Health Professionals

Health Information Sheet

Meningococcal meningitis

 

Introduction

Meningococcal meningitis is caused by a Gram-negative bacterium, Neisseria meningitidis. There are 13 serotypes of N. meningitides, although only five serotypes; A, B, C, W135 and Y, are clinically important. Serotypes A, B and C are the most common causes of illness worldwide. W135 has emerged in recent years in Africa and the Middle East.

 

Epidemiology

Global epidemiology

Meningococcal disease occurs sporadically all over the world, with seasonal variations [1]. N. meningitidis serogroups B and C are the most common cause of disease in Europe, the Americas, Australia, and New Zealand. Cases tend to occur more frequently in winter and spring. Serogroup A is the main cause of disease in Africa and Asia. 

Worldwide, the highest rates of disease occur in the ‘meningitis belt’ of sub-Saharan Africa [1, 2] see Figure 1. This extends across the dry, savannah regions from Senegal in the west, across to Ethiopia in the east. During epidemics, this region can have an annual incidence rate of 1,000 cases per 100,000 population [2]. The largest recorded outbreak of meningococcal disease in history occurred in Africa in 1996 when over 20,000 deaths were reported to the World Health Organization (WHO) [3].

In the 2009 epidemic season 14 African countries reported 78,416 suspected cases and 4,053 deaths. This is the largest reported number since the 1996 epidemic [1]. More than 85% of these cases were reported in one epidemic foci, encompassing northern Nigeria and Niger, and were characterised by the predominance of N. meningitidis serogroup A [4].

Epidemics in meningitis belt countries occur in cycles, usually in the dry season. In the dry season (December to June) a combination of factors; cold nights, dust winds, increased incidence of upper respiratory tract infections, overcrowding and seasonal population displacement, facilitate outbreaks [1]. In west Africa, the dry season is usually between December and June. In east Africa, the seasons vary.

The serogroups most commonly associated with the African meningitis belt are A and C. However, serogroup W135 has been isolated from other west African countries including Cameroon [5], Chad [6], the Gambia [7] and Burkina Faso [8, 9]. Serogroup A was identified in a subsequent outbreak in Burkina Faso in 2007, in which 22,255 suspected cases and 1,490 deaths were reported [10].

In 2002, countries south of the meningitis belt in the Great Lakes region, including Tanzania, Rwanda, Burundi and the Democratic Republic of Congo, reported over 2,200 cases of meningococcal disease, including 200 deaths [11,12]. Small villages and refugee camps were most affected.

Figure 1: WHO map meningococcal meningitis countries or areas at high risk, 2011

View a larger version of the WHO map (opens in new window)

 

Image from WHO Serogroup A was responsible for two pandemics in Asia throughout the 1960s, 70s and 80s. It spread from China in the early 1980s to Nepal and India. In 1987 serogroup A was responsible for an outbreak involving 2,000 pilgrims to the Hajj in Mecca, Saudi Arabia [13]. In situations of overcrowding, such as during the Hajj, carriage rates can be as high as 80% [14]. Subsequent outbreaks occurred among pilgrims returning to their home countries. This led to the introduction of a bivalent polysaccharide vaccine (against A and C serogroups) in 1988 as an entry requirement for Hajj and Umrah.

In 2000, an international outbreak of meningococcal infection due to serogroup W135 was associated with the Hajj pilgrimage. More than 330 cases in pilgrims or contacts of pilgrims in 12 countries were reported to the WHO between 28 February 2000 and 26 May 2000 [16]. The quadrivalent (A, C, W135, Y) vaccine was recommended for Hajj pilgrims in 2001, but uptake was not 100%. Cases of W135 associated with the Hajj occurred again in 2001 [17]. Quadrivalent vaccine was therefore made an entry requirement for all pilgrims to the Hajj and Umrah from 2002. There are two quadrivalent vaccines currently available in the UK: ACWY Vax® and Menveo®.

Current outbreaks of meningococcal disease are recorded in the NaTHNaC Outbreak Surveillance Database.

