Nancy Messonnier, M.D. Chief, Meningitis and Vaccine Preventable Diseases Branch

Epidemiology of Meningococcal Disease

Division of Bacterial Diseases National Center for Immunization and Respiratory Diseases

The “Meningitis Belt” of sub-Saharan Africa*

*“Meningitis belt” defined by Lapeyssonnie in 1963 Redefined by Greenwood in 1987

430 million at risk

Epidemic Meningitis Cases and Case-Fatality Rates – AFRO Region, 1965-2006*

*Meningitis in the Africa Region, 1965 – 2006, WHO/AFR, October 2006

Potential of MenA Conjugate Vaccine Programs in Africa*

•  Prevent 123,000 deaths by 2018 •  Prevent permanent disability in 287,000

children and adults •  Prevent 11 million DALYs lost •  Save approximately $99.7 million in

medical costs for diagnosis and treatment

*Meningitis Vaccine Project, 2010

Incidence of laboratory confirmed invasive meningococcal infection, EU-IBIS participants, 1999 or baseline year

Incidence per 100,000

≥ 4.00

2.00-3.99

1.00-1.99

0.5-0.99

< 0.5

年流脑分省发病率 the incidence rate of epidemic meningitis by province from 1990 to 2005（/105）*�

1990 1995

2000 2005

To To To To To To

2005

*courtesy, China, CDC

Invasive meningococcal disease case fatality ratio, by selected country* 2003 & 2004

• EU-IBIS, courtesy Mary Ramsay, • Countries with sufficient numbers, consistent reporting

Incidence of Meningococcal Meningitis by Age Groups - Niger, 1981-1994*

*Campagne et al. Bull World Health Organ 1999;77(6):499-508.

Cases of Meningococcal Meningitis, by Age Group, 1981-1996, Niamey, Niger*

*Campagne et al. Bull World Health Organ 1999;77(6):499-508.

Clinically Significant Meningococcal Serogroups*

Serogroup Characteristics

A •  Leading cause of epidemic meningitis worldwide •  Most prevalent serogroup in Africa and China •  Rare in Europe and the Americas

B •  A major cause of endemic disease in Europe and the Americas •  No vaccine commercially available for endemic disease •  Predominant serogroup in infants

C •  A major cause of endemic disease in Europe and North America •  Multiple outbreaks in schools/communities

Y •  Infrequent worldwide; emerged in the U.S. in the 1990s W-135 •  Infrequent worldwide; global outbreak- 2000 Hajj pilgrimage

X •  Infrequent worldwide; small outbreaks reported in Africa

*Modified from Granoff DM, Harrison LH, Borrow R. Vaccines. WB Saunders; 2008

Age specific incidence of IMD by serogroup All EU countries combined, 1999 baseline year*

02468

1012141618

<1 year 1 - 4years

5-9years

10-14years

15 - 19years

20-24years

25-44years

45 - 64years

65+years

Serogroup BSerogroup C

*EU-IBIS, courtesy Mary Ramsay

*Modified from Caugant, APMIS 1998;106:505-525

1985

15:P1.7,16

15:P1.7,16

4:P1.19,15 15:P1.7,16

4:P1.19,15

15:P1.3 4:P1.19,15

4:P1.19,15 15:P1.7,16 * *

Oregon, 1994

Chile Brazil 1985

South Africa 1980

Cuba 1980

Spain 1974

Norway 1969

Japan 1979

Australia 1982

Distribution of Serogroup B ET-5 Epidemics*

New Zealand 1992 4:P1.4

Dec '04 ~12%

Dec '05 ~78%

Dec '06 ~83%

Vaccine Coverage (3 doses)

0

100

200

300

400

500

600

700

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year

Num

ber

Group C Group B Other Group B with P1.4 Total Meningococcal Cases*

New Zealand Meningococcal B Notified Cases, 1990-2007*

*D. Lennon, presented to SAGE WG 2010

Serogroup B: distribution by major phenotypes All countries and years combined, Europe

others

BntP1.5/BntP1.2

BntP1.4

BntP1.15

BntP1.9

B15P1.7,16

B4P1.15

Bnt:nst

B4P1.4

*EU-IBIS, courtesy Mary Ramsay

2006–2007 1989–1991

B (46%)

C (45%)

Y (2%)

Other (7%)

B (25%)

C (30%)

Y (37%)

Other (8%)

Meningococcal Serogroup Distribution in US, Emergence of Serogroup Y

CDC, Active Bacterial Surveillance Report. 2007; CDC MMWR 1993.

Meningococcal Disease in Saudi Arabia, February 17– May, 4 2000

*Lingappa, EID 2004

France 21

Finland 2

S. Arabia 241

Singapore 4 USA 4

Indonesia 14

Morocco 3

Sweden 2 Norway 1

Germany 10

Denmark 1

Netherlands 9 Scotland 1

Belgium 1

England & Wales 50

Kuwait 3 Oman 18

International W-135 Outbreak 2000*

*cases 4/00-12/00, WHO

Burkina Faso (2002), 13,000 cases

Capsular Switching: Emergence of Serogroup W-135 N. meningitidis*

Serogroup C (C:2a:P1.5)

Serogroup W-135 (W-135:2a:P1.5)

Serogroup W-135

Recombination

*courtesy, Lee Harrison

Predominence of Serogroup A in Epidemic Districts, Africa, 2003-2007*

Serogroup 2003

(n=44) 2004

(n=22) 2005

(n=19) 2006

(n=74) 2007

(n=96) Total

A 70.5 95.5 89.5 85.1 95.8 87.8

W-135 29.5 4.5 10.5 9.5 3.1 10.2

X 0 0 0 4.1 1.0 1.6

A/X 0 0 0 1.4 0 0.4

*WHO, unpublished data

Epidemiology of Meningococcal Disease Summary

•  Epidemiology of disease varies by region •  Case fatality ratio high globally •  Burden and impact of disease in Africa

“Meningitis Belt” substantial •  Analysis limited by lack of laboratory-

based serogroup surveillance