PENNY:
Good evening everyone and welcome to tonight’s Meningococcal W update webinar, another in the Twilight online series. My name is Penny and I am your host for this evening. Tonight I am joined by our facilitator, Dr Tim Senior and presenter Dr Vicky Sheppeard. Before we begin I would like to make an acknowledgement of country. We recognise the traditional custodians of the land and sea on which we live and work. Once again we are lucky to be joined by Dr Vicki Sheppeard, our presenter for this evening. Vicky is a public health physician who has been working for NSW Health since 1999. Vicki’s current role is Director of Communicable Diseases Branch Health Protection NSW. This role includes overseeing surveillance of notifiable diseases in NSW, coordinating communicable disease control activities, oversight of immunisation programmes including delivery of the school-based adolescent vaccination programme and representing NSW on Communicable Disease Network Australia. Previously, Vicky managed Health Protection Services in the Nepean Blue Mountains and Western Sydney LHD from 2008 to 2013. And welcome Vicky.
VICKY SHEPPEARD:
Thank you Penny and welcome everyone.
PENNY:
We are also joined by our facilitator - Dr Tim Senior. Tim is a GP at Tharawal Aboriginal Corporation in southwestern Sydney, and originally trained in the UK. Tim also an RACGP medical advisor for the National Faculty of Aboriginal and Torres Strait Islander Health, and is a Senior Lecturer in general practice and indigenous health at UWS and Tim is also a RACGP medical educator. And welcome this evening Tim.
TIM SENIOR:
Thank you very much indeed, it’s lovely to be with you all tonight.
PENNY:
I am now going to hand over to Tim and we will talk you through the learning outcomes and then Vicky will take through the remainder of the webinar.
TIM SENIOR:
Lovely, thank you very much Penny.These learning outcomes coming up on your screen shortly and this is what we think by the end of tonight we hope that we have covered and this you will be more confident about doing.
You should be able to identify the signs and symptoms of meningococcal disease, you should be able to identify the emergency management of meningococcal disease including public health notification of that. We’ll talk a bit about the epidemiology of men in meningococcal disease in Australia and we’ll recognise the types of meningococcal vaccines that are available to us and the recommended usage of each of those vaccines, and hopefully as a result you will be able to maximise the uptake of the meningococcal ACWY vaccine in recommended groups. So Vicky, I think you’ll take us on through the first slide about what meningococcal disease actually is?
VICKY SHEPPEARD:
Yeah. And thanks Tim and I guess just to comment that we will go through recognition and management of cases and contacts but this is in the context of increasing meningococcal disease in NSW and Australia and our recently started Meningococcal W Response Program in NSW. So we’ll get on to those very current topics further on the presentation.
Just back to basics and I am sure it never hurts to go back to basics. So invasive meningococcal diseases I am sure everyone on the phone is aware it’s a serious bacterial infection and the serogroups are important to understand and quite crucial to understanding protection and epidemiology. So the ones we see in Australia are mainly B, C, W and Y. There are other serogroups and certainly in Africa, for example, serogroup A was the predominant type. And invasive meningococcal disease typically presents as either meningitis or septicaemia or both, and I am sure you are all aware that it can be fatal, even with appropriate antibiotic treatment and relatively high proportion of survivors have long term complications, usually neurological or the loss of limbs or parts of limbs.
So carriage is important concept to understand. It really feeds into our preventive strategies for meningococcal disease. So I’ll just talk briefly about that. And a common statistic which I am sure you’ve all heard is that about 10% of the population are carriers of meningococcal bacteria. And it’s carried really at the back of the throat. And it’s carriage that drives infection, so a person who has invasive meningococcal disease, have usually recently acquired it from a carrier and rather than just developing colonisation, they immediately develop invasive disease.
But your carriage isn’t straight forward, it’s not a uniform 10% across the population so the studies that have been done in similar industrialised first-world countries such as ourselves find that the carriage peaks at around 19 years of age, where about 1 in 4 young people would be carrying a meningococcal bacteria in their throat, and decreases down to less than 10% in 50 year olds and it’s also rather low actually in infants and young children.
So it’s thought that the older adolescents, the young adults are the ones that really drive the carriage in the community and so other ones that when we – to control meningococcal disease in the community – if we can control and reduce carriage in older adolescents and young adults, then we can reduce the rate of colonisation and infection right across the community. So this is the basis of responding to a case but it’s also a basis of our meningococcal vaccination programs.
So of course meningococcal disease remains a rare condition and most GPs will not see a case. But of course if you do see a case it’s really important to recognise and respond to that case. So unfortunately, as with many conditions, the early symptoms are non-specific and can be difficult or almost impossible to pick up. The meningococcal disease is characterised by a sudden onset of fever, often headache, neck stiffness and joint pain. Young children might just be irritable, they might complain that their legs hurt, they can’t walk. They might also have cold extremity or very young infants might just have high pitched crying and refusal to eat. We do emphasize in our community education that while the rash is characteristic, so a non-blanching rash that might be a pink prick or larger bruise like rash, that is typical of meningococcal but it’s a late sign in most cases, so we certainly don’t want to wait until we see that classic rash before we act on suspected meningococcal disease.
