Neonatal meningitis in the UK
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Dr Ifeanyichukwu Okike's presentation at Meningitis Research Foundation's 2013 conference Meningitis & Septicemia in Children & Adults 2013

Dr Ifeanyichukwu Okike's presentation at Meningitis Research Foundation's 2013 conference Meningitis & Septicemia in Children & Adults 2013

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  • I would like to thank the Organisers for the opportunity to present this study of bacterial meningitis in babies <90 days of age a Uk and ROI prospective study. The project was funded bt the Meningitis Resaerch foundation
  • Historical studies that described the burden of the diseae in England and Wales are shown in this table. Incidence has gone down, Incidence is highest in the low birth weight babies, CFR has declined however, the proportion of survivors who develop a neurological sequelae remain at 50%. Therefore the burden is still significant.
  • We used the BPSU methodology for case ascertainment. This is a well established active surveillance system where Clinicians are sent an orange card for them to report any case of bacterial meningitis ( amongst other ix dis) in the last months. All reports go to the BPSu office whether positive or negative. The BPSu then passes the pos returns to me and I contact the local Paediatrician with a questionnaire to complete for the case. We also ascertained cases from the National surveillance laboratories of the countries that make up the UK and RoI. Parents were also encouraged to report via Support charities.. Surveillnace was 13 months between 1 july 2010 and 31 July 2011.
  • We had 868 reports from all sources. 365 met our analytical case definition, most of the babies were male, median age was 14 days. Most babies were admitted from home and 27% were born premature.
  • The presenting features for all cases, 1st month of life and afterwards are shown on this bar chart. The non specific features on the left and the specific features on the right. Non specific features were commonly seen in all groups. Another important feature here is that fever was not universally present (only present in 54% of all the cases). This proportion goes up to 70% beyond the first month of life. On the right you can see that the specific features of meningitis were less commonly seen. RASH was extremely rare. This table shows the proportion of babies with a combination of features. The most common being fever and irritability etc. The triad of Convulsion, bulging fontanel and neck stiffness was only seen in 1%.
  • The top 4 causal bacteria are shown by month of life in this table. GBS is responsible for 50% of cases upto the 2nd month after which SPN and NM contribute equally (the three making up 77% ). The proportion caused by E coli remains just over 10%. There was no case of listeria meningitis beyond the first month of life. This will have implications in the choice of empiric antibiotics beyond the first month of life.
  • 25 babies died at the time of reporting or completion of questionnaire giving a CFR of 7.6%.Poor outcome defined as either death or complication was observed in 28%.This table shows poor outcome by bacteria. S pneumoniae stands out with a high CFR and also a high rate of complication in survivors
  • In a multivariate logistic regression analysis we identified independent risk factors for poor outcome. These include prematurity <28 weeks (OR 6), temperature instability (OR2), convulsions (OR6), coma on admission OR 17 and having a pneumococcal meningitis OR 7 and being of Asian origin OR 3.
  • In a multivariate logistic regression analysis we identified independent risk factors for poor outcome. These include prematurity <28 weeks (OR 6), temperature instability (OR2), convulsions (OR6), coma on admission OR 17 and having a pneumococcal meningitis OR 7 and being of Asian origin OR 3.
  • LP was done in 315, post 197, pre abx 110, uK 8. Of the14 (4%) of 329 cases without an LP, seven (50%) presented with seizures, abnormaltemperature, lethargy, and poor perfusion, and a bacteria was isolated from blood(GBS 5, S. pneumoniae 2). The remaining seven cases were diagnosed at post-mortemexamination
  • 13/121 (11%) were multiple births in 2000, whilst this proportion 9/131 (7%) were twins in 2010-2011
  • We can also compare all GBS cases with a study done in 2000/1 which was prior to the introduction of the IAP for the prevention of EO GBS disease. Our study shows that the number of cases increased but the incidence remains similar. There was no change in the proportion that was early onset or median age. However, our study show that the proportion that were preterm overall and for EO cases has decreased significantly. Our study 32/135 (24%) were preterm. For EO cases: 6/50 (12%) of EO cases were preterm. 9/44 (20%) had ROM >18hrs, 2/46 (46 completed this Q as yes or no ) had maternal fever, 6/51 (12%) mum had GBS positive swab prior to delivery. 41/51 () Vaginal delivery, 10/51 () C/S delivery. 2/102 term (2%) died compared to 5/32 (16%) preterm died.
