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. In particular, even with appropriate therapy, meningococcal disease is often fatal and approximately 20% of those who survive will suffer from complications, including hearing loss, skin scarring, amputations and neurological fall out. 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.
Meningococcal disease is endemic to South Africa. Sporadic cases occur throughout the year and the incidence peaks during the winter and spring months of May to October. Although all ages may be affected, the highest incidence occurs among children younger than 10 years, and especially infants. Over the last 10 years, the average incidence per 100 000 people was 1 overall and 8 among infants. More than 1 in every 6 individuals with the disease died.
In South Africa, 75% of meningococcal disease has been caused by serotypes A, C, W and Y.
From 1 January to 30 September 2019, 74 laboratory-confirmed, invasive meningococcal disease episodes were reported by the GERM-SA surveillance program. Two thirds of these occurred during the first 6 months of the year. Most of the affected people were from Gauteng (34%), Western Cape (30%), KwaZulu Natal (14%) and the Eastern Cape (12%). Approximately 60% were due to Neisseria meningitidis serotypes Y, W and C.
Up to 10% of the population are asymptomatic carriers of N. meningitidis, which is a prerequisite for invasive disease. However, carriage is higher among children and adolescents, and, in some areas, up to 25% of teenagers (15 to 19 years of age) may unknowingly carry and transmit the disease to others.
Person-to-person spread occurs from the nasopharynx via respiratory droplets. Risk factors for colonisation include intimate personal contact (including kissing), passive smoking, pub attendance, overcrowding, attendance at mass gatherings and previous antibiotic use. 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. Clinical features characteristic of this pathogen include a nonblanching petechial rash (some have a maculopapular rash) and conjunctival lesions. Nevertheless, invasive meningococcal disease should be considered in anyone who presents with sudden onset of fever, vomiting, headache, neck-stiffness or petechial rash. Acute meningitis is a medical emergency, requiring immediate antibiotics and hospital admission. 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.
Vaccination is recommended especially for people who are at higher risk of acquiring the disease. 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.
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. 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. It is indicated for routine active immunisation for individuals aged 2 to 55 years. Children older than 2 years, adolescents and adults require a single primary dose. Local guidelines also recommend vaccination of infants aged 9 to 23 months, who require two primary doses separated by an interval of 12 weeks.
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 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.
 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.
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 Menactra Package Insert, Sanofi-Aventis, South Africa; March 2014.