The W's of Meningococcal Disease in Tasmania: Who, What, Where and Why Dr Gabriela Willis Public Health Registrar CDPU Slides Prepared by Dr Faline Howes, Specialist Medical Advisor, CDPU June 2017

Overview What is Meningococcal Disease? Evolving epidemiology National Local Public Health response International

Background Rare but serious disease Neisseria meningitides bacterium 6 main serogroups: A, B, C, W-135, X and Y Bacteria normally colonise the mucosa of the upper respiratory tract without causing disease Occasionally IMD occurs

Background Spectrum of clinical illness Meningitis Septicaemia Fever, headache, neck stiffness, photophobia, muscle aches, vomiting, rash, leg pain, cold extremities. Can progress rapidly to serious disease or death in previously healthy persons. Mortality 5-10% Survivors can develop permanent sequelae, including limb deformity, skin scarring, deafness and neurologic deficits.

Epidemiology - National

Epidemiology - National

Epidemiology - National Figure 4: National notification rates for invasive meningococcal disease by serogroup, Australia, 2002–2016 Serogroup

Epidemiology - National Table 1. Notifications and rates of MenW, Australia, 2014 to 2017 YTD*, by state and territory *YTD 13 April 2017

Epidemiology - Seasonality Figure 5. Notifications of IMD, Australia, 2014 to 2017 YTD*, by month and year of diagnosis and serogroup Note: Other includes where meningococcal isolates could not be identified (‘not groupable’), other isolates not grouped and where serogroup was not known. *Data extracted from the National Notifiable Diseases Surveillance System on 13 April 2017.

Epidemiology – Age Distribution Figure 6: Notifications of IMD by age group, Australia, 2016*, by serotype.

Epidemiology – Aboriginal and Torres Strait Islander Population

Epidemiology- Carriage Meningococcal carriage by age: a systematic review and meta-analysis Hannah Christensen, Margaret May, Leah Bowen, Matthew Hickman, Caroline L Trotter Observed carriage prevalences Fitted data Range of 95% CI

Epidemiology –Hypervirulent Strain Many MenW strains identified in Australia belong to the hypervirulent sequence type ST 11, which is part of the ST 11 clonal complex (CC 11) ST11 strains are associated with a high case fatality and atypical clinical presentation, making early diagnosis challenging.

Epidemiology – Mortality Table 2: Notifications, deaths and case fatality ratio of invasive meningococcal disease, Australia, 2003 to 2015, by serogroup Serogroup B Serogroup C Serogroup W Serogroup Y All serogroups CFR (%) Cases Deaths 4.2 9.1 10.7 4.1 3,720 173 4.7 CFR Case fatality rate.

Epidemiology – Tasmania Figure 9: Notifications of IMD in Tasmania by serogroup, year and notification rate, 2001 to 2017 YTD (17 May)

Implications for Tasmania Population-based rate of Men W is higher than in other jurisdictions. Likely local transmission of the disease within Tasmania. No epidemiological links between the cases Cases did not report recent travel Rapid rise in incidence Wide geographical spread Wide age range Vaccination is the only intervention available.

Vaccines Meningococcal C conjugate vaccine (MenCCV): NeisVac-C®, or in a combination with Hib: Menitorix® Multicomponent meningococcal B vaccine (MenBV): Bexsero® Quadrivalent (A, C, W, Y) meningococcal conjugate vaccines (4vMenCV): Menactra®, Menveo®, Nimenrix®

Vaccines Who should be vaccinated? People at increased risk of IMD: MenBV and 4vMenCV. People within age groups with increased incidence of IMD or high carriage rates Infants and young children particularly those aged ≤2 years of age: Routine MenCCV at 12 months. MenBV is recommended and 4vMenCV may be offered. Adolescents and young adults (15–19 years): MenBV is recommended and 4vMenCV may be offered. Travellers: 4vMenCV Anyone wishing to reduce their risk of IMD: MenBV (from 6 weeks of age) and 4vMenCV (from 2 months of age) recommended but not funded

MenW Conjugate Vaccines Age at Commencement of Vaccine Course Recommended Brand Primary Immunisation Recommended interval between primary doses 2-6 months Menveo 3 doses 8 weeks 7-11 months 2 doses 12 weeks 12-23 Months Either Or Nimenrix 1 dose N/A  2 years Menactra, Menveo, or Nimenrix Source: NCIRS Factsheet- Meningococcal Vaccines for Australians: Information for Immunisation providers

Public Health Response - International MenW has increased internationally. England (from 2015) and Chile (from 2012) have implemented immunisation programs. England initiated MenW immunisation program when incidence = 3 cases per million. Incidence in Australia in 2016 = 4.6 cases per million. Evidence on the effectiveness of the campaigns in England and Chile is limited. Immunisation protects individuals who are immunised, but cases continue in wider population.

