All South Africans should be vaccinated against meningococcal meningitis

Johannesburg, 16 April 2020: In Southern Africa, acute bacterial or viral meningitis causes considerable morbidity and mortality.[1] In particular, even with appropriate therapy, meningococcal disease is often fatal[2] and approximately 20% of those who survive will suffer from complications, including hearing loss, skin scarring, amputations and neurological fall out.[2] Therefore, even though the incidence of meningococcal disease is relatively low in South Africa, all South Africans, starting from 9 months of age, should be vaccinated to protect against meningococcal infection.[2]

Meningococcal disease is endemic to South Africa.[2] Sporadic cases occur throughout the year and the incidence peaks during the winter and spring months of May to October.[3][4] Although all ages may be affected, the highest incidence occurs among children younger than 10 years, and especially infants.[3][4] Over the last 10 years, the average incidence per 100 000 people was 1 overall and 8 among infants.[2] More than 1 in every 6 individuals with the disease died.[2]

In South Africa, 75% of meningococcal disease has been caused by serotypes A, C, W and Y.[2]

 

From 1 January to 30 September 2019, 74 laboratory-confirmed, invasive meningococcal disease episodes were reported by the GERM-SA surveillance program.[3] Two thirds of these occurred during the first 6 months of the year.[4] Most of the affected people were from Gauteng (34%), Western Cape (30%), KwaZulu Natal (14%) and the Eastern Cape (12%).[3] Approximately 60% were due to Neisseria meningitidis serotypes Y, W and C.[3]

Up to 10% of the population are asymptomatic carriers of N. meningitidis, which is a prerequisite for invasive disease.[2] However, carriage is higher among children and adolescents,[2] and, in some areas, up to 25% of teenagers (15 to 19 years of age) may unknowingly carry and transmit the disease to others.[2][5]

Person-to-person spread occurs from the nasopharynx via respiratory droplets.[2] Risk factors for colonisation include intimate personal contact (including kissing), passive smoking, pub attendance, overcrowding, attendance at mass gatherings and previous antibiotic use.[2] Consequently, in a person presenting with features of meningitis, risk factors that suggest infection with meningococcus include exposure to childcare facilities, learning institutions and military barracks.[1] Clinical features characteristic of this pathogen include a nonblanching petechial rash (some have a maculopapular rash) and conjunctival lesions.[1]   Nevertheless, invasive meningococcal disease should be considered in anyone who presents with sudden onset of fever, vomiting, headache, neck-stiffness or petechial rash.[3] Acute meningitis is a medical emergency, requiring immediate antibiotics and hospital admission.[1] It is a category 1 notifiable medical condition, and each case should be reported immediately to ensure contact tracing, responsible prescription of chemoprophylaxis and case counting.[3]

Vaccination is recommended especially for people who are at higher risk of acquiring the disease.[2] In addition to immunocompromised individuals, consideration should be given to healthy infants, young children attending creche and school children, university students, army recruits and others living in crowded conditions, people attending a mass gathering (e.g., sporting event) and those travelling to hyperendemic areas.[2]

Menactra is a quadrivalent meningococcal vaccine targeting serotypes A, C, W and Y, which on average, have been the most common N. meningitidis serotypes in South Africa over the past 10 years.[2][6] Unlike polysaccharide vaccines, because it is a protein-conjugate polysaccharide vaccine, Menactra stimulates immune memory and induces mucosal immunity, so in addition to providing protection against invasive disease, it also decreases carriage of the organism.[2] It is indicated for routine active immunisation for individuals aged 2 to 55 years.[6] Children older than 2 years, adolescents and adults require a single primary dose.[2][6] Local guidelines also recommend vaccination of  infants aged 9 to 23 months, who require two primary doses separated by an interval of 12 weeks.[2]

References:

[1] Boyles TH, Bamford C, Bateman K, et al. Guidelines for the management of acute meningitis in children and adults in South Africa. South Afr J Epidemiol Infect 2013; 28(1):5-15.

[2] Meiring S, Hussey G, Jeena P, et al. Recommendations for the use of meningococcal vaccines in South Africa. S Afr J Infect Dis 2017; 32(3):82-86.

[3] National Institute for Communicable Diseases (NICD). Communicable Diseases Communiqué. October 2019, Vol. 18(10). Meningococcal disease update – January to September 2019. http://www.nicd.ac.za/wp-content/uploads/2019/10/NICD-Communicable-Diseases-Communique_Oct2019_final.pdf. Accessed 13 January 2020.

[4] National Institute for Communicable Diseases (NICD). Communicable Diseases Communiqué. July 2019, Vol. 18(7). Invasive meningococcal disease surveillance update: January to June 2019. http://www.nicd.ac.za/wp-content/uploads/2019/07/Invasive-meningococcal-disease-surveillance-update_January-to-June-2019.pdf. Accessed 13 January 2020.

[5] Anonychuk A, Woo G, Vyse A, et al. The cost and public health burden of invasive meningococcal disease outbreaks: A systematic review. PharmacoEconomics. 2013;31. https://doi.org/10.1007/s40273-013-0057-2.

[6] Menactra Package Insert, Sanofi-Aventis, South Africa; March 2014.

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