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Mouss KA, Nzoyikorera N, Razki A, Zaki B, Soraa N, Zerouali K. Neisseria meningitidis with decreased susceptibility to penicillin G and molecular characterization of the penA gene in strains isolated at University Hospital Centers of Casablanca and Marrakech (Morocco). Pan Afr Med J 2024; 47:56. [PMID: 38646132 PMCID: PMC11032073 DOI: 10.11604/pamj.2024.47.56.42328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 01/09/2024] [Indexed: 04/23/2024] Open
Abstract
Introduction the laboratory diagnosis of meningococcal meningitis relies on conventional techniques. This study aims to evaluate the correlation between the reduced sensitivity to penicillin G of Neisseria meningitidis (N.m) strains and the expression of the altered PBP 2 gene. Methods out of 190 strains of N.m isolated between 2010 and 2021 at the bacteriology laboratories of Ibn Rochd University Hospital Centre (IR-UHC) in Casablanca and the UHC Mohammed VI in Marrakech, 23 isolates were part of our study. We first determined their state of sensitivity to penicillin G by E-Test strips and searched for the expression of the penA gene by PCR followed by Sanger sequencing. Results of all the confirmed cases of N.m, 93.15% (n=177) are of serogroup B, 75.2% (n = 143) are sensitive to penicillin G and 24.73% (n = 47) are of intermediate sensitivity. No resistance to penicillin G was observed. Reduced sensitivity to penicillin G in N.m is characterized by mutations namely F504 L, A510 V, I515 V, G541 N and I566 V located in the C-terminal region of the penA gene encoding the penicillin-binding protein 2 (PBP2) (mosaic gene). Conclusion our study presents useful data for the phenotypic and genotypic monitoring of resistance to penicillin G in N.m and can contribute to the analysis of genetic exchanges between different Neisseria species.
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Affiliation(s)
- Khadija Ait Mouss
- Department of Microbiology, Laboratory of Clinical Immunology, Inflammation and Allergy, Faculty of Medicine and Pharmacy, Hassan II University of Casablanca, Casablanca, Morocco
- Bacteriology-Virology and Hospital Hygiene Laboratory, University Hospital Centre Ibn Rochd, 1 Rue des Hôpitaux, 20100, Casablanca, Morocco
- Institut Pasteur du Maroc, 1 Place Louis Pasteur, 20360, Casablanca, Morocco
| | - Néhémie Nzoyikorera
- Department of Microbiology, Laboratory of Clinical Immunology, Inflammation and Allergy, Faculty of Medicine and Pharmacy, Hassan II University of Casablanca, Casablanca, Morocco
| | - Aziza Razki
- Institut Pasteur du Maroc, 1 Place Louis Pasteur, 20360, Casablanca, Morocco
| | - Bahija Zaki
- Bacteriology-Virology and Hospital Hygiene Laboratory, University Hospital Centre Ibn Rochd, 1 Rue des Hôpitaux, 20100, Casablanca, Morocco
| | - Nabila Soraa
- Faculty of Medicine and Pharmacy of Marrakech Cadi Ayyad University, Microbiology Department, Mohamed VI University Hospital Center, Marrakech, Morocco
| | - Khalid Zerouali
- Department of Microbiology, Laboratory of Clinical Immunology, Inflammation and Allergy, Faculty of Medicine and Pharmacy, Hassan II University of Casablanca, Casablanca, Morocco
- Bacteriology-Virology and Hospital Hygiene Laboratory, University Hospital Centre Ibn Rochd, 1 Rue des Hôpitaux, 20100, Casablanca, Morocco
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Limitation of
ctrA
as a Target for Neisseria meningitidis Identification and Potential Alternative Targets. J Clin Microbiol 2022; 60:e0015222. [DOI: 10.1128/jcm.00152-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Smaoui H, Tali-Maamar H, Zouhair S, Bouheraoua S, Mefteh K, Bouskraoui M, Amiche A, Khris M, Deghmane AE, Taha MK. Implementation of a prospective study for enhancing surveillance of invasive bacterial infections in North Africa. Int J Infect Dis 2021; 115:101-105. [PMID: 34843957 DOI: 10.1016/j.ijid.2021.11.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 11/12/2021] [Accepted: 11/23/2021] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVES We implemented a project named MENINGSTOP in three countries of North Africa (Algeria, Morocco and Tunisia). The main objective was to use real-time PCR to detect, identify and type the three main agents (Neisseria meningitidis, Streptococcus pneumoniae and Haemophilus influenzae) responsible for invasive bacterial infections (IBI). METHODS The protocol of WHO and US CDC for real-time PCR was used to detect and type the three bacterial agents in clinical samples. We also designated two quality exercises using an external interlaboratory study and cross-testing of 10% of randomly selected samples. RESULTS Among the 752 samples tested, 18% were positive for one of the three agents. N. meningitidis was the most frequent globally reaching 9% of all samples (7% to 17% range) followed by S. pneumoniae 8% of all samples (6% to 15%). Group B meningococci was the most frequent (74% of all positive samples for meningococci and ranging from 50% to 90%). Quality assurance showed >85% correlation scores. CONCLUSIONS Real-time PCR can help improving epidemiological surveillance. Data confirm the prevalence of meningococci B. Our project adds a reliable tool to enhance surveillance and to help decision making in vaccination strategies against IBI.
