BACTERIAL MENINGITIS IN CHILDREN

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1 Overview Bacterial meningitis in children : rare, severe, mostly preventable What should GPs advise Australian parents in 2018? Peter McIntyre Professorial Fellow, National Centre for Immunisation Research & Surveillance Professor of Paediatrics, University of Sydney 1. Bacterial meningitis in children Organisms Death and long-term sequelae Where are we now? 2. Free vaccines for meningitis National Immunisation Program changes July 1 Queensland - high school ACWY program 3. Extra protection - vaccines for private purchase Ask and you shall receive No conflicts of interest BACTERIAL MENINGITIS IN CHILDREN Incidence and Sequelae - Hib most common, Pneumo most sequelae, Meningo most deaths 1

2 BACTERIAL MENINGITIS WORTH PREVENTING IMPACT OF VACCINES GREATEST FOR HIB Significant long term sequelae even in children who seem normal at discharge Bacterial meningitis post vaccines: Hib disappears, Pneumo reduces, Meningo varies SITUATION IN 2O18: PNEUMO AND MENINGO Invasive Pneumococcal Disease: breakthrough cases 2

3 IMD notification rate (per 100,000 population) IMD notification rate (per 100,000) Notifications per 100,000 population IMD notification rate (per 100,000 population) Count 7vPCV & 13vPCV 3-dose breakthroughs: Breakthroughs > 12 of age Pneumonia, not meningitis vPCV 13vPCV Meningococcal disease emergence of serotypes W and Y Diagnosis year Data source: National Notifiable Diseases Surveillance System Confirmed IMD cases, Australia IMD notification rate by serogroup and year, Introduction of MenCCV Serogroup B 4.0 All notifications 2.00 Serogroup C 3.5 Serogroup B Serogroup C Other serogroups Serogroup W Serogroup not determined Serogroup Y Non-groupable Not grouped Year Diagnosis year Trends are not shown for serogroups A (n=6) and X (n=2) 16 IMD notification rate by serogroup and year, All notifications Serogroup B 3.5 Serogroup C Serogroup W 3.0 Serogroup Y Non-groupable 2.5 Not grouped IMD notification rate by serogroup and age group, Total MenB MenW MenY Diagnosis year 0 < Age group Trends are not shown for serogroups A (n=6) and X (n=2)

4 Aggregate number of deaths Mean annual deaths per 100,000 person- Meningococcal disease in infants MenB death rates by age group <2 yrs 2-4 yrs 5-14 yrs yrs yrs 50 yrs Age Number of MenB deaths , by age in (to <2 ) deaths in children < 2 (average 3 per year) IMD mortality and case fatality ratios, (comparison with MenC ) Serogroup Number of deaths Number of cases Case Fatality Ratio MenB % MenC % MenW % Age () MenY % 23 Where are we in 2018? Hib meningitis occasional cases in unvaccinated infants Pneumococcal meningitis significant reduction persistent cases due to non-vaccine serotypes Meningococcal meningitis and sepsis Type B disease reduced significantly in absence of vaccine peak< 2 ; smaller adolescent Type W and Y emerged; now approx. = type B 24 Hib, Pneumo and Meningo vaccines changes July 1 Hib vaccine: hexavalent 2,4,6 ; 12 month booster to move to 18 as Hib vaccine alone (current Hib-MenC) Pneumococcal vaccine: 3 rd dose to move to 12 (2+1) High risk kids (Aboriginal and medical conditions) continue 2,4, Meningococcal vaccines: replaces 12 Adolescent programs for meningococcal vaccination through high schools in Queensland since 2017 No MenB vaccine on NIP 25 4

5 THE FINE PRINT Amendment to Immunisation Handbook 2+1 pneumococcal vaccine and meningitis Most 3 dose breakthrough cases after 12 Most pneumonia or empyaema Moving booster to 12 will give stronger and more long-lasting protection with same number of doses BUT. Meningitis mostly before 12 Experience in UK with 2+1 suggests meningitis cases after (between 4 and 12 ) could occur Like meningo, 2 dose meningitis breakthrough rare but serious Important points about 2+1 Between July 1 and Dec : Infants turning 12 of age receive PCV13 12 ; ie 4 doses (3rd 6 ) Infants turning 6 DO NOT get PCV 13 dose No change with high risk babies inc Aboriginal From Jan 1, 2019: 3 rd dose at or slightly before 12 no delay! Important points about Men ACWY Between July 1 and Dec : ACWY replaces Hib-Men C 12 Supplies expected soon no definite date as yet No catch up funded high school programs continue From January : Cohort turning 18 receives monovalent Hib 18 with MMR-V and DTPa Hib risk so low that no issue with delay to 18 for Hib dose 5

6 Extra vaccine options EXTRA PROTECTION: VACCINES FOR PRIVATE PURCHASE PCV 13: Continue to have 3 rd 6 (4 doses) Chemist Warehouse: N/A Men ACWY: Infants: Additional doses from 6 weeks Children who have previously received Men C Chemist Warehouse: Nimenrix = $56 Men B: Infants: Additional doses from 6 weeks; older children Chemist Warehouse: Nov 2017: $110 Age group 2-<9 (from 6 wks) 3 dose Total 9 - <12 2 dose Total / / Vaccines against meningococcal disease minimum doses by age group 1 Men B (Bexsero) 2 nd 12m or > 8 weeks (Menveo) 2 nd 12m or > 8 weeks (Nimenrix) 2 nd 12m or > 8 weeks Single dose (Menactra) No data >8 wks apart Single dose Single dose Single dose 1 = UK 2+1 schedule data suggest similar efficacy Age group 2-<6 (from 6 wks) 4 dose Total Vaccines against meningococcal disease more doses in youngest infants 1 Men B (Bexsero) 3 doses 4 th 12m (Menveo) 3 doses 4 th 12m (Nimenrix) 3 doses 4 th 12m (Menactra) No data Bexsero and Fever 6 - <12 3 dose Total / / 2 nd > 8 weeks 3 rd 12 m 2 nd > 8 weeks 3 12 m 2 nd > 8 weeks Single dose >8 wks apart Single dose Single dose Single dose 1. Highest achievable antibody responses 6

7 SUMMARY: Take home messages -1 SUMMARY: Take home messages At population level, bacterial meningitis much less common post Hib, Pneumo and Meningo vaccines but at individual level devastating disease 2. 6, 12 and 18 from July 1: Important that later 3 rd dose of PCV13 AT 12m 6 month dose continues for high risk? Purchase for concerned parents Men ACWY replaces combo Hib-Men C 1. Meningococcal disease individual risk is greatest in first 2 of life rare but devastating 2. Doses of Men B (Bexsero) and ACWY (Nimenrix) can be given from 6 weeks of age Protection from one dose uncertain; biggest increase in protection after 2 nd dose 3 rd 12 will likely increase duration of protection Acknowledgements Data: National Notifiable Diseases Surveillance Scheme (NNDSS) & Communicable Disease Network Australia NCIRS: Dr Sanjay Jayasinghe, Ms Cyra Patel, Dr Clayton Chiu NCIRS is supported by the Australian Government Department of Health, the NSW Ministry of Health and the Sydney Children s Hospitals Network. 40 7