And in a number of cases that we’ve had notified to us have had an astute GP or emergency department position just pick up one single non-blanching spot. So the overall examination of the patient presenting with sudden onset of fever and these symptoms is really important to detect if that rash or even one spot of the rash is present. But Tim, I don’t know if you’d like to comment at all on the presentation?
TIM SENIOR:
No, I think it’s always difficult because so much of that sort of – minor – self-limiting viral illness starts off looking like that and it’s one of the things that I think we all think about is being able to recognise and pick that at an early stage and also an appropriate safety netting so that we’re advising people and parents about what to do if things do look like, if they’re getting worse ‘cause this is one of the classic GP presentations that none of us want to miss. But it’s very difficult.
VICKY SHEPPEARD:
I think one thing that we emphasise in communication to the public is that it is hard to diagnose in the early stages but that if a parent is worried about their child, they’re getting worse, don’t be concerned to go back even if it’s later the same day rather than sitting on a deteriorating patient at home just because in the morning the GP didn’t suspect meningococcal disease.
TIM SENIOR:
So we’ve just got a question about that treatment there of benzylpenicillin or Ceftriaxone if they are allergic, what would be the recommendation if they are allergic to both?
VICKY SHEPPEARD:
Wow. There is – I don’t know Tim – if you have another recommendation, those are the recommendations in the therapeutic guidelines, would we often find someone allergic to both penicillins and Cephalosporins?
TIM SENIOR:
So it’s not that common but there’s some cross over in allergy and I think it’s about 10% of people who are allergic to penicillins are also allergic to Cephalosporin. So it would be a small group, we might have to get back to you on that see what it is, but the therapeutic guidelines is normally very good for advice on that. So yes we might check that out and get back to you.
VICKY SHEPPEARD:
Yeah, and of course depending on where you’re practicing, immediate transport to hospital might be the safest option in that kind of setting. But of course, for many GPs, there will be a significant delay between suspecting meningococcal disease and getting the patient to an appropriate emergency department. So that’s where the GP instituting emergency antibiotics is really crucial.
TIM SENIOR:
Absolutely – we have got a question there. If there is no facility to do blood cultures, can we administer antibiotics and I think in general it’s my feeling that this is such a serious illness, that early antibiotics save lives. If you can’t get the cultures, just get the antibiotic into someone would that be your position as well?
VICKY SHEPPEARD:
Exactly. That’s exactly right. And with PCR now, even though cultures may not be viable once they have arrived at hospital, certainly a blood sample taken at hospital will be able to be subjected to PCR and very likely to still be able to confirm the diagnosis even if nothing has been collected prior to antibiotics.
TIM SENIOR:
So that’s really helpful.
VICKY SHEPPEARD:
Sorry there’s some other questions coming through there.
TIM SENIOR:
Yes there are. Someone is commenting on their immunologic spot test which would be similar to a different sort of test but similar functions that PCR and wondering about giving steroids as well as antibiotics in that initial treatment?
VICKY SHEPPEARD:
No that’s not a recommendation and that would be something that we’d leave to the Emergency Department and Intensive Care to initiate.
TIM SENIOR:
Antibiotics and that thing and IM in the gluteal legion?
VICKY SHEPPEARD:
Yes.
TIM SENIOR:
Good. And some comments coming through about lesion cultures but actually it’s – as some point out there isn’t an open wound to swab, it’s either septicaemia or meningitis so – simply blood cultures or ????? I would imagine?
VICKY SHEPPEARD:
You can take a skin scraping if there is a skin rash, so that is and particularly if you’re not able to collect a blood culture and there is a rash, a skin scraping is the easiest way to go.
TIM SENIOR:
That’s helpful.
VICKY SHEPPEARD:
Okay. So just an important message now, I’m just not sure if you are aware but not all hospital doctors are efficient and reliable on notifying public health units, so certainly public health units in New South Wales and ACT would very much value a call from a general practitioner if you are suspecting meningococcal disease and arranging a transfer. And that enables that the public health unit to start to implement the contact, the case investigation and the contact management in a very timely fashion.
TIM SENIOR:
So then just before we move on - just another question there – asking if the rash is blanching can we exclude meningococcal rash, that would depend on the clinical scenario, if someone is looking unwell, don’t purely rely on the rash to exclude that I would think.
VICKY SHEPPEARD:
And in fact one of the cases we had last week on their initial presentation did have a blanching rash and then they progressed to non-blanching. So as you know in medicine there are many ways to present with a condition as there are people.
TIM SENIOR:
Exactly right. Thank you.
VICKY SHEPPEARD:
All right. There’s some questions on vaccination coming in but we will cover that later and perhaps a question for you there Tim, about the location of the intramuscular?