 

Meningococcal disease in travellers from England, Wales and Northern Ireland

In England, Wales and Northern Ireland, there is currently no routine reporting of travel-related meningococcal infections. Between 1998 and 2003, the most recent period for which data is available, there were 29 laboratory confirmed cases of meningitis associated with overseas travel. Of these, fifteen were serogrouped; serogroup C was the most frequent. The majority of cases (24/28) were associated with travel to Spain [17].

Classifying a case of meningococcal disease as travel-related is difficult. A traveller can have nasopharyngeal colonisation with meningococcal bacteria before travel and develop symptoms while away, rather than acquiring infection in another country. A link with travel can be inferred when a strain of N. meningitidis is isolated that is rarely seen in the UK, such as strains of serogroup A or W135 [18]. More information on which strains occur in the UK can be found on the Health Protection Agency website.

 

Risk for travellers

Meningococcal disease occurs worldwide. Most travellers will be at a similar risk of infection during travel as they would be in the UK. A retrospective questionnaire study in 1994 identified 13 cases of meningococcal disease among travellers from industrialised countries [19]. The overall incidence was estimated to be 0.4 per 100,000 travellers per month.

Transmission of meningococcal disease is via droplet infection, with risk increasing in overcrowded conditions. Travellers at higher risk include healthcare workers, those living or working with local people, especially for prolonged periods, in endemic areas or where outbreaks are occurring (e.g. the African meningitis belt). A statement on risk in individual countries can be found on the NaTHNaC Country Information Pages.

 

Transmission

The reservoir for N. meningitidis is exclusively human, with the bacteria carried in the nasopharynx. Transmission occurs via the respiratory route, from coughing and sneezing, during close contact with a carrier. Most epidemics occur during the winter-spring period in temperate areas and during the dry season in tropical areas. In the meningitis belt of sub-Saharan Africa, the highest transmission period in west Africa is from December to June. Seasons vary in east Africa.

 

Signs and symptoms

Meningococcal meningitis usually presents with sudden onset of fever, intense headache, nausea and vomiting. These symptoms can develop within minutes or hours. The patient is often irritable and prefers to lie still. Neck stiffness from meningeal irritation is characteristic.

A non-blanching petechial or purpuric rash usually occurs with septicaemia. Delirium, coma and shock can ensue. With early diagnosis and treatment, the case fatality rate varies from 9% to 12% [20].

 

Treatment

Suspected meningococcal infection is a medical emergency. On admission to hospital, treatment with parenteral antibiotics should be commenced immediately. Intensive care, monitoring and supportive treatment are necessary.

 

Prevention

A conjugated meningococcal type C vaccine is a routine UK vaccination and is offered to all children. The schedule consists of a single dose given at three and four months of age, with a third dose combined with Haemophilus influenzae type b (Hib) at 12 months of age.

A meningitis B vaccine (Bexero®) has recently been introduced in the UK; its use is currently restricted to certain groups at increased risk of invasive meningococcal disease such as those with and an absent or dysfunctional spleen or complement disorders. There are currently no recommendations for meningitis B vaccination for individuals who are travelling or planning to reside abroad [21].

A quadrivalent (ACW135Y) vaccine should be offered to travellers going to areas considered a risk for transmission. Travellers should be advised on the mode of transmission and to avoid overcrowded situations.

 

Indications for use of vaccine

Travellers visiting risk areas for meningococcal disease, whose planned activities put them at higher risk. All pilgrims travelling to Saudi Arabia for the Hajj or Umrah are required to show proof of vaccination.

Vaccine recommendations for specific countries can be found on the NaTHNaC Country Information Pages.

The Summary of Product Characteristics (SmPC) for individual vaccines should be consulted for specific information relating to the product [22-24].

 

Vaccine information (Updated 4 June 2014)

Conjugate meningitis C vaccine forms part of the UK immunisation schedule. Further information can be found in the Department of Health / Public Health England Immunisation against infectious disease.