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Affiliation(s)
- Hanen Smaoui
- University of Tunis El Manar, Faculty of Medicine of Tunis; Children's Hospital Béchir Hamza of Tunis, Laboratory of Microbiology, Tunis, Tunisia
| | | | - Saïd Zouhair
- Faculty of Medicine and Pharmacy of Marrakech, University of Cadi Ayyad, Marrakech, Morocco
| | - Selma Bouheraoua
- Université d'Alger 1; Institut Pasteur of Algeria, Algiers, Algeria
| | - Khaoula Mefteh
- University of Tunis El Manar, Faculty of Medicine of Tunis; Children's Hospital Béchir Hamza of Tunis, Laboratory of Microbiology, Tunis, Tunisia
| | - Mohammed Bouskraoui
- Faculty of Medicine and Pharmacy of Marrakech, University of Cadi Ayyad, Marrakech, Morocco; Hospital of Mère-Enfant, Teaching hospital of Mohammed VI Marrakech, Marrakech, Morocco
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Dogu AG, Oordt-Speets AM, van Kessel-de Bruijn F, Ceyhan M, Amiche A. Systematic review of invasive meningococcal disease epidemiology in the Eastern Mediterranean and North Africa region. BMC Infect Dis 2021; 21:1088. [PMID: 34686136 PMCID: PMC8540099 DOI: 10.1186/s12879-021-06781-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 10/06/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Invasive meningococcal disease (IMD) represents a global health burden. However, its epidemiology in the Eastern Mediterranean (EM) and North Africa (NA) regions is currently not well understood. This review had four key objectives: to describe asymptomatic meningococcal carriage, IMD epidemiology (e.g. serogroup prevalence, case-fatality rates [CFRs]), IMD presentation and management (e.g. clinical diagnosis, antibiotic treatments) and economic impact and evaluation (including health technology assessment [HTA] recommendations) in EM and NA. METHODS A systematic literature search (MEDLINE and EMBASE) was conducted (January 2000 to February 2021). Search strings included meningococcal disease and the regions/countries of interest. Identified publications were screened sequentially by title/abstract, followed by screening of the full-text article; articles were also assessed on methodological quality. Literature reviews, genetic sequencing or diagnostic accuracy studies, or other non-pertinent publication type were excluded. An additional grey literature search (non-peer-reviewed sources; start date January 2000) was conducted to the end of April 2019. RESULTS Of the 1745 publications identified, 79 were eligible for the final analysis (n = 61 for EM and n = 19 for NA; one study was relevant to both). Asymptomatic meningococcal carriage rates were 0-33% in risk groups (e.g. military personnel, pilgrims) in EM (no data in NA). In terms of epidemiology, serogroups A, B and W were most prevalent in EM compared with serogroups B and C in NA. IMD incidence was 0-20.5/100,000 in EM and 0.1-3.75/100,000 in NA (reported by 7/15 countries in EM and 3/5 countries in NA). CFRs were heterogenous across the EM, ranging from 0 to 57.9%, but were generally lower than 50%. Limited NA data showed a CFR of 0-50%. Data were also limited in terms of IMD presentation and management, particularly relating to clinical diagnosis/antibiotic treatment. No economic evaluation or HTA studies were found. CONCLUSIONS High-risk groups remain a significant reservoir of asymptomatic meningococcal carriage. It is probable that inadequacies in national surveillance systems have contributed to the gaps identified. There is consequently a pressing need to improve national surveillance systems in order to estimate the true burden of IMD and guide appropriate prevention and control programmes in these regions.
