Inject to Protect: The Importance of Immunisation in Custodial Settings

1. Inject to Protect: The Importance of Immunisation in Custodial Settings Immunisation Department HPA Centre for Infections

2. Why immunise in Custodial setting? • 50% of 1st time receptions are not registered with GP • Unlikely to have completed a full course of immunisation in childhood • Prison environment ideal for spread of viruses, bacterial and other pathogens due to often close proximity living conditions • Lifestyle risks both in and outside prison e.g. injecting drug use, heightened sexual risk taking, tattoos, alcoholism • Ideal opportunity to provide protection for life

3. Immunisation of Prisoners: Who benefits? • Prisoners themselves • Staff • Prison community • Prisoners’ families • Community

4. Which immunisations should prisoners be given? • As appropriate to their age and need, prisoners should be offered the following vaccines: • Hepatitis A • Hepatitis B • Meningitis C • BCG • MMR • Pneumococcal • Influenza • Tetanus, diphtheria, polio

5. Hepatitis A Photo courtesy of CDC

6. Hepatitis A • Since 2000, significant numbers of HepA infections occurring in IDUs • Infection acquired through • - poor hygiene • - blood through sharing contaminated injected equipment • - sexual activities that increase the risk of oro-faecal contamination • - drugs contaminated with faeces during smuggling

7. Hepatitis A vaccination • Hep A vaccine should offered to those at risk: • IDUs • MSMs • During outbreaks • Recommend the single HepA vaccine is used because: • HepA antigen content in combined vaccine is half that of single HepA vaccine • Offers more rapid protection (1m after 1 dose, 99% single v 94% combined) • Less risk of not completing schedule • Combined vaccine course more expensive • Only single vaccine shown to be effective post-exposure • Can use combined HepA&B vaccine for 12m booster

8. MMR Photo courtesy of CDC

9. MMR – why give it to prisoners? • Highly infectious diseases • Increasing numbers of susceptibles (both inside and out) • Recent cases and outbreaks of measles, mumps and rubella • Serious disease in adults • Risk of congenital rubella syndrome in pregnant women • Outbreaks seriously disrupt prison and prison health services

10. Are prisoners susceptible? • 2001 study male offenders aged 18-21y showed: • 92% immune to rubella 81% immune to measles • MMR vaccine introduced 1988 • Varying uptake of single measles vaccine, MR vaccine and MMR • Low incidence of disease means little opportunity to acquire immunity through natural infection until now • = susceptibility levels large enough for outbreaks of all 3 diseases to occur in prisons

11. Confirmed measles cases by age group England and Wales: January–September 2008

13. Notified and confirmed mumpsNov 1994 – Dec 2007* Testing suspended in 2005 of those born 1981-6 *provisional

14. Confirmed cases of Mumps by year of birthEngland and Wales, 1999-2004 *provisional

15. MMR recommendations • No reliable vaccine history or history of single measles or MR vaccine only – give 2 doses MMR vaccine one month apart • All women of child-bearing age should be protected against rubella • Establishing accurate vaccine history may be difficult • Where doubt exists, offer MMR • Screening impractical and unnecessary

16. MenC Photo courtesy of CDC

17. Confirmed meningococcal disease 1998 - 2006

18. Identified risk factors for meningococcal disease include: • being age 15-24y • white race • male sex • household or institutional crowding • active and passive exposure to smoke • recent history of URTI • US study found high carriage rates amongst prisoners and spread to community from released prisoners

19. MenC vaccination • One dose of MenC conjugate vaccine recommended for all prisoners 24 years and under with no reliable vaccine history • Introduced into UK infant schedule in 1999 • School catch-up programme in 2000 • Poor school attenders and children in care less likely to have received MenC vaccine • Two doses for prisoners with asplenia and splenic dysfunction of all ages

20. Pneumococcal and Influenza

21. Pneumococcal and Influenza vaccines • Influenza vaccine: • should be offered to all prisoners over 65 years plus prisoners under 65yrs in high risk groups annually(October - December) • Pneumococcal polysaccharide vaccine: • should be offered to all prisoners over 65 years plus prisoners under 65yrs in high risk groups once only • asplenics, splenic dysfunction, chronic renal disease – five yearly boosters