TIM SENIOR:
I think, I mean my impression would be anywhere IM as long as the antibiotics get in, then that’s the most important thing, so do it where you can, if that’s gluteal do that, if that’s thigh, do that. And I think the – I think take the point about being neurologically safe and avoiding the nerve I remember being taught upper outer quadrant of the gluteal muscles, I remember. But I think the most important thing is getting the antibiotics in first.
VICKY SHEPPEARD:
All right. Well maybe we’ll just move on to contact management and this is a role for the public health unit but it’s done in collaboration with general practitioners and the hospital staff. And the purpose and you know – depending on when you did do medical school, I think some of the terminology here has changed, so this used to be called prophylactic antibiotics. But we now call it clearance antibiotics. And the purpose of the antibiotics given to close contacts is to clear carriage from whichever in the group of close contacts of the case is carrying that invasive strain of meningococcal bacteria. So this is based on empiric evidence of who is the most likely person or group of people to have been the source of infection for this recently presented case.
So it’s close contacts, household members of a case, or people who’ve had household like contact with the case. So someone if it’s a student staying in a dormitory, the same students that are sharing the bathrooms and bedrooms would be a close contact. Of course intimate contact – so any deep kissing or sexual contacts of the case 7 days before onset are close contacts, and then also if it’s a pre-schooler, they’re attending child care and attended more than a couple of days in the 7 days before onset, the whole care group is considered close contacts. So that’s all the other pre-schoolers and the teachers.
And then the other type of close contact would be if someone develops invasive meningococcal disease within 7 days of an international flight – the people sitting either side of the case during that flight is considered close contacts. All these scenarios do arise. So the public health units do that work if identifying the close contacts and determining the appropriate antibiotic clearance. And then of course there’s a wider group of contacts. So for example, workplace colleagues, children in primary school or high school in the same class, visitors that might have come to the house. This is what we call low level contacts and we do strive to give them information as well and of course, the close contacts get information and that information really is about letting them know that they are at some risk, increased risk of a meningococcal disease in the next few weeks, the symptoms to look out for, and what to do if they suspect the symptoms.
So on this slide we’ve just outlined the main agent that we use for close contacts of meningococcal disease cases. So really now it’s Ciprofloxacin is the preferred agent, because it’s single dose and it’s you know – a safe agent at any age, if it’s just one dose. So that’s the optimal clearance antibiotic to use. There’s some problems in using that for small children in that there’s no suspension available of Ciprofloxacin in Australia, but sometimes we can get the pharmacy to make up a suspension. But if that’s not an option we can Rifampicin and it’s fine and safe to use in children, but there – you know – it does require a four-dose course, about 12 hourly, for 2 days. So it’s slightly less desirable to use, and then we can’t use either of those agents in pregnant women, so in that case we use Ceftriaxone and sometimes, for example, in remote communities where there might be a concern of access to the other agents or adherence to the course of Rifampicin we might also use Ceftriaxone there as well, so that we know that the clearance antibiotics have been received and doing its job.
TIM SENIOR:
So we’ve got a question here about the guidelines regarding a place where – it’s a good place to transmit disease in outpatient settings or waiting rooms or things, and I imagine those are low-level contacts unless there’s a lot of kissing going on in the waiting rooms.
VICKY SHEPPEARD:
Yeah, meningococcal disease isn’t all that transmissible. So we just need standard and droplet precautions when the patient’s hospitalised. And even, you know, health care workers that are looking after a patient in hospital don’t usually require clearance antibiotics and unless they have for example intubated without wearing a mask. So it’s not highly transmissible like flu or other infections. So just standard and droplet precautions are adequate and unless the case is kept in a – you know – if they’re not suspected as meningococcal disease and their initial admission is in a shared ward, and they stay overnight, then we might need clearance antibiotics for the other patients, but generally it’s not that transmissible.
TIM SENIOR:
And do you do any testing of contacts to see if they’re carrying meningococcal?
VICKY SHEPPEARD:
No there’s quite clear guidance against doing that, that’s it’s a fairly futile activity. So it’s really the antibiotics should be given as soon as possible without waiting for any testing. And given to the group that empirically is known to be most likely to have carriage.
TIM SENIOR:
Yes. Excellent. Thank you.
VICKY SHEPPEARD:
All right, so the next slide is just reinforcing that information about written information for all contacts and then if we have contacts of a serogroup A, C, W or Y where we’ve got an infective rapidly active vaccine, we also then supply that vaccine for – you know – the household contacts or other very close contacts of those cases and that’s part of the public health response, so that vaccine’s free. And so the public health unit will arrange that and will often send it to the general practice for those contacts to come and receive it. And yes, it’s free of charge.
TIM SENIOR:
Excellent.
VICKY SHEPPEARD:
And there’s a question, is there – if the GP needs to do investigation for contacts, and really that’s a public health role, sometimes they might ask for assistance if there’s you know, difficulty contacting a family or something like that, but it’s usually led by the public health unit and then seeking the GPs assistance with perhaps prescribing antibiotics or administering the vaccine.
VICKY SHEPPEARD:
So if it’s all right, we might just go onto epidemiology of meningococcal disease.