  • G pos 22 (71%): GBS 16, e coli 3, listeria 3, other gram neg 5, other gram pos 3, Hi 1. 9 cases were LO ( 6 of which were GNB). Mean time to antibiotics 7 hours
  • GBS 46 (70), e coli 8 (12%), spn 2, NM 4, LM 1, Gram neg 4
  • 1/3 of in patient cases had abx after 3 hours, ¼ of cases admitted from home it was after 3 hours

Neonatal meningitis in the UK Presentation Transcript

  • 1. Group B streptococcal infection & neonatal meningitis Neonatal meningitis in the UKDr Ifeanyichukwu O Okike Paediatric Infectious Diseases Research Group St George’s, University of London MRF Conference, London.
  • 2. OUTLINE  Burden of bacterial meningitis (BPSU) study*  GBS meningitis*  Assessment of healthcare delivery* *Note. All data are preliminary and unpublished
  • 3. bacterial meningitis in E+W, 20042011 (PHE, LabBase2) Age group % of total population No of cases (%) Incidence (95% CI) (/ 100,000 population) Incidence Rate Ratio <3months 0.3 978 (16) 72.19 (67.74-76.86) 136 (118155) 3-11 months 0.9 755 (12) 18.58 (17.27-19.95) 35 (30-40) 1-4 years 4.7 522 (8) 2.54 (2.33-2.77) 4.8 (4.1-5.5) 5-14 years 11.6 270 (4) 0.53 (0.47-0.60) Reference 15-44 years 41.0 1538 (25) 0.86 (0.82-0.91) 1.6 (1.4-1.8) 45-64 years 25.3 1331 (22) 1.21 (1.14-1.27) 2.3 (2.0-2.6) ≥65 years 16.2 752 (12) 1.07 (0.99-1.15)p values <0.0001 2.0 (1.7-2.3) All The rate in <3month-olds is >70 x that of adults! Okike IO, Ribeiro S, Ramsay M, Heath PT, Sharland M & Ladhani SN. Paper submitted
  • 4. Previous neonatal surveillance studies in E+W (≤28 days of age) Location Period / 1000 LB <2500g Fatality (%) Leeds 19471960 0.5 NW Thames 19691973 0.26 Nottingham 19801989 0.37 25 Oxford region 19841991 0.25 Sequelae 26 Lancet. 1976;1:701 Arch Dis Child 1991;66:603-7 Arch Dis Child Fetal Neonatal Ed 2001;84:F85-9 E+W 19851987 0.2 2.5 E+W= England & Wales 25 50%
  • 5. Isolated bacteria (%) Isolated bacteria 1985-87 (E+W) 1996-97 (E+W) GBS 38% 48% E. coli 25% 18% S. pneumoniae 6% 6% Listeria 7% 5% N. meningitidis 4% 4% Other Gram positive bacteria Other Gram negative bacteria 5% 12% 12% 8% Arch Dis Child 1991;66:603-7 Arch Dis Child Fetal Neonatal Ed 2001;84:F85-9
  • 6. Initiatives in the last two decades (UK) PCV 13 Davidson & Ramsay e ADC 2003 Ladhani et al CID 2012 • National Guidelines - Feverish illness 2007 (2013) - Bacterial meningitis 2010 • Neonatal networks • Regional transport
  • 7. Burden of disease study : objectives To define: • The minimum incidence in the UK and Ireland • The clinical presentation • The bacterial pathogens and resistance pattern • The case fatality and short-term complication rates
  • 8. Methods Any case where a clinician has made a clinical diagnosis of bacterial meningitis in babies <90 days of age between 1 Jul 2010 & 31 Jul 2011 3200 Return rate 93% Orange card: Other Sources -National laboratory surveillance
  • 9. Incidence (/ 1000 live births): by country Place of birth 13-month adjusted LB 2010 *Cases (%) Incidence (95% CI) UK & RoI 954189 364 (100) 0·38 (0·34-0·42) England 744258 298 (82) 0·40 (0·36-0·45) Wales 38948 15 (4) 0·41 (0·25-0·67) England & Wales 783206 313 (86) 0·40 (0·36-0·45) Scotland 63690 19 (5) 0·30 (0·19-0·46) Northern Ireland 27425 7 (2) 0·26 (0·12-0·53) Republic of Ireland 79868 25 (7) 0·31 (0·20-0·46) * Confirmed: 298 (82%) = Isolation of a significant bacterial pathogen from CSF OR isolation of a significant bacterial pathogen from blood culture AND CSF pleocytosis (≥20 cells / mm3 for babies 0-28 days of age and ≥10cells/ mm3 for babies 29-90 days of age). * Probable: 66 (18%) = Clinical signs of meningitis (fever or hypothermia or temperature instability) PLUS 1 or more neurological findings (e.g. coma, seizures, neck stiffness, apnoea, bulging fontanel) AND CSF pleocytosis AND appropriate IV antibiotics are given for > 7 days BUT where no significant pathogen is isolated from blood or CSF.
