Multicenter surveillance of invasive meningococcal infections in children

The impact of childhood meningococcal serogroup C conjugate vaccine programs in Canada

BACKGROUND

Conjugate meningococcal vaccines may decrease the incidence of disease. The staggered implementation of universal childhood meningococcal C conjugate (MenC) immunization programs across Canada offers an opportunity to evaluate the influence of these programs.

METHODS

From 2002 to 2006, we conducted active, population-based surveillance for adult and pediatric hospital admissions related to meningococcal infections at the 12 centers of the Canadian Immunization Monitoring Program, Active (IMPACT), in collaboration with local public health officials.

RESULTS

A total of 376 cases were reported during the 5 years of surveillance. Yearly totals were as follows: 96 in 2002, 73 in 2003, 81 in 2004, 58 in 2005, and 68 in 2006. Case fatality was 9.3% and adults had a significantly higher case fatality rate than children.Average incidence per 100,000 was 0.62 (95% confidence interval [CI]: 0.50-0.76) in 2002 and 0.42 (95% CI: 0.32-0.53) in 2006. The highest rates were in children age 0 to 4 years, followed by adolescents age 15 to 19 years. Incidence of group C disease decreased significantly during the 5 years from 0.23 (95% CI: 0.16-0.32) in 2002 to 0.08 (95% CI: 0.04-0.14) in 2006, whereas incidence remained stable for groups B, Y, and W135. The decrease in group C disease was seen in provinces that first implemented MenC immunization programs.

CONCLUSIONS

A substantial decrease in group C incidence occurred in provinces with early MenC immunization programs. Serogroup C incidence remained stable in provinces without MenC programs. We found no evidence of serogroup replacement.

Attenuation of monocyte proinflammatory cytokine responses to Neisseria meningitidis in children by erythropoietin

Meningococcal disease is a leading infectious cause of death in children in industrialized countries. The induction of high levels of proinflammatory cytokines has been implicated in the pathogenesis of Neisseria meningitidis-related multi-organ failure. Here, we demonstrate that N. meningitidis serotypes A and B induce significantly higher levels of tumour necrosis factor (TNF)-alpha positive cells in vitro in infants and young children compared with adults (serotype A/B; infants: 64.9%/63.9%; children: 77.8%/64.3% versus adults: 27.7%/32%; P < 0.005). Serotype A induces also higher levels of interleukin (IL)-6 positive cells in neonates and infants compared with adults (serotype A; newborn 55.4%; infants 58.8% versus adults 49%; P < 0.05). Treatment with human recombinant erythropoietin in vitro resulted in significant attenuation of the N. meningitidis-induced proinflammatory response in all age groups (reduction rate of erythropoietin for IL-6 after stimulation with serotype B: newborn 28%, infants 15%, children 23% and adults 28% and for TNF-alpha after stimulation with serotype B: newborn 27%, infants 22%, children 20% and adults 28%; P < 0.05). We conclude that (i) Neisseria meningitidis induces a higher TNF-alpha response in infants and children compared with adults and (ii) erythropoietin was able to attenuate IL-6 and TNF-alpha production in all investigated age groups. These data may explain the high incidence of meningococcal infection in infants and makes erythropoietin a potentially attractive candidate for interventional strategies in an otherwise devastating course of the disease.

Bactericidal antibody responses elicited by a meningococcal outer membrane vesicle vaccine with overexpressed factor H-binding protein and genetically attenuated endotoxin

BACKGROUND

Outer membrane vesicle (OMV) vaccines from mutant Neisseria meningitidis strains engineered to overexpress factor H-binding protein (fHbp) have elicited broadly protective serum antibody responses in mice. The vaccines investigated were not treated with detergents to avoid extracting fHbp, which is a lipoprotein. Because of their high endotoxin content, the vaccines would not be safe to administer to humans.

METHODS

We prepared a native OMV vaccine from a strain engineered to overexpress fHbp and in which the gene encoding LpxL1 was inactivated, which reportedly decreases endotoxin activity.

RESULTS

The OMV vaccine from the mutant had a similar or lower ability to induce the expression of proinflammatory cytokines by human peripheral blood mononuclear cells, compared with a detergent-extracted wild-type OMV, and 1000-10,000-fold lower activity than a native wild-type OMV. In mice, the OMV vaccine from the mutant elicited higher serum bactericidal antibody responses to a panel of heterologous N. meningitidis strains than did a control multicomponent recombinant protein vaccine or a detergent-extracted OMV vaccine that has been demonstrated to confer protection against meningococcal disease in humans.

CONCLUSIONS

The data illustrate the potential to develop a broadly immunogenic native OMV vaccine that has decreased endotoxin activity and is potentially suitable for testing in humans.