So the first graph that we have is of NSW meningococcal disease notification back to 1990 for when we have reliable data. So there’s a few interesting things here to point out. So the dark blue line, which is quite high back in the 90s, that untyped so that reflects the laboratory state at that time whereas most of the cases of meningococcal disease when we were getting around 100 or so a year, we didn’t have the ability to do any further typing. But then as the 90s progressed, we see an increase in both B which is the purple line and C which is the kind of the teal line. And you can see that once we did get typing in, B had been the predominant strain even though C had a vaccination program implemented, there was always more cases of B. But over time, without a dedicated vaccination program, meningococcal B notifications have decreased. Now meningococcal C was around about 60 cases a year in NSW, and the national program introduced meningococcal C vaccine in 2003 and you can see after 2003, quite a sharp decreased in the number of cases down to zero or a few – one or two per year – since that program has been effective. And then the other thing to note, for NSW is that you know – W which is the kind of orangey colour and Y which is the pale blue, just kind of kicking along the bottom, you know 5-10 cases per year and we’ll have more detail on this in a minute, a real upswing in W but also Y in 2016 and of course, the 2017 numbers are low for all because we’ve only got a few months of the year in there.
So we’ll just go onto the next slide, which just summarises the total number of meningococcal cases in NSW in the recent years. So I think this kind of shows that by 2014 we were feeling very comfortable with only about 30 or 40 cases notified per year. And then we’ve had this big increase in to 2015 and then a very substantial increase during 2016, so that we’ve lost a lot of the gains we’ve made in the decreasing meningococcal B cases. If we could go onto the next one, that’s showing the different serogroups in NSW in the recent times and the purple line there which is the serogroup W basically doubled each year from 2013 to 2014, and then 2014 to 2015 and almost tripled from 2015 to 2016. At the same time, the light blue, the Y has also increased above the levels that we had been seeing over the longer term period.
If we can go onto the next one, the next slide, this is our national data, and this is available on the Commonwealth website, and a similar picture, there is no new information here but I think it’s very clear to see particularly in these recent years – 2013, 2014, 2015, 2016 – the increase in W nationally, which is the bright purple section, where it doubled year on year and then tripled with 110 cases notified in 2016. And also nationally there’s been an increase in the serogroup Y cases and that right across the country, there’s been this decrease in this meningococcal B which is the red bars. And then we’ve got a question that we’re just about to look at in the next slide about the seasonal trend.
TIM SENIOR:
That’s right, it’s coming up I was thinking.
VICKY SHEPPEARD:
So yes, meningococcal disease typically peaks winter and early spring and so this is the last 3 years across the country and it’s quite clear in 2014 and 2015 the peaks are kind of August/September and then 2016 another very worrying feature, we did have a big August but you can see there – October was nearly as high as August and then if you look at the months following October - November, December, January are all the summer months – are much higher than what we normally see during the summer period and, you know, similar to what the normal peak months of the year.
And this is mainly contributed from the increase in meningococcal W but also quite substantially for meningococcal Y. So this is a worrying trend to all of us, across Australia, and so very concerned to see this increase in an unseasonal increase in meningococcal disease. And then if we just move on to the next slide it’s showing the age groups affected by year, in Australia. And of course 2017 remains an incomplete year, so that’s a bit hard to judge. But for the under ones, you can see that this is meningococcal W disease in Australia, the rate in the number ones, which is the black line, has reached in 2016 3 cases per 100,000. It’s gone up in the 1-4s and also particularly in the 20-24 year olds. But the other interesting thing I guess about meningococcal W diseases is that you can see here that it’s affecting the whole age spectrum from under ones to right through to people over 65 years of age. So it’s a bit of a wicked problem about knowing how to target an immunisation program or other interventions to combat this increase in meningococcal W disease.
The other feature that we’re seeing if we could just move on to the next slide about meningococcal W disease is that it is more severe than other strains of meningococcal disease in Australia. So it’s contributed more than half the deaths in 2015 and 2016. So it’s running around twice the case fatality rate than meningococcal B disease. And about a fifth of the cases have an atypical presentation, so some of the cases have just presented with an epiglottitis or severe pharyngitis picture. Some have presented with septic arthritis and others with pneumonia, and this is particularly been the case in the older patients with meningococcal W disease. So what we’ve learnt is that there’s many different disease of classifying and looking at the molecular structure of the meningococcal W cases we’re seeing. They’re said to belong to what’s called a hyper-virulent strain that’s called serotype 11 and this is known internationally to be associated risk of invasive disease and increased case fatality rate. And co-incidentally, it’s the same clonal complex as the meningococcal C disease that we had in Australia back in the early 2000s that also had much higher case fatality rate. And sorry, Tim?
TIM SENIOR:
I was just going to say there’s a few questions coming through about different vaccinations and so we’re not ignoring those, they are actually coming up very shortly in the presentation, so we’ll cover those answers. We’ll be coming to that very soon.