Public Health Response - National Coordinated national response, involving immunisation of teenagers and possibly children and infants. Mechanism for Australian Government funding of vaccines for such a pre-emptory or emergency response is currently not available. Four states (WA, NSW, Victoria, Queensland) have recently announced that they will implement immunisation of older teenagers (usually 15 to 19 year-olds) over 2017-18.

Current Tasmanian Approach Respond to each case in line with the national public health guideline for IMD. Advice to GPs: newsletter, FaxStream The Fact Sheet on IMD has been updated Updated advice to GPs and specialists Representation on national committees Issues Briefing

Public Health Response to Individual Cases Transmission from a symptomatic case is uncommon Identification of contacts Contact management Information and advice Clearance antibiotics Vaccine

Identification of Contacts The aim of identifying contacts is to: Clarify their degree of contact with the case Provide them with information about meningococcal infection and their level of risk aimed at both allaying unnecessary anxiety and advising them of what action to take if they develop symptoms Media/ Fact sheets/Letters to those affected and those not affected/ Ministerials/phone calls

Identification of Contacts Time period: 7 days prior to the onset of symptoms  Higher-Risk Contacts: Household contacts who lived in the same house (or dormitory-type room) Intimate kissing and sexual contacts Child-care as a guide, 20 hours in total Passengers seated immediately adjacent (>8 hours) Healthcare workers rarely at risk, direct contact with the nasopharyngeal secretions during a procedure e.g. intubation without wearing a surgical mask

High-risk Contact Management The aim of identifying contacts is to: Clarify their degree of contact with the case Provide them with information about meningococcal infection and their level of risk aimed at both allaying unnecessary anxiety and advising them of what action to take if they develop symptoms Media/ Fact sheets/Letters to those affected and those not affected/ Ministerials/phone calls

High-risk Contact Management Clearance antibiotics Main rationale is to eliminate from a carrier IM Ceftriaxone x 1 dose: pregnant women PO Ciprofloxacin x 1 dose: adults and children ≥ 12 years PO Rifampicin BD 2/7: younger children Vaccination Due to the prolonged risk of secondary cases in household settings. Vaccination with 4CMenB vaccine, however, is not recommended for higher risk contacts after a single case of IMD caused by serogroup B. PHUs provide free vaccine for this purpose. Education Provide information to the network of contacts about the disease and how it is spread and include the message that contacts, or anyone close to them, who develop symptoms consistent with meningococcal disease, should seek urgent medical attention. Isolation and restriction None required

Clearance antibiotics4 Vaccination5 Information Table 1: Public health responses in defined settings in which a single case of invasive meningococcal disease has occurred3 Settings Clearance antibiotics4 Vaccination5 Information Household and other higher-risk contacts of a case (refer above) Yes Childcare facilities (children and staff not high-risk contacts of a case) No Schools and universities Only students who are household-like contacts of a case All other students in the same classroom (schools) or tutorial groups (universities). Those exposed to a case after the onset of symptoms No, unless meet other criteria for higher risk contacts Those in seats directly beside a case during long duration travel (>8 hours) Healthcare workers who have performed airway management (e.g. suctioning, intubation) of a case wearing a mask. Sporting team and work contacts (including both shared office or open air settings) 3

Public Health Hotline -1800 671 738 Public Health Urgent Notify upon clinical suspicion Do not wait for lab confirmation Public Health Hotline -1800 671 738

Summary The number of cases of invasive meningococcal disease (IMD) and overall risk remains low; however, since 2013 serogroup W (MenW) has emerged as a significant cause of IMD. The situation is evolving and continues to be closely monitored The most appropriate response is being considered at a national and at a local level