The following section refers to:

  • conjugate meningococcal quadrivalent ACW135Y vaccines (conjugate MenACWY) Menveo®  and Nimenrix® and
  • polysaccharide meningococcal quadrivalent vaccine (polysaccharide MenACWY): ACWY Vax® (which is no longer manufactured)

As of April 2014, Menveo® (conjugate MenACWY) has a marketing authorisation for use in children from 2 years of age, adolescents and adults.

As of March 2014, Nimenrix® (conjugate MenACWY) has a marketing authorisation for individuals 12 months and above.

Conjugated vaccine is expected to be more immunogenic in young children. Menveo® is therefore the preferred vaccine (off license) for infants aged over 2 months [21] and either Menveo® or Nimenrix® for children from one year of age (see table 1.)  

 

Table 1. Recommendations for the use of quadrivalent meningococcal vaccines for travel

Age (years)

Vaccine

Infants under one year**

Menveo®

  • First dose of 0.5 ml
  • Second dose of 0.5ml one month after the first dose

1 - 4

Menveo® or Nimenrix®

  • Single dose of 0.5ml

5 – 10

Either Menveo® or Nimenrix® (preferred to polysaccharide vaccine)

  • Single dose of 0.5ml

 

OR ACWYVax

  • Single dose of 0.5ml

 

≥11

Either Menveo® or Nimenrix®

(preferred to polysaccharide vaccine)

  • Single dose of 0.5ml

 

OR ACWYVax

  • Single dose of 0.5ml

 

**  Where an infant requires conjugate MenACWY vaccination at the same time as their routine Men C vaccine, Menveo® should be given in place of the Men C conjugate vaccine [21].

 

Nimenrix® is a black triangle medicine. Black triangle medicines are monitored intensively by the UK safety regulators – the Medicines Healthcare products Regulatory Agency (MHRA) and Commission on Human Medicines (CHM) and require all suspected reactions to be reported to the MHRA.

 

Contraindications

Confirmed anaphylactic reaction to a previous dose of vaccine, or to any constituent of the vaccine

 

References

1. World Health Organization. Meningitis Fact sheet N 141. Revised February 2010. [Accessed 6 July, 2010]. Available at: http://www.who.int/mediacentre/factsheets/fs141/en/ 

2. Harrison L, Trotter CL, Ramsay ME. Global epidemiology of meningococcal disease. Vaccine. 27S:51-63, 2009.

3. World Health Organization. Global Alert and Response: Meeting the public health challenge of epidemic meningitis in Africa. Undated. [Accessed 6 July, 2010]. Available at:

http://www.who.int/csr/disease/meningococcal/challenge2004

_11_10/en/index.html

4. World Health Organization. Global Alert and Response: Meningococcal Disease: situation in the African Meningitis Belt. 25 March 2009. [Accessed 6 July,2010]. Available at:

http://www.who.int/csr/don/2009_03_25/en/index.html

5. Massenet D, Inrombe J, Mevoula DE, Nicholas P. Serogroup W135 meningococcal meningitis, northern Cameroon 2007-2008. Emerg Infect Dis 15:340-342, 2009.

6. World Health Organization. Global Alert and Response: Meningococcal disease in Chad. 1 April 2010. [Accessed 6 July, 2010]. Available at: http://www.who.int/csr/don/2010_04_01a/en/index.html

7. Kwara A, Adegbola RA, Corrah PT, et al. Meningitis caused by a serogroup W135 clone of the ET-37 complex of Neisseria meningitidis in West Africa. Trop Med Int Health 3:742–6, 1998.

8. Koumaré B, Ouedraogo-Traoré R, Sanou I, The first large epidemic of meningococcal disease caused by serogroup W135,Burkina Faso, 2002. Vaccine 25(S1):A37–4, 2007

9. Decosas J, Koama JBT. Chronicle of an outbreak foretold: meningococcal meningitis W135 in Burkina Faso. Lancet Inf Dis 3:68-70, 2003.