VICKY SHEPPEARD:
This is the last slide about the epidemiology so - just to put it in an international context. So this hyper-virulent meningococcal W disease first arose in South America, mainly Chilé about 10 years ago. And then from 2010, the UK started experiencing an increase in hyper-virulent meningococcal disease, and in response to that, introduced a meningococcal ACWY vaccine for adolescents and it’s showing good signs of giving good individual protection, not yet seeing any herd protection from that. And now other European countries are starting to see this increase in meningococcal W disease. And we’ve done genetic studies on the Australian cases and they’re very close that the bugs, the bacteria from Australian people with meningococcal W disease, very closely related to the UK strain. And just to note, that in the United States, they’ve had this adolescent dose of ACWY vaccine since 2005. And the graph here – and I’m sorry the reference isn’t showing up on the slide but we can send that later – shows in the US from 1997 through to 2013, a very steady decrease in deaths and incidence of meningococcal disease. And their rate of meningococcal disease in the US is only around about 0.2 per 100,000 whereas in Australia now we’re at 1.1 per 100,000. So it’s very interesting, you know, to look at different vaccination approaches in different countries and what impact that might be having on the disease incidence in the different countries, though we don’t have any proof behind that.
Yes and so that question here – has the US avoided the same increase in W strain? Yes, there’s been no indication of any take off of meningococcal W disease in the US.
All right, I think we’ll move on to vaccines now. So this seems to be a good time – what questions about them?
TIM SENIOR:
That’s right.
VICKY SHEPPEARD:
So we’ve got really two types of meningococcal vaccines now. I’m not going to talk about the polysaccharide vaccines which were common available but I’m really now – we’d only be recommending the conjugate vaccines or the recombinant vaccines. So the conjugate vaccines are highly effective – probably at least 85% individual protection but they’re very specific for the serogroup that they’re manufactured for and we’ll talk about the individual ones in a minute, this is just the general approach. And they give high level protection and it comes very soon after just a single dose. And that high level protection persists for at least up to 5 years. And they’re known to have a good impact on carriage. So meningococcal C vaccine is an example of a conjugate meningococcal vaccine and we can see from the epidemiology, the impact that wide – so when that was introduced we vaccinated 1-19 year olds and that had a very rapid impact on meningococcal disease right across the Australian population and by continuing to vaccinate 1 year olds, we’re just maintaining good herd immunity and reducing colonisation and having good control on meningococcal C vaccine on the disease with that conjugate vaccine.
The next class of vaccine which is really just Bexsero at the moment, it’s a recombinant meningococcal vaccine and it has a completely different approach to protection against meningococcal disease. So it’s using protein antigens that are found across multiple strains of meningococcal disease but because it’s using protein antigens rather than the coding of the serogroup, it is expected to provide some cross protection against other serogroups, and in the United Kingdom they are hoping, with some evidence, that by using meningococcal B vaccine in infants, that they will give them some cross protection against other groups such as meningococcal W. But you know – a limitation of the recombinant vaccines is that it requires at least two doses to develop a protective antibody response. And we also don’t know the duration of protection because they’re just recently introduced. And we don’t really know exactly what their effectiveness is – even against meningococcal B. So that’s something that we’re still gathering evidence on.
So just moving through the conjugate vaccines – so Menitorix is one you’re all familiar with, the combination of the haemophilus influenzae B and meningococcal C - of course it’s recommended at 12 months of age but it can be used from 6 weeks of age, if necessary. But children who do receive a dose under 12 months of age should have a booster dose when they turn 12 months of age.
The next slide is -
TIM SENIOR:
I was just going to say there are a few questions coming through but the answers to those are also coming up I think and we’ll make sure we cover those eventually.
VICKY SHEPPEARD:
We’ll go back through them if not.
So these are the conjugant ACWY vaccines, so same principle as the meningococcal C vaccine but covering C, A, W and Y serogroups. There are 3 bands available in Australia, so Menactra, Nimenrix and Menveo. They are all registered at different minimum ages, and also the number of doses in the interval depends on the age of the person you’re vaccinating and the brand of vaccine. I haven’t put all that detail in the presentation but it’s very nicely laid out in the handbook but basically – our basic thing we can say is that for all 3 vaccines, for anyone 7 years of age or older, a single dose is all that’s required and if ongoing protection is required, and we’ll talk about that again in a minute, then a booster after 5 years.
TIM SENIOR:
Excellent, so there’s a question here about someone whose daughter has Menitorix at the scheduled 12 months’ vaccine and should she also have Nimenrix two months’ later?
VICKY SHEPPEARD:
Yes. That would be a very sensible approach. So if you or parents are wanting to give a broader range of protection against for further or 3 more strains of meningococcal disease, that would be the optimal interval. So 2 months after Menitorix you could give Nimenrix or Menveo. And – it could be given as soon as 4 weeks’ after but really the recommendation would be to wait 8 weeks and then that would give a booster for the C and give good protection against A, W and Y.
TIM SENIOR:
Excellent. Now for all of you asking questions about meningococcal B vaccination, pay attention to the next slide.