22. Invasive pneumococcal disease incidence rate per 100,000 population by age groupingEngland and Wales, 1996-2005

23. Pneumo outbreaks in prisons • Reports of pneumococcal outbreaks in US prisons • Associated with overcrowding and underlying medical conditions • alcoholism, IV drug use, cirrhosis, asplenia, chronic conditions • Important to investigate outbreaks of respiratory infections • Vital to know which risk groups pneumococcal vaccine is recommended for

24. Clinical risk groups:Influenza and Pneumococcal vaccine • chronic respiratory and lung disease including asthma • chronic renal disease including nephrotic syndrome • chronic heart disease • chronic liver disease including cirrhosis • chronic neurological disease • diabetes mellitus • immunodeficiency or immunosuppression due to disease or treatment • HIV infection at all stages • asplenia or severe dysfunction of the spleen, including sickle cell disease and coeliac syndrome • individuals with cochlear implants • individuals with CSF leaks

25. Prisoners with asplenia or splenic dysfunction

26. Asplenia or splenic dysfunction Asplenia is not a contraindication to routine immunisation Can usually give all vaccines as per UK Schedule including live vaccines BUT: consider why spleen removed (if underlying immunocompromising condition, live vaccines may be contraindicated) • Pneumococcal polysaccharide (every 5y) • Hib conjugate (x2, 2m apart) • Men C conjugate (x2, 2m apart) • Influenza (annually) Now given as a combined vaccine (Menitorix)

27. Tetanus Photo courtesy of CDC

28. Tetanus in IDUs • In 2003, an outbreak of tetanus developed amongst IDUs in the UK • The majority had generalised tetanus and three cases died • Most cases reported subcutaneous injection of heroin (‘skin popping’) • Majority were in women with the male cases being older • Many cases were un-immunised or partially immunised • Tetanus continues to affect IDUs: • From 2005 to 2007, 7 out of 14 cases of tetanus reported in the UK were in IDUs • Potential sources for tetanus infection in IDUs are: • contaminated drugs, injecting equipment, skin abscesses • This has led to vaccination guidance for IDUs being updated to ensure that their tetanus immunisation status is actively checked

29. Tetanus vaccination recommendations • Vaccination of vital importance as no ‘herd immunity’ effect for tetanus • Five doses of diphtheria, tetanus and polio vaccines should ensure long-term protection • Prisoners of all ages who have not completed the five doses should have their remaining doses at the appropriate interval • Primary course: 3 X Td/IPV one month apart • then • Two Booster doses: first - 5y after primary course • second - 5-10y after first booster

30. Uncertain immunisation status

31. General guidelines • Every effort should be made to determine previous immunisation history • If immunisation status uncertain or unknown, treat as unimmunised and a full course of vaccines should be given • It is never too late to start a course of vaccinations

32. Interval Spacing of vaccines • No interval need be observed between: • live and inactivated vaccines • doses of different inactivated vaccines • Doses of the same inactivated vaccine – 4 weeks apart (except HepB) • Live vaccines – 4 weeks apart • No limit to number of vaccines that can be given on one day • If need to use same limb, space vaccines 2.5cm apart • Give as much as you can as soon as you can

33. General Contraindications to vaccination • Almost all individuals can be safely vaccinated with all vaccines • In very few individuals, vaccination is contraindicated or should be deferred • Where there is doubt, rather than withholding vaccine, seek advice

34. !!! True Contraindications !!! • Anaphylaxis to previous dose of vaccine or a vaccine component • Live vaccines in immunocompromised individuals

35. Severe allergic reactions (not anaphylaxis) nota contraindication • obtain good history of reaction as vaccination in controlled conditions may be possible • specialist advice should be sought • risk versus benefit assessment

36. NOT contraindications to vaccination • Family history of adverse reaction following immunisation • Contact with an infectious disease or previous history of the disease • Treatment with antibiotics or locally acting steroids • Personal or family history of epilepsy • Being a close contact of an immunosuppressed individual • Recent or imminent elective surgery

37. Sources of vaccine information

39. Green Book updates

44. Human Resources • PCT Immunisation Lead • Local Health Protection Unit (HPU) • Consultant in Communicable Disease Control (CCDC) or Health Protection Nurse • Vaccine Manufacturer • Centre for Infections

45. What do you need to do? • Ensure you have a vaccination policy in place • Assess vaccination status of all new receptions • Consider your high risk groups • IDUs, MSMs, prisoners with asplenia or chronic conditions • Plan schedule and encourage/ensure completion • Be proactive and opportunistic • Maintain good immunisation records