  • 10. Incidence by birth weight & gestation at birth (/1000LB) Category 223 (71) 0·31 (0·27-0·35) 1.00 Reference 43 (14) 0·95 (0·68-1·27) 3·09 (2·22- 4·28) <0.0001 1000-1499g 26 (8) 5·18 (3·38-7·58) 16·83 (11·22- 25·23) <0.0001 <1000g Gestation at birth (weeks) ≥ 2500g 1500-2499g Birth weight (grams) No of cases (%) Incidence/ 1000 LB (95% CI) IRR (95% CI) P value 21 (7) 4·77 (2·95-7·28) 15·51 (9·92- 24·23) <0.0001 ≥ 37 201 (70) 0·29 (0·25-0·34) 1.00 Reference <37 81 (28) 1·36 (1·08-1·70) 4·62 (3·58- 5·99) <0.0001 32-36 39 (14) 0·99 (0·70-1·35) 3·36 (2·39- 4·74) <0.0001 <32 42 (15) 2·09 (1·51-2·82) 7·11 (5·10- 9·91) <0.0001
  • 11. Demographics of cases Category Value Male 202 (55%) Median age in days (IQR) Admitted from home 17 (4-41)* Preterm (<37 weeks) 27% 63% *No difference between age at onset by birth weight category
  • 12. Combination of features Presenting Percentage of cases 80% Percentage of cases features Fever and irritability 60% Fever and lethargy 50% 40% Fever, lethargy and poor feeding 30% 70% 41 33 29 20% 10% Fever, irritability and poor perfusion 19 0% All 0-28 d >28 d Fever and convulsion Convulsion and bulging fontanelle 11 7 Convulsion, bulging fontanelle Presenting Non-specificneck stiffness features and 1 Specific
  • 13. Presentation by route of admission & gestation Feature All n (%) Home In patient OR (95%CI) P value Term Preterm OR (95% CI) P value Poor feeding 221 (67) 166 (81) 53 (44) 5.4 (3.3-9.0) 0.000 1 176 (75) 42 (47) 3.3 (2.0-5.6) 0.0001 Irritability 208 (63) 157 (77) 50 (42) 4.6 (2.8-7.5) 0.000 1 174 (74) 32 (36) 5.1 (3.0-8.6) 0.0001 Abnormal Temp 216 (66) 157 (77) 59 (49) 3.5 (2.1-5.7) 0.000 1 160 (69) 49 (55) 1.8 (1.1-3.0) 0.0001 Fever 176 (54) 142 (69) 33 (28) 5.9 (3.6-9.7) 0.000 1 142 (60) 30 (33) 3.0 (1.8-5.0) 0.0001 Temp instability 65 (20) 31 (15) 34 (28) 0.4 (0.3-0.8) 0.004 38 (16) 27 (30) 0.4 (0.3-0.8) 0.004 Apnoea 74 (22) 33 (16) 40 (33) 0.4 (0.2-0.7) 0.000 1 33 (14) 41 (46) 0.2 (0.1-0.4) 0.0001
  • 14. (%) Presenting features Baumgartner N=24, USA 2-6 weeks Riordan N=42, Merseyside <3months Okike et al N=329, UK &RoI <3months Neck stiffness 17 13 3 Seizures 17 35 24 Full fontanelle 13 45 20 Fever 79 70 53 Poor feeding 50 76 67 Lethargic 25 33 63 Irritable 79 70 63 Baumgartner Am J Dis Child 1983 Riordan Postgrad Med Journal 1995
  • 15. Other Gram pos 24 8 CONS 6 2 S. aureus 5 2 E. faecalis 4 1 S. bovis 4 1 S. pyogenes 2 1 S. salivarius 1 <1 S. viridans 1 <1 Bacillus spp. 1 <1 Other Gram neg 24 8 Pseudomonas 4 1 Klebsiella spp 4 1 Enterobacter 4 1 Serotype or serogroup H. influenzae 3 1 Unknown Gram 7F 13 (59%), 3 2 (9%), 1 2 (9%) and one each of 9F, neg bacilli 2 1 Citrobacter 1 <1 35B, 19A, 15B, 12F M. morganii 1 <1 Pasteurella 1 <1 Men B 21 (91%), one each Prevotella C and Men Y<1 of Men 1 Raoultella 1 <1 1 <1 Hib 1 Salmonella Ureaplasma 1 <1 Identified bacteria (n=300) Organism GBS Cases 150 % 50 40 13 S. pneumoniae N. meningitidis Bacteria 28 23 9 8 LMSPN 11 4 24 8 24 8 E. coli (n=22) Other Gram pos NM (n=23) Other Gram neg Hi (n=3) SPN= S. pneumoniae, NM= N. meningitidis, LM= Listeria monocytogenes Hi= H. influenzae.