VICKY SHEPPEARD:
So – look I’m sure you’ve heard a lot about Bexsero because I think it’s been directly marketed to general practice. Again, here the course is complex depending on the age at which it’s started. So there’s – you think of a primary dose which is either 3 or 2 doses, depending on the age and then the need for a booster at 12 months of age if the primary cause is done given prior to 12 months’ of age. So were they the questions about recommendations for meningococcal B vaccine and also probably availability?
TIM SENIOR:
Yeah that’s right. But it’s a recommendation.
VICKY SHEPPEARD:
Recommended and not funded for infants and for adolescents. So this is a discussion to have with the parent or the young adolescent or older adolescent that – as it’s expected to give good individual protection, but it’s not considered cost effective to fund on the National Immunisation Program so it’s an individual decision about whether they would seek to have protection but certainly it’s apparently a safe vaccine and effective, as far as we know. So if parents are prepared to spend, then that should be supported.
TIM SENIOR:
What is the cost, do you know, to the patient?
VICKY SHEPPEARD:
Yeah, it’s around about $150.00 per dose. And at the moment there is a shortage of Bexsero so the UK program that I mentioned has a – as we know – vaccines are part of a global market and the UK program has sucked up a lot of the supplies, so I understand it is hard to obtain in Australia at the moment, even if parents are wanting to get it.
TIM SENIOR:
Yep.
VICKY SHEPPEARD:
And there’s a question there – what age would you recommend it considering the epidemiology, well certainly we do see a lot of meningococcal disease under 12 months of age, so really incorporating it into the primary course with the other vaccines or soon after, is probably getting optimal protection from it. Of course, if it is – the down side with Bexsero is that it is quite pyrexic and it is recommended to take Panadol prior to the dose and so – whether parents want to have that at the same time as the NIP vaccines or wait a couple of weeks.
TIM SENIOR:
And it can be used alongside routine? Yeah?
VICKY SHEPPEARD:
It can be given with other childhood vaccines or you could give it two weeks or a month later, to kind of break it up depending on what the parents –
TIM SENIOR:
It can be used with older children as well?
VICKY SHEPPEARD:
Yes it can be used and so that would be a two dose primary course and a booster is not required, and what we saw from the other sides, we seen variable disease in primary aged children, but you know, as children are entering into older adolescent, there certainly isn’t a pick up in the number of cases. And in particularly if it’s young people who might going to boarding school, colleges, universities, military, then it would be a good recommendation for those adolescents.
VICKY SHEPPEARD:
So if it’s all right, we might just go onto epidemiology of meningococcal disease. So the first graph that we have is of NSW meningococcal disease notification back to 1990 for when we have reliable data. So there’s a few interesting things here to point out. So the dark blue line, which is quite high back in the 90s, that untyped so that reflects the laboratory state at that time whereas most of the cases of meningococcal disease when we were getting around 100 or so a year, we didn’t have the ability to do any further typing. But then as the 90s progressed, we see an increase in both B which is the purple line and C which is the kind of the teal line. And you can see that once we did get typing in, B had been the predominant strain even though C had a vaccination program implemented, there was always more cases of B. But over time, without a dedicated vaccination program, meningococcal B notifications have decreased. Now meningococcal C was around about 60 cases a year in NSW, and the national program introduced meningococcal C vaccine in 2003 and you can see after 2003, quite a sharp decreased in the number of cases down to zero or a few – one or two per year – since that program has been effective. And then the other thing to note, for NSW is that you know – W which is the kind of orangey colour and Y which is the pale blue, just kind of kicking along the bottom, you know 5-10 cases per year and we’ll have more detail on this in a minute, a real upswing in W but also Y in 2016 and of course, the 2017 numbers are low for all because we’ve only got a few months of the year in there.
So we’ll just go onto the next slide, which just summarises the total number of meningococcal cases in NSW in the recent years. So I think this kind of shows that by 2014 we were feeling very comfortable with only about 30 or 40 cases notified per year. And then we’ve had this big increase in to 2015 and then a very substantial increase during 2016, so that we’ve lost a lot of the gains we’ve made in the decreasing meningococcal B cases. If we could go onto the next one, that’s showing the different serogroups in NSW in the recent times and the purple line there which is the serogroup W basically doubled each year from 2013 to 2014, and then 2014 to 2015 and almost tripled from 2015 to 2016. At the same time, the light blue, the Y has also increased above the levels that we had been seeing over the longer term period.
If we can go onto the next one, the next slide, this is our national data, and this is available on the Commonwealth website, and a similar picture, there is no new information here but I think it’s very clear to see particularly in these recent years – 2013, 2014, 2015, 2016 – the increase in W nationally, which is the bright purple section, where it doubled year on year and then tripled with 110 cases notified in 2016. And also nationally there’s been an increase in the serogroup Y cases and that right across the country, there’s been this decrease in this meningococcal B which is the red bars. And then we’ve got a question that we’re just about to look at in the next slide about the seasonal trend.
TIM SENIOR:
That’s right, it’s coming up I was thinking.
