Professor Finn on the risks of meningococcal disease. The slideset face the effects of vaccines, the speculation about meningococcal infection and respiratory viruses, so as the epidemiology & evolving vaccine strategies in Europe and Africa.

1. 19/02/16
1
The Meaning of Meningococcal
Carriage
Adam Finn
@adamhfinn
live.voxvote.com 75665
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
live.voxvote.com 75665
Live.voxvote.com 75665
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
Live.voxvote.com 75665

2. 19/02/16
2
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
8
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
Carriage(%)
UK Students - carriage
12Maiden MC, et al. J Infect Dis. 2008;197:737-743

3. 19/02/16
3
Birth 10 years 20 years
ACYW
Throat Swabs
14
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
17
Density vs. month
• Unpublished data

4. 19/02/16
4
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
0
200
400
600
800
1000
1200
1400
Number
of
laboratory
confirmed
cases
Epidemiological
years
(July-­‐June)
B
C
W135
Y
Other
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

5. 19/02/16
5
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
0
1
2
3
4
5
6
7
8
9
Weeklyincidence/100,000
2009 2010 2011
2012
N'Djamena
2013
Vaccination
2012
Vaccination
2011
0
1
2
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