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Prof James Stuart @ MRF's Meningitis & Septicaemia in Children & Adults 2017

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Implications of epidemic pneumococcal meningitis in meningitis belt countries
https://www.meningitis.org/mrf-conference-2017

Published in: Health & Medicine

Prof James Stuart @ MRF's Meningitis & Septicaemia in Children & Adults 2017

  1. 1. Implications of epidemic pneumococcal meningitis in meningitis belt countries James Stuart University of Bristol London School of Hygiene and Tropical Medicine World Health Organization MRF Conference, London November 2017
  2. 2. Bacteriological profile of confirmed meningitis cases in the African belt 2003-2017 Predominance of non NmA after 2010 (Introduction of MenA) In 2017: NmC (35%) Spn (27%) NmX (13%) increasing NmW (10%) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 (Week 30) NmA NmB NmW NmC NmX NmY Other Nm S.pneumoniae Hib Other Pathogens WHO Intercountry Support Team, West Africa
  3. 3. Epidemic of pneumococccal meningitis Ghana 2016
  4. 4. Epicurve as of February 15, 2016: All cause meningitis 1 Dec 15 1 Jan 16 15 Jan 15 23 Jan 15 2 Feb 2016 9 Feb 16 Ghana Health Services
  5. 5. Meningitis caseload by district, Ghana 1 Dec 2015 - 2 Mar 2016 Ghana Health Services Upper West NmW Brong Ahafo Spn
  6. 6. Comparing two districts (popn 100,000) Wenchi, Brong Ahafo, (23/24 confirmed Spn) Jirapa, Upper West (18/24 confirmed NmW) 0 5 10 15 20 25 30 51 52 53 1 2 3 4 5 6 7 8 9 10 11 Wenchi Spn Jirapa NmW Alert threshold Epidemic threshold Ghana Health Services
  7. 7. Pathogens by age Ghana Dec 2015 - Feb 2016 Ghana Health Services
  8. 8. Brong Ahafo • 104 Spn/135 confirmed meningitis cases • Largest outbreak of pneumococcal meningitis to date (886 suspected cases) • 80% Spn serotype 1 • 59% Spn cases aged 5-29 years • Case fatality among all Spn cases 24% • Six districts with weekly attack rates >10/100,000 • PCV-13 into infant immunisation programme in 2012, coverage 84% in 2013 to 95% in 2015. Kwambana-Adams BA, BMC Infect Dis, 2016
  9. 9. Epidemiology of pneumococcal meningitis in the meningitis belt • Many similarities to meningococcal meningitis – incidence in dry season 10x wet season – majority of cases in older children and adults • Previous outbreaks: Burkina Faso 2009 &2011, Chad 2009, Ghana 2010 • Outbreaks of pneumococcal meningitis confined to this region of Africa cf outbreaks in other countries that are smaller scale and predominantly pneumonia & bacteraemia • High burden outside epidemics – >25% of confirmed meningitis cases in the belt are Spn, – 53% (1528 Spn/2858 confirmed) in Burkina Faso 2011-13 (45% serotype 1) – high case fatality ratio of Spn meningitis (20% - 60%) – severe sequelae
  10. 10. Issues raised by Brong Ahafo outbreak • Large Spn outbreak outside traditional meningitis belt • NmW and Spn predominant in different parts of the country • Delays in laboratory confirmation (lack of RDTs, insufficient reference lab capacity) • Lack of guidance for Spn outbreaks (definition, case treatment, chemoprophylaxis) • Mass vaccination in NmW outbreaks. Why not pneumococcal vaccine in Spn outbreaks? • Infant vaccination schedule 3+0. Could 2+1 regime lead to herd protecton and reduce risk of outbreaks?
  11. 11. Rapid diagnosis • Challenging to identify Spn outbreaks especially if mixed with Nm • Rapid diagnostic test mainly used in meningitis belt is latex agglutination test (Pastorex): high cost, limited heat stability, not serotype specific • Immunochromatographic tests (ICT) preferable: easy to use, heat stable – Binax, good performance on CSF, Spn only, expensive Implications – Improved RDTs needed – New ICT on trial (WHO)
  12. 12. Antibiotic treatment • WHO recommends 5 days (7 days in children <2/12) treatment of suspected bacterial meningitis with ceftriaxone during outbreaks of meningococcal meningitis • Duration for children based on GRADE review (low quality evidence) • Longer courses (10-14 days) normally recommended for Spn meningitis Implications • New recommendation for suspected cases of bacterial meningitis in pneumococcal outbreaks or for confirmed Spn cases – Extend ceftriaxone treatment up to 14 days if clinical condition not improving Chemoprophylaxis to household members not recommended given lack of data on risk or benefit
  13. 13. Reactive Vaccination No guidance for use of PS or PCV vaccines in mass campaigns for pneumococcal meningitis outbreaks Implications • Need for guidance but – mass campaigns inefficient, often late in outbreak but recommended for outbreaks of meningococcal meningitis – duration of pneumococcal outbreaks, thresholds set for action, age groups affected would all affect numbers of preventable cases & deaths – logistic challenges: vaccine cost, availability, stockpile
  14. 14. As reactive vaccination inefficient, how about preventive vaccination? • PCV 10 and PCV 13 introduced or being introduced into infant schedule across meningitis belt as 3+0 schedules (no booster). Alternative schedule 2+1 (with booster). Both vaccines include serotype 1 • Direct protection: Low attack rates in Ghana in vaccinated age groups • No suggestion of indirect protection in older age groups in this outbreak nor in one study from The Gambia using 3+0 Do 2+1 schedules offer higher chance of persistent carriage reduction and herd protection (South Africa)? • Current SAGE view: no evidence to recommend one schedule over the other • Meningitis belt countries at high risk of pneumococcal meningitis in older age groups, so herd protection important. Should meningitis belt countries switch to 2+1 schedule? Should older age groups be immunised in mass campaigns for direct protection?
  15. 15. Epidemic pneumococcal meningitis in the belt: Implications • Need for – Heat stable RDTs including Spn in addition to NmW, NmC, NmX, NmY. – Extension of antibiotic treatment in Spn epidemics – More evidence on duration of antibiotic treatment for cases • Reactive vaccination imperfect, but pneumococcal meningitis high risk of death and disability. Can we deny use of an effective vaccine for outbreak control when PCV already in country? • Preventive vaccination should have high priority. Even without conclusive evidence, will moving to infant schedule with a booster at around 12 months be more likely to offer herd protection at same cost? • How about mass preventive campaigns with PCV10/13 or a monovalent conjugate serotype 1 vaccine?
  16. 16. Acknowledgements • Ghana Health Services: Franklin Asiedu-Bekoe • WHO Country Office, Ghana: Charles Okot • WHO : Olivier Ronveaux, Katya Fernandez • University of Cambridge: Laura Cooper, Caroline Trotter

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