Bactericidal antibody responses induced by meningococcal recombinant chimeric factor H-binding protein vaccines

Factor H-binding protein (fHbp) is a novel meningococcal vaccine candidate that elicits serum antibodies that activate classical complement pathway bacteriolysis and also inhibit binding of the complement down-regulatory protein, factor H, to the bacterial surface. One limitation of fHbp as a vaccine candidate is antigenic variability, since antibodies to fHbp in the variant 1 (v.1) antigenic group do not protect against strains expressing v.2 or v.3 proteins, and vice versa. We have identified amino acid residues of epitopes recognized by bactericidal anti-fHbp monoclonal antibodies prepared against fHbp from each of the variant groups. One epitope expressed by nearly all v.1 proteins mapped to the B domain, while epitopes expressed by fHbp v.2 or v.3 mapped to the C domain. The results provided the rationale for engineering chimeric fHbp molecules containing the A domain (which is conserved across all variant groups), a portion of the B domain of a v.1 protein, and the carboxyl-terminal portion of the B domain and the C domain of a v.2 protein. By enzyme-linked immunosorbent assay, the resulting recombinant chimeric proteins expressed epitopes from all three variant groups. In mice, the chimeric vaccines elicited serum antibodies with bactericidal activity against a panel of genetically diverse strains expressing fHbp v.1, v.2, or v.3. The data demonstrate the feasibility of preparing a meningococcal vaccine from a single recombinant protein that elicits broad bactericidal activity, including group B strains, which account for 50 percent of cases of meningococcal disease and for which there currently is no broadly protective vaccine.

The evolving approach to the young child who has fever and no obvious source

Fever is a common complaint of young children who seek care in the emergency department. Recent advances, such as universal vaccination with the pneumococcal conjugate vaccine, require the review of traditional approaches to these patients. This article discusses newer strategies in the evaluation and management of the young child with fever, incorporating changes based on the shifting epidemiology of bacterial infection.

A novel combined Haemophilus influenzae type b-Neisseria meningitidis serogroups C and Y-tetanus-toxoid conjugate vaccine is immunogenic and induces immune memory when co-administered with DTPa-HBV-IPV and conjugate pneumococcal vaccines in infants

Immunogenicity and safety of a novel combined Haemophilus influenzae type b-Neisseria meningitidis serogroups C and Y-tetanus-toxoid conjugate vaccine (Hib-MenCY-TT) candidate was evaluated when co-administered with DTPa-HBV-IPV(Pediarix)+PCV7(Prevnar) at 2-4-6 months of age. Anti-PRP concentrations >or= 1.0 microg/mL were observed in 92.9-98.7%, rSBA-MenC/Y titres >or= 1:8 in >98%, rSBA-MenC/Y titres >or= 1:128 in >95.8 and >89.9% subjects. PRP and MenC responses were similar to respective controls (ActHIB and Menjugate) including for antibody persistence. Response to co-administered vaccines was not impaired. Polysaccharide challenge (PRP, PSC, PSY at 11-14 months of age) evidenced immune memory was induced for Hib, MenC/Y conjugate components. The safety profile of Hib-MenCY-TT was similar to controls. Hib-MenCY-TT administered according to the current US Hib vaccine schedule has the potential to induce protective antibodies against Hib and meningococcal-CY disease in infants and toddlers.

Immunogenicity, safety and tolerability of meningococcal C CRM197 conjugate vaccine administered 3, 5 and 11 months post-natally to pre- and full-term infants

A total of 79 pre-term infants with a gestational age > or =32 weeks and 74 full-term infants were studied in order to evaluate the immunogenicity, safety and tolerability of meningococcal C (MenC)-CRM(197) conjugate vaccine administered 3, 5 and 11 months post-natally. The evoked immune response seemed to be substantially similar in the pre- and full-term infants, and there were only clinically marginal differences in safety and tolerability between the groups. The results support the use of two doses of MenC-CRM(197) vaccine at 3 and 5 months of age for primary immunisation, with a booster dose being given at about 1 year. In addition to reducing costs, this scheme seems to assure global immunogenicity and potential efficacy that is better than that offered by the accelerated scheme of administration with only three doses of vaccine in the first months of life, and similar to that observed with a fourth dose used as booster after the first year.

Prevalence of factor H-binding protein variants and NadA among meningococcal group B isolates from the United States: implications for the development of a multicomponent group B vaccine

BACKGROUND

Two promising recombinant meningococcal protein vaccines are in development. One contains factor H-binding protein (fHBP) variants (v.) 1 and 2, whereas the other contains v.1 and 4 other antigens discovered by genome mining (5 component [5C]). Antibodies against fHBP are bactericidal against strains within a variant group. There are limited data on the prevalence of strains expressing different fHBP variants in the United States.

METHODS

A total of 143 group B isolates from patients hospitalized in the United States were tested for fHBP variant by quantitative polymerase chain reaction, for reactivity with 6 anti-fHBP monoclonal antibodies (MAb) by dot immunoblotting, and for susceptibility to bactericidal activity of mouse antisera.

RESULTS

fHBP v.1 isolates predominated in California (83%), whereas isolates expressing v.1 (53%) or v.2 (42%) were common in 9 other states. Isolates representative of 5 anti-fHBP MAb-binding phenotypes (70% of isolates) were highly susceptible to anti-fHBP v.1 or v.2 bactericidal activity, whereas 3 phenotypes were approximately 50% susceptible. Collectively, antibodies against the fHBP v.1 and v.2 vaccine and the 5C vaccine killed 76% and 83% of isolates, respectively.

CONCLUSIONS

Susceptibility to bactericidal activity can be predicted, in part, on the basis of fHBP phenotypes. Both vaccines have the potential to prevent most group B disease in the United States.