after Ig administration if Ig was given intramuscularly, and no later than 8 months if Ig was given intravenously.

Ordering and payment
Ig and MMR vaccine for use in post-exposure treatment may be ordered at pharmacies or from the SSI; costs are defrayed by the Region. When acute dispatch from the SSI is needed, the transportation costs are covered by the regional authorities.

(N.V. Følsgaard, Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital (Rigshospitalet), C.B. Christiansen, DCM, Copenhagen University Hospital (Rigshospitalet), P.H. Andersen, Department of Infectious Disease Epidemiology)

Booster vaccination against polio - updated recommendations for travel to certain countries

The global eradication of polio has entered a crucial phase, and on a meeting held on 10 November 2015, the WHO's IHR Emergency Committee reassessed the special requirements/recommendations on polio booster vaccination (IPV or OPV) for persons travelling to and staying in certain countries for more than 4 weeks, which have been in place since the summer of 2014, EPI-NEWS 27a+b/1426a+b/15 and 44/15.

The WHO maintains its assessment that the polio situation constitutes a public health emergency of international concern (PHEIC) and has directed additional focus to circulating vaccine-derived polio viruses (cVDPV). Disease outbreaks due to these vaccine strains (Type 1 and Type 2) continue to occur, and it is crucial that outbreaks of cVDV Type 2 are curbed as all vaccination against wild polio virus of type 2 is to be phased out globally in the course of a 3-month period starting in April 2016 when all countries using OPV will shift from trivalent to bivalent OPV vaccine.

Polio (booster) vaccination is still required only in persons who leave Afghanistan or Pakistan (from where virus export is still observed) after stays exceeding 4 weeks, provided they have not received their latest polio vaccination within 1 year. In this situation, the Danish authorities recommend that booster vaccination be administered before departure from Denmark, primarily to ensure that the traveller receives a quality-assured vaccine in sterile conditions. As previously, the vaccination shall be documented in the yellow international vaccination certificate.

As previously reported, EPI-NEWS 26a+b/15, according to the WHO publication International Travel and Health 2015, Syria has also introduced a requirement for polio booster vaccination for everyone leaving Syria. As previously, everyone who will be travelling to Syria is therefore (re)commended a polio booster vaccination before departure from Denmark, regardless of the planned duration of the stay. The same publication states that Nepal introduced a polio (booster) vaccination requirement that applies to all travellers entering the country, EPI-NEWS 26a+b/15. There are reports that this requirement is not being enforced, but we have not been able to achieve clarification from official sources. Until further notice, we recommend that anyone travelling to Nepal receives polio (booster) vaccination.

Anyone planning to stay for a longer period of time (> 4 weeks) in a country in which circulating vaccine-derived polio viruses (cVDPV) have currently (in 2015) been detected (Madagascar, the Ukraine, Nigeria, Guinea, Myanmar and Laos) are recommended a polio vaccine 4 weeks to 12 months before leaving the country in question. This vaccination should also be documented in the yellow international vaccination certificate or a similar official document.

There is no current recommendation concerning polio booster vaccination for travellers who have previously received full primary vaccination who are travelling to countries with no current polio virus circulation, but which are vulnerable to international spreading (Cameroun, Equatorial Guinea, Ethiopia, Iraq, Israel, Somalia and South Sudan).

As per 2 December 2015, a total of 60 cases of wild polio virus had been detected in the two remaining endemic countries, 17 in Afghanistan (the latest case was observed on 3 November) and 43 in Pakistan (latest case observed on 2 November). The latest case in Africa (Nigeria) was seen in August 2014. A total of 21 cases of cVDP have been detected, two in the endemic countries and the remaining in 19 countries mentioned above.
(P.H. Andersen, A.H. Christiansen, Department of infectious Disease Epidemiology)

New publication from the Danish Health and medicines authority on the handling of sexually transmitted infections

The Danish Health and Medicines Authority has compiled the recommendations on prevention, diagnosis and treatment of sexually transmitted infections in a single publication that also allows printing of copies for patients.
Major progress has been recorded in diagnostics and treatment of sexually transmitted infections; and therefore the recommendation offers many new items of information about these areas, e.g. about gonorrhoea treatment. Furthermore, the recommendation has a new feature as it is now possible to directly print off information for patients. Additionally, the publication describes the many existing prophylactic options related to sexually transmitted infections, and it explains which tasks are handled by municipalities and the NGOs of this field.

The publication describes how the efforts to prevent, diagnose and treat the infections are organised, outlines the principles employed to counter infection and presents current provisions. Furthermore, the publication holds an outline of infections, epidemiology, disease courses, diagnostics, treatment and prevention of gonorrhoea, hepatitis A, B and C, genital herpes, chlamydia, condyloma and other sexually transmitted infections.

The publication's target group is GPs, practicing medical specialists, hospital physicians, healthcare workers affiliated with the municipal preventive efforts and educational institutions. The recommendations will provide a joint overview for all persons involved in the efforts made, and at the same time provide specific and actionable instructions for each clinical situation.
The publication replaces 2 previous guidelines: "Guideline on the diagnosis and treatment of sexually transmitted infections" from 1999 and "Chlamydia infections. Guideline on diagnosis and treatment in general practice" from 2005, which are hereby replaced.
(Danish Health and Medicines Authority)

European training programme to become a field epidemiologist (epiet) or a field microbiologist (euphem)

Once again, it is possible to apply for the two-year European training programme to become a field epidemiologist, EPIET (European Programme for Intervention Epidemiology Training). Participants will achieve skills comprising, among others, monitoring and control of infectious diseases, outbreak tracing and handling, applied research, communication, etc. The programme consists of two years of stationing in another European country. It is “on-the-job training” and participation in the study programme is remunerated. Participants are expected to have undergone relevant training, possess experience in the field of public health and to have an interest in field epidemiology.

It is also possible to apply for a similar two-year European training programme for microbiologists, EUPHEM (European Public Health Microbiology Training). This training programme is also completed as two years' of stationing in another European country. Programme participants will achieve proficiency in performing independent laboratory tasks in connection with the surveillance and control of infectious diseases, tracing and management of outbreaks, applied research and communication, etc. Participants are expected to have some work experience in the field of microbiology, to have a PhD degree and an interest in field epidemiology.
Both programmes are offered by the European Centre for Disease Prevention and Control (ECDC), and starts as a joint three-week introductory course held mid-September 2016.

Applicants to EPIET and EUPHEM shall be citizens of the EU, Iceland, Liechtenstein or Norway with proficiency in English. The deadline for application is 10 January 2016.

For further information, please see or contact Consultant Kåre Mølbak, Department of Infectious Disease Epidemiology (EPIET) or Consultant Robert Skov, Microbiology and Infection Control (EUPHEM).
(Statens Serum Institut)

Link to previous issues of EPI-NEWS

9 December 2015