  • 16. Identified bacteria by month of life (%) Bacteria All 1st month 2nd month 3rd month Group B strep E. coli 50 58 47 24 13 15 12 11 S. 9 6 7 pneumoniae N. 8 2 15 meningitidis of Listeria meningitis after 29 days No case 29 24
  • 17. Identified bacteria: 100% by route of admission & gestation at birth 90% 80% 47% Percentage of cases 70% 60% 50% N. meningitidis 40% Other G negative E. coli 30% Other G positive L. monocytogenes 20% Non pyogenic streptococci S. pneumoniae 10% Group B strep 0% Home (term) Home (preterm) In-patient (term) Route of admission and maturity at birth In-patient (preterm)
  • 18. Aetiology of neonatal (0-28 days of age) current vs historical for England & Bacteria 1985-87 Wales1996-97 (0.22/1000) (0.21/1000) 2010-11 (0.21/1000) GBS 38% 48% 60% E. coli 25% 18% 14% S. pneumoniae 6% 6% 6% L. monocytogenes N. meningitidis 7% 5% 3% 4% 4% 2% Other Gram 12% 8% 8% neg Other Gram 5% 12% 7% pos Arch Dis Child 1991;66:603-7 . Arch Dis Child Fetal Neonatal Ed 2001;84:F85-9
  • 19. Comparison of aetiology with other international studies Cases 0-28 days of age Bacteria GBS E. coli NM SPN LM Other GNB Other GPC France 200107 N=439 258 (59%) 123 (28%) 14 (3%) 8 (2%) 7 (2%) 19 (4%) 10 (2%) UK & ROI 201011 N=195 111 (57%) 29 (15%) 3 (2%) 11 (6%) 10 (5%) 17 (9%) 14 (7%)
  • 20. Comparison of aetiology with other international studie UK & ROI 2010-11 100% 90% GBS: 86.1% Percentage of total cases USA 2003-07 Cases < 2 months of age 80% 70% 60% GBS: 78.1% 50% 40% 30% 20% 10% 0% <2mo
  • 21. Overall Outcome Overall CFR 25/329 = 7.6% [95% CI: 5.2-11.0] Death or any serious complication 90/329 = 27% [95% CI: 23-33] Organism Total Died (%) *Complication in survivors (%) None detected 65 2 (3) 5 (8) Group B strep 135 7 (5) 28 (22) E. coli 35 3 (9) 7 (22) S. pneumoniae 26 5 (19) 11 (52) N. meningitidis 20 0 (0) 5 (25) L. monocytogenes Non-pyogenic streptococci 9 0 (0) 2 (22) 7 1 (14) 2 (33) Other Gram positive 11 2 (18) 1 (11) Other Gram negative 19 5 (26) 4 (29) *seizures 26 (9%), motor disorder/abnormal neurology 24 (8%), hydrocephalus 15 (5%), abnormal hearing 8 (3%), severe skin/musculoskeletal defect 5 (2%), other 2 (1%) [drainage cerebral abscess 1,
  • 22. Independent risk factors for death / any serious complication Variable OR (95% CI) p value Prematurity (<28 weeks) 4.8 (1.7- 13.1) 0.003 Temperature instability on admission 2.1 (1.1- 4.2) 0.03 Convulsions on admission 4.5 (2.3 - 8.8) <0.0001 Coma on admission 10.4 (2.1- 52.0) Multivariate logistic regression analysis of risk of death or developing a serious complication. Features present at the time of admission 0.004
  • 23. Independent risk factors for death / any serious complication Variable OR (95% CI) p value Prematurity (<28 weeks) 4.6 (1.8- 11.6) 0.001 Temperature instability on admission 3.0 (1.5- 5.8) 0.001 Convulsions on admission 4.8 (2.4 - 9.4) <0.0001 Coma on admission 19.7 (3.9- 98.7) <0.001 S. pneumoniae 6.6 (2.3- 19.3) <0.0001 Multivariate logistic regression analysis of risk of death or developing a serious
  • 24. Role of LP in making a diagnosis • LP was done in 315/329 (96%) • Post antibiotics 197/307 (64%) - in-patient vs. home admissions: 84% vs. 52%, p<0.0001 Timing of LP No bacteria in the CSF (%) Pre antibiotics 27 (21) Post antibiotics 103 (79) [X2, p=0.001]
