1. 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

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

3. 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

4. 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.

5. Epidemiology - National

6. Epidemiology - National

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

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

9. 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.

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

11. Epidemiology – Aboriginal and Torres Strait Islander Population

12. 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

13. 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.

14. 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.

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

16. 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.

17. 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®

18. 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

19. 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

20. 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.

21. 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

22. 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

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

24. 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

25. 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

26. 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

27. 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

28. 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

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

30. 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