VICKY SHEPPEARD:
So yes, meningococcal disease typically peaks winter and early spring and so this is the last 3 years across the country and it’s quite clear in 2014 and 2015 the peaks are kind of August/September and then 2016 another very worrying feature, we did have a big August but you can see there – October was nearly as high as August and then if you look at the months following October - November, December, January are all the summer months – are much higher than what we normally see during the summer period and, you know, similar to what the normal peak months of the year.
And this is mainly contributed from the increase in meningococcal W but also quite substantially for meningococcal Y. So this is a worrying trend to all of us, across Australia, and so very concerned to see this increase in an unseasonal increase in meningococcal disease. And then if we just move on to the next slide it’s showing the age groups affected by year, in Australia. And of course 2017 remains an incomplete year, so that’s a bit hard to judge. But for the under ones, you can see that this is meningococcal W disease in Australia, the rate in the number ones, which is the black line, has reached in 2016 3 cases per 100,000. It’s gone up in the 1-4s and also particularly in the 20-24 year olds. But the other interesting thing I guess about meningococcal W diseases is that you can see here that it’s affecting the whole age spectrum from under ones to right through to people over 65 years of age. So it’s a bit of a wicked problem about knowing how to target an immunisation program or other interventions to combat this increase in meningococcal W disease.
The other feature that we’re seeing if we could just move on to the next slide about meningococcal W disease is that it is more severe than other strains of meningococcal disease in Australia. So it’s contributed more than half the deaths in 2015 and 2016. So it’s running around twice the case fatality rate than meningococcal B disease. And about a fifth of the cases have an atypical presentation, so some of the cases have just presented with an epiglottitis or severe pharyngitis picture. Some have presented with septic arthritis and others with pneumonia, and this is particularly been the case in the older patients with meningococcal W disease. So what we’ve learnt is that there’s many different disease of classifying and looking at the molecular structure of the meningococcal W cases we’re seeing. They’re said to belong to what’s called a hyper-virulent strain that’s called serotype 11 and this is known internationally to be associated risk of invasive disease and increased case fatality rate. And co-incidentally, it’s the same clonal complex as the meningococcal C disease that we had in Australia back in the early 2000s that also had much higher case fatality rate. And sorry, Tim?
TIM SENIOR:
Was just going to say there’s a few questions coming through about different vaccinations and so we’re not ignoring those, they are actually coming up very shortly in the presentation, so we’ll cover those answers. We’ll be coming to that very soon.
VICKY SHEPPEARD:
This is the last slide about the epidemiology so - just to put it in an international context. So this hyper-virulent meningococcal W disease first arose in South America, mainly Chilé about 10 years ago. And then from 2010, the UK started experiencing an increase in hyper-virulent meningococcal disease, and in response to that, introduced a meningococcal ACWY vaccine for adolescents and it’s showing good signs of giving good individual protection, not yet seeing any herd protection from that. And now other European countries are starting to see this increase in meningococcal W disease. And we’ve done genetic studies on the Australian cases and they’re very close that the bugs, the bacteria from Australian people with meningococcal W disease, very closely related to the UK strain. And just to note, that in the United States, they’ve had this adolescent dose of ACWY vaccine since 2005. And the graph here – and I’m sorry the reference isn’t showing up on the slide but we can send that later – shows in the US from 1997 through to 2013, a very steady decrease in deaths and incidence of meningococcal disease. And their rate of meningococcal disease in the US is only around about 0.2 per 100,000 whereas in Australia now we’re at 1.1 per 100,000. So it’s very interesting, you know, to look at different vaccination approaches in different countries and what impact that might be having on the disease incidence in the different countries, though we don’t have any proof behind that.
Yes and so that question here – has the US avoided the same increase in W strain? Yes, there’s been no indication of any take off of meningococcal W disease in the US.
All right, I think we’ll move on to vaccines now. So this seems to be a good time – what questions about them?
TIM SENIOR:
That’s right.
VICKY SHEPPEARD:
So we’ve got really two types of meningococcal vaccines now. I’m not going to talk about the polysaccharide vaccines which were common available but I’m really now – we’d only be recommending the conjugate vaccines or the recombinant vaccines. So the conjugate vaccines are highly effective – probably at least 85% individual protection but they’re very specific for the serogroup that they’re manufactured for and we’ll talk about the individual ones in a minute, this is just the general approach. And they give high level protection and it comes very soon after just a single dose. And that high level protection persists for at least up to 5 years. And they’re known to have a good impact on carriage. So meningococcal C vaccine is an example of a conjugate meningococcal vaccine and we can see from the epidemiology, the impact that wide – so when that was introduced we vaccinated 1-19 year olds and that had a very rapid impact on meningococcal disease right across the Australian population and by continuing to vaccinate 1 year olds, we’re just maintaining good herd immunity and reducing colonisation and having good control on meningococcal C vaccine on the disease with that conjugate vaccine.