  • 25. CSF WCC Values: The challenge Category (all cases) Value Median CSF WCC 335/ mm3 (IQR: 70-1540) CSF WCC >100/ mm3 198 (68%) CSF WCC >1000/ mm3 95 (33%) CSF WCC <20/ mm3 (AND bacteria identified) 30/329 (10%) Category 0-28 d olds CSF WCC < 20/ mm3 Category 17/196 (9%)* CSF WCC < 10/ mm3 8/94 (9%)** 29-89 d olds
  • 26. Role of blood culture in diagnosis (n=329) Overall blood culture negative 134/329 (41%) Study Category Garges (all B/C negative et alcases) Wiswell et al Negative blood culture (%) EO (0-6d) LO (7-89d) P-value (38) 43/112 35/9291/217 (42) 0.5 (38) 12/43 (28) Variable Visser et al 6/39 (15) Blood culture positive where no bacteria identified in CSF Vergnano et al 9/27 (33) n/N (%) 75/143 (52) Wiswell et al Pediatrics. 1995, Vissser at J Pediatr.1980, Garges Pediatrics. 2006, Vergnano ADC- Fetal and Neonatal
  • 27. GBS meningitis
  • 28. Demographics: Group B strep meningitis cases Category No of cases 2010-2011 150 Male 77 (51%) Median age in days (IQR) 14 (2-30) Early onset (EO, <7 days) 51 (35%) Median gestation at birth in weeks (IQR) 39 (37-40) Preterm (<37 weeks): All EO 31 (24%) 12%
  • 29. Presenting features: GBS vs. others 80% 70% Percentage of total cases 60% 50% 40% 30% 20% GBS 10% Other bacteria 0% Non specific Presenting features Specific
  • 30. Comparison of meningitis vs. GBS study in 2000-1 Category 2000-2001 (UK & ROI) 2010-2011 (UK & ROI) Duration 13 months 13 months Age group 0-89 days 0-89 days 122 0.15 (0.13 - 0.18) 150 0.16 (0.13 - 0.19) Early onset 40 (33%) 51 (38%) Late onset 82 (67%) 84 (62%) Median age (days) 11 (2-29) 14 (2-30) 38 (35-40) 3030 (2110-3460) 39 (37- 40) 3130 (2530-3530) Total cases Incidence (/ 1000 LB) Median gest age (IQR) Median BW (IQR)
  • 31. 2000 vs. 2010: GBS Case fatality (%) Category 2000-2001 2010-2011 p value All Term (≥ 37 weeks) Preterm (<37 weeks) All EO (0-6 days) All LO (7-89 days) Category Term EO Preterm EO Term LO Preterm LO 12 10 16 15 11 2000-2001 11 23 10 13 5 2 16 2 7 0.04 0.02 1 0.04 0.4 2010-2011 p value 0 0.05 17 1 3 0.2 15 1
  • 32. Outcome
  • 33. Percentage of total cases Percentage of total number of cases Timing of onset 2000/1 vs 2010/11 40 35 30 25 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 2000-2001 2010-2011 0-2 20 3 4 5 6 Day of life 2010-11 (n=150) 15 2000-01 (n=122) 10 5 0 1 2 3 4 5 6 7 8 Week of life 9 10 11 12 13
  • 34. Risk factors / clinical practice No change 2000-1 vs. 2010-11: • % with known risk factors for EO GBS: -i.e. prematurity, ROM >18hrs, known GBS carrier 40% vs. 33% (2000-1 vs. 2010-11), p=0.5 • C/S delivery 28% vs. 20% (2000-1 vs. 201011), p=0.4 • blood culture negative cases (%) 23% vs. 19% (2000-1 vs. 2010-11), p=0.4
  • 35. Independent risk factors for poor outcome in GBS meningitis Variable OR (95% CI) p value Prematurity (<28 weeks) 9.0 (1.2- 64.8) 0.03 Temperature instability on admission 3.2 (1.1- 9.7) 0.04 Convulsions on admission 3.2 (1.2- 8.6) 0.02 13.1 (2.3- 73.9) 0.003 Coma on admission Multivariate logistic regression analysis of risk of death or developing a serious complication.