10. World Health Organization. Global Alert and Response: Meningococcal disease in Burkina Faso – update 2. 19 April 2007. [Accessed 6 July, 2010]. Available at: http://www.who.int/csr/don/2007_04_17/en/index.html

11. World Health Organization. Global Alert and Response: Meningococcal disease in the Great Lakes area (Burundi, Rwanda, United Republic of Tanzania) Disease Outbreak News. 23 August 2002. [Accessed 6 July, 2010]. Available at: http://www.who.int/csr/don/2002_08_23a/en/index.html.

12. Teyssou R, Muros-Le Rouzic E. Meningitis epidemics in Africa: A brief overview. Vaccine 25 (S1):A3-7, 2007.

13. Wilder-Smith A, Memish Z. Meningococcal disease and travel. Int J Antimicrob Agents 21:102-6, 2003.

14. Al-Gahtani YM, El Bushra HE, Al-Qarawi SM, et al. Epidemiological investigation of an outbreak of meningococcal meningitis in Makkah (Mecca), Saudi Arabia, 1992.  Epidemiol Infect 115:399-409, 1995.

15. Anon. Meningococcal disease, serogroup W135. Wkly Epidemiol Rec 75:180, 2000.

16. Anon.  Meningococcal disease, serogroup W135.  Wkly Epidemiol Rec 76:141-2, 2001.

17. Health Protection Agency. Illness in England, Wales and Northern Ireland associated with foreign travel – a baseline report to 2002. London: Health Protection Agency Communicable Disease Surveillance Centre: 2004.

18. Health Protection Agency. Foreign travel-associated illness, England, Wales, and Northern Ireland – annual report 2005. London, Health Protection Agency: 2005. [Accessed 6 July,2010]. Available at: http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPA

web_C/1202487126306?p=1158945066450.

19. Koch S, Steffen R. Meningococcal disease in travelers: Vaccination recommendations. J Travel Med. 1:4-7, 1994.

20. Rosenstein NE, Perkins BA, Stephens DS, et al. Meningococcal disease. N Engl J Med 344:1378-88, 2001.

21. Meningococcal (updated 11 April 2014). In Salisbury D, Ramsay M, Noakes K. eds. Immunisation against Infectious Disease. London. 2006:  [Accessed 9 June 2014]. Available at:  https://www.gov.uk/government/publications/meningococcal-the-green-book-chapter-22

22. GlaxoSmithKline. Summary of product characteristics for ACWY Vax. Updated 14 March 2014 [Accessed 9 June 2014]. Available at: http://www.medicines.org.uk/EMC/medicine/4204/SPC/

ACWY+Vax+Vaccine/

23. Novartis. Summary of product characteristics for Menveo Group A, C, W135 and Y conjugate vaccine.  Updated 8 April 2014 [Accessed 9 June]. Available at: http://www.medicines.org.uk/EMC/medicine/27347/SPC/Menveo

+Group+A,C,W135+and+Y+conjugate+vaccine/%C2%A0 

24. GlaxoSmithKline. Summary of product characteristics for Nimenrix last updated 11 March 2014 [Accessed 9 June]. Available  at: http://www.medicines.org.uk/EMC/medicine/26514/SPC

/Nimenrix/

  

Reading list

Mueller JE, Borrow R, Gessner BJ. Meningococcal serogroup W135 in the African meningitis belt: epidemiology, immunity and vaccines. Expert Rev. Vaccines 5:319-336, 2006. [Accessed 6 July, 2010]. Available at: http://www.expert-reviews.com/doi/pdf/10.1586/14760584.5.3.319

Wilder-Smith A. Meningococcal disease: Risk for international travellers and vaccine strategies. Trav Med Infect Dis 9:182-6, 2008

 

Links

Meningococcal meningitis belt in Africa  

NaTHNaC Advice for Hajj pilgrims

NHS Choices: Meningitis

Department of Health / PHE: Immunisation against infectious disease: Chapter 22 Meningococcal

 

Advice current at: 10 June 2014