19/02/16

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The Meaning of Meningococcal

Carriage

Adam Finn @adamhfinn

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Bristol Childrens Vaccine Centre

Milano 19th Feb 2016

Conflicts of interest •  Prior to Oct 2014 – research,

consultancy & postgraduate lectures for Novartis, GSK, Pfizer, Sanofi-Pasteur-MSD

•  All income paid to Univ of Bristol and Hospital NHS Trust

•  Currently member UK JCVI and Chair WHO ETAGE and ex officio SAGE

•  No benefits in kind. No shares/IP.

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www.espid.org

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Summary •  Likelihood/risks of meningococcal

disease •  Colonisation and indirect effects of

vaccines •  Speculation about meningococcal

infection and respiratory viruses •  Epidemiology & evolving vaccine

strategies in –  Europe –  Africa

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If you are Italian your life-time risk of getting meningococcal disease is about the same as: 1.  Winning the Euromillions jackpot 2.  Winning a Nobel prize 3.  Becoming president of Italy 4.  Playing in the Italian soccer team 5.  Having Downs Syndrome 6.  Getting into medical school

Choose one best answer

Vote  Now  

Vote  Now  

If you are Italian your life-time risk of getting meningococcal disease is about the same as: 1.  Winning the Euromillions jackpot (1 in 116.5M) 2.  Winning a Nobel prize (1 in 20M) 3.  Becoming president of Italy (1 in 5M) 4.  Playing in the Italian soccer team (1 in 250K

unless you are a woman) 5.  Having Downs Syndrome (1 in 700) 6.  Getting into medical school (1 in 150)

Choose one best answer

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19/02/16

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Meningococcal Disease Incidence in Italy

•  1 / 100k population •  So approx 600 cases a year •  If annual risk 1 in 100k •  Lifetime risk 1 in 1,250 •  Risk in first 2 years of life approx. 1

in 3,500; of death/sequelae 1 in 15k

http://ec.europa.eu/health/ph_information/dissemination/echi/docs/meningoccocal_en.pdf

MenC disease following start of immunisation

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MenC - UK Colonisation Essential facts

•  Oropharynx •  Age distribution (next slide)

explained by smoking/kissing/social habits

•  No difference between sexes or ethnic groups

•  Does not predict disease either at individual or population level

Hannah Christensen et al Lancet ID 2010

Age - years

Carr

iage

(%)

UK Students - carriage

12 Maiden MC, et al. J Infect Dis. 2008;197:737-743

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Birth 10 years 20 years

ACYW

Throat Swabs

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Direct plating Stored STGG broth

All high density carriers by PCR were culture

positive

Mening’ carriage density

Data from Coimbra, Portugal – submitted for publication

•  Unpublished data

Pneumococcal carriage pre-school children

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Density vs. month

•  Unpublished data

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Influenza & IMD

Cartwright Lancet Aug 31 1991; Tully BMJ 2006

Research Questions

•  How does colonisation density affect transmission?

•  How do vaccines affect colonisation density?

•  What is going on with meningococcal carriage in different countries and regions?

Epidemiology in Europe •  C very rare in immunised countries

(but not gone) •  B going down over last 10-15 years •  Y going slowly up in all age groups •  W going up rapidly (cases doubling

annually 46, 88, 170) in England since 2009/10 and ???elsewhere soon – ST11cc single hyper-virulent strain.

•  CFR 12%. Atypical presentations 25% •  Origin ?? Latin America - Chile

Eurosurveillance, Vol 20, Issue 28, 16 July 2015 22

Laboratory confirmed cases of invasive meningococcal disease in England by capsular

group, epidemiological years 2005/06 – 2014/15*

*2014/15 data is provisional Date source: PHE Meningococcal Reference Unit. Surveillance by PHE Immunisation Department – Last Update August 2015 Please see link for more information and data https://www.gov.uk/government/collections/meningococcal-disease-guidance-data-and-analysis

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200

400

600

800

1000

1200

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Num

ber  o

f  laboratory  confirm

ed  cases

Epidemiological  years  (July-­‐June)

BCW135YOther

Campbell Eurosurveillance July 2015

MenW age distribution – adults, adolescents and young children

Campbell Eurosurveillance July 2015

UK response •  School-based adolescent programme

for 13-18 year olds since Aug 2015 using MenACWY conjugate vaccine – special focus school leavers (17-18 year olds)

•  First example of a national programme designed primarily to work via indirect effects on onward transmission

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Meningococcus in Africa •  Seasonal epidemics with very high

incidence rates up to 1 per 1000 (i.e. 100-1000 times higher than Italy)

•  Mostly group A (group X and W also seen)

•  Many cases of meningitis and many cases in healthy young adults

•  Response mode polysaccharide vaccine campaigns have had limited impact

MenAfriVac MenA conjugate vaccine

2011 2011

Impact of MenAfriVac on meningitis in Chad

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Wee

kly

incide

nce/

100,

000

2009 2010 2011 2012

N'Djamena

2013

Vaccination 2012

Vaccination 2011

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13-15 months 2-4 months 4-6 months

All meningococci Epidemic strain

VACCINATION

Pre-vaccination Post-vaccination

Percentage carriage

Impact of MenAfriVac on carriage in Chad

[Adjusted OR = 0.019, 95% CI 0.002, 0.14]. (Daugla et al. Lancet 2014; 383:40-47)

2015 MenC outbreak in Niger

Conclusions •  You can’t predict the future – ESPECIALLY

not with meningococcus •  IMD is rare but a much bigger risk than

winning the lottery (so better to spend money on vaccines than lottery tickets!)

•  As with many vaccines, impressive effects can be seen if given at high coverage to produce indirect/transmission effects

•  Important to study carriage & improve understanding of transmission and effects of new vaccines on colonisation