  • 36. Can we improve our management? Objectives To define • Clinical presentation & early symptoms/signs (from parents’ perspective) • The current management AND To identify opportunities for improving outcome through detailed analysis of early case management
  • 37. Methodolog y Participant Identification centres (PICS) 95 NHS Trusts in England, 7 health boards in Wales Parental Pack (Study information, Consent form, parental questionnaire for onset to progression) Hospital review of case management (Research fellow visits hospital to review case management) Expert panel review of case management (PID, Neonatologist, General Paediatrician, trainee) Sept 2010 to July 2013 Ethics Cambs 2 REC: Ref: 10/H0308/64
  • 38. diagnosis (preliminary data) Category Male Age in days: median (IQR) Value 18 (59%) 1 (0-7) Prematurity (<37 weeks) 15 (50%) Birth risk factors 17 (42%) Maternal risk factors 10 (32%) Onset to 1st dose of antibiotics in hours: median (IQR) 2.6 (1.3-8.5) First dose of antibiotics to LP in hours: median (IQR) 39.4 (9.8-80.9) Inappropriate empiric antibiotics* 19 (61%) *Based on NICE bacterial meningitis (2010) and NICE EO infection 2012 (empiric antibiotics)
  • 39. Cases admitted from home (preliminary data) Category Value Male 34 (52%) Age in days: median (IQR) 16 (11-34) Prematurity (<37 weeks), n=66 8 (12%) Inappropriate pre hospital management, n=52 20 (38%) Onset to 1st help in hours: median (1QR), n=50 4.8 (2-10) Triage in hospital to 1st dose of antibiotics in hours : median (IQR), n-51 1.7 (1.0-3.3) Inappropriate empiric antibiotics* 30 (54%) Discharged at age < 2 years, n=56 23 (41%)** * Empiric antibiotic recommendation as per NICE bacterial meningitis guideline
  • 40. Summary 1: Burden of disease  Incidence - Has not changed in neonates over last 3 decades  Risk factors - Prematurity and low birth weight  Presentation - Non specific, fever absent in around half of cases  Aetiology - GBS> E. coli> S. pneumoniae. - No Listeria meningitis in infants >1 month of age • Outcome - CFR has not changed over last 2 decades
  • 41. Summary 2: GBS meningitis  Incidence of GBS meningitis has not changed over last decade  Presenting features are not different to those of other bacteria  1/3 are EO cases; 1/3 of EO cases have risk factors  CFR has significantly declined over last decade in term
  • 42. Summary 3: Current management • Management - Meningitis can occur with normal initial CSF WCC values - Timing of LP has a significant impact on bacterial identification  There are important gaps in current management! - Inappropriate pre hospital management in 1/3 of home admissions - Median time from triage to antibiotics is long EFNS/ neutropaenic sepsis guideline: antibiotics within 1hour - Inappropriate empiric antibiotics in over half
  • 43. Acknowledgements Chief Investigator Prof Paul T Heath Dr Nelly Ninis (London) Dr. Mark Anthony (Oxford) Dr. Laura Jones (Edinburgh) Prof Mary Cafferkey (Ireland) Dr. Katy Sinka (Scotland) AMR & HCAI Prof. Alan Johnson Katherine Henderson Ruth Blackburn Dr. Berit Muller-Pebody Helen Friend Richard Lynn MRL Manchester All Paediatricians Prof. Ray Borrow in the UK & the RoI Support Charities: Meningitis UK/ Meningitis Trust Dr. Claire Cameron and Group B Strep Support Dr. Alison Smith-Palmer St George’s Vaccine Institute Dr. Eisin McDonald meningitis@sgul.ac.uk staff Dr. Robert Cunney Others (HSE Ireland) Dr Eva Galiza UK & ROI Paediatricians and PIC contacts Dr. S Ladhani (HCD) Funding