The next class of vaccine which is really just Bexsero at the moment, it’s a recombinant meningococcal vaccine and it has a completely different approach to protection against meningococcal disease. So it’s using protein antigens that are found across multiple strains of meningococcal disease but because it’s using protein antigens rather than the coding of the serogroup, it is expected to provide some cross protection against other serogroups, and in the United Kingdom they are hoping, with some evidence, that by using meningococcal B vaccine in infants, that they will give them some cross protection against other groups such as meningococcal W. But you know – a limitation of the recombinant vaccines is that it requires at least two doses to develop a protective antibody response. And we also don’t know the duration of protection because they’re just recently introduced. And we don’t really know exactly what their effectiveness is – even against meningococcal B. So that’s something that we’re still gathering evidence on.
So just moving through the conjugate vaccines – so Menitorix is one you’re all familiar with, the combination of the haemophilus influenzae B and meningococcal C - of course it’s recommended at 12 months of age but it can be used from 6 weeks of age, if necessary. But children who do receive a dose under 12 months of age should have a booster dose when they turn 12 months of age.
The next slide is -
TIM SENIOR:
I was just going to say there are a few questions coming through but the answers to those are also coming up I think and we’ll make sure we cover those eventually.
VICKY SHEPPEARD:
We’ll go back through them if not.
So these are the conjugant ACWY vaccines, so same principle as the meningococcal C vaccine but covering C, A, W and Y serogroups. There are 3 bands available in Australia, so Menactra, Nimenrix and Menveo. They are all registered at different minimum ages, and also the number of doses in the interval depends on the age of the person you’re vaccinating and the brand of vaccine. I haven’t put all that detail in the presentation but it’s very nicely laid out in the handbook but basically – our basic thing we can say is that for all 3 vaccines, for anyone 7 years of age or older, a single dose is all that’s required and if ongoing protection is required, and we’ll talk about that again in a minute, then a booster after 5 years.
TIM SENIOR:
Excellent, so there’s a question here about someone whose daughter has Menitorix at the scheduled 12 months’ vaccine and should she also have Nimenrix two months’ later?
VICKY SHEPPEARD:
Yes. That would be a very sensible approach. So if you or parents are wanting to give a broader range of protection against for further or 3 more strains of meningococcal disease, that would be the optimal interval. So 2 months after Menitorix you could give Nimenrix or Menveo. And – it could be given as soon as 4 weeks’ after but really the recommendation would be to wait 8 weeks and then that would give a booster for the C and give good protection against A, W and Y.
TIM SENIOR:
Excellent. Now for all of you asking questions about meningococcal B vaccination, pay attention to the next slide.
VICKY SHEPPEARD:
So – look I’m sure you’ve heard a lot about Bexsero because I think it’s been directly marketed to general practice. Again, here the course is complex depending on the age at which it’s started. So there’s – you think of a primary dose which is either 3 or 2 doses, depending on the age and then the need for a booster at 12 months of age if the primary cause is done given prior to 12 months’ of age. So were they the questions about recommendations for meningococcal B vaccine and also probably availability?
TIM SENIOR:
Yeah that’s right. But it’s a recommendation.
VICKY SHEPPEARD:
Recommended and not funded for infants and for adolescents. So this is a discussion to have with the parent or the young adolescent or older adolescent that – as it’s expected to give good individual protection, but it’s not considered cost effective to fund on the National Immunisation Program so it’s an individual decision about whether they would seek to have protection but certainly it’s apparently a safe vaccine and effective, as far as we know. So if parents are prepared to spend, then that should be supported.
TIM SENIOR:
What is the cost, do you know, to the patient?
VICKY SHEPPEARD:
Yeah, it’s around about $150.00 per dose. And at the moment there is a shortage of Bexsero so the UK program that I mentioned has a – as we know – vaccines are part of a global market and the UK program has sucked up a lot of the supplies, so I understand it is hard to obtain in Australia at the moment, even if parents are wanting to get it.
TIM SENIOR:
Yep.
VICKY SHEPPEARD:
And there’s a question there – what age would you recommend it considering the epidemiology, well certainly we do see a lot of meningococcal disease under 12 months of age, so really incorporating it into the primary course with the other vaccines or soon after, is probably getting optimal protection from it. Of course, if it is – the down side with Bexsero is that it is quite pyrexic and it is recommended to take Panadol prior to the dose and so – whether parents want to have that at the same time as the NIP vaccines or wait a couple of weeks.
TIM SENIOR:
And it can be used alongside routine? Yeah?
VICKY SHEPPEARD:
It can be given with other childhood vaccines or you could give it two weeks or a month later, to kind of break it up depending on what the parents –
TIM SENIOR:
It can be used with older children as well?
VICKY SHEPPEARD:
Yes it can be used and so that would be a two dose primary course and a booster is not required, and what we saw from the other sides, we seen variable disease in primary aged children, but you know, as children are entering into older adolescent, there certainly isn’t a pick up in the number of cases. And in particularly if it’s young people who might going to boarding school, colleges, universities, military, then it would be a good recommendation for those adolescents.