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Affiliation(s)
| | | | | | - Mehmet Ceyhan
- Faculty of Medicine, Hacettepe University, Ankara, Turkey
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de Lemos APS, Sacchi CT, Gonçalves CR, Camargo CH, Andrade AL. Genomic surveillance of Neisseria meningitidis serogroup B invasive strains: Diversity of vaccine antigen types, Brazil, 2016-2018. PLoS One 2020; 15:e0243375. [PMID: 33347452 PMCID: PMC7751880 DOI: 10.1371/journal.pone.0243375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 11/19/2020] [Indexed: 11/19/2022] Open
Abstract
Background Neisseria meningitidis serogroup B remains a prominent cause of invasive meningococcal disease (IMD) in Brazil. Because two novel protein-based vaccines against serogroup B are available, the main purpose of this study was to provide data on the diversity and distribution of meningococcal vaccine antigen types circulating in Brazil. Methodology Genetic lineages, vaccine antigen types, and allele types of antimicrobial-associated resistance genes based on whole-genome sequencing of a collection of 145 Neisseria meningitidis serogroup B invasive strains recovered in Brazil from 2016 to 2018 were collected. Results A total of 11 clonal complexes (ccs) were identified among the 145 isolates, four of which were predominant, namely, cc461, cc35, cc32, and cc213, accounting for 72.0% of isolates. The most prevalent fHbp peptides were 24 (subfamily A/variant 2), 47 (subfamily A/variant 3), 1 (subfamily B/variant 1) and 45 (subfamily A/variant 3), which were predominantly associated with cc35, cc461, cc32, and cc213, respectively. The NadA peptide was detected in only 26.2% of the isolates. The most frequent NadA peptide 1 was found almost exclusively in cc32. We found seven NHBA peptides that accounted for 74.5% of isolates, and the newly described peptide 1390 was the most prevalent peptide exclusively associated with cc461. Mutated penA alleles were detected in 56.5% of the isolates, whereas no rpoB and gyrA mutant alleles were found. Conclusion During the study period, changes in the clonal structure of circulating strains were observed, without a predominance of a single hyperinvasive lineage, indicating that an epidemiologic shift has occurred that led to a diversity of vaccine antigen types in recent years in Brazil.
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Affiliation(s)
| | | | | | | | - Ana Lúcia Andrade
- Institute of Tropical Pathology and Public Health, Federal University of Goiás, Goiânia, Brazil
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A Review of the Epidemiology of Invasive Meningococcal Disease and Vaccination Strategies in North Africa. Int J Infect Dis 2020; 104:189-197. [PMID: 33227521 DOI: 10.1016/j.ijid.2020.11.162] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 11/12/2020] [Accepted: 11/14/2020] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE This narrative review considers the epidemiology of invasive meningococcal disease (IMD) in North Africa and the adequacy of current preventive measures to provide guidance for future vaccination strategies. METHODS Literature searches were conducted using PubMed for articles published from 1998 onwards to identify publications on IMD in North Africa. Additional relevant articles not included within the search results and data sources were identified from the reference lists of identified publications, authors' personal files, and publicly available government or regional surveillance data. RESULTS Although IMD is an endemic and notifiable disease in several North African countries, inadequacies exist regarding each country's surveillance, vaccination strategies, and disease understanding. Studies showed bacterial meningitis in North Africa caused by Neisseria meningitidis mostly affects young children (aged <5 years), with meningococcal serogroup B (MenB) being the most frequently identified serotype. Importantly, MenB isolates were genetically heterogeneous. Serogroup A incidence and meningococcal outbreaks decreased over time in Morocco and Egypt, possibly because of their nationwide or school-based vaccination programs. Within the region, meningococcal vaccines are only included in the national immunization program of Egypt. CONCLUSIONS Improving IMD diagnosis and surveillance would provide a reliable estimate of IMD burden, leading to better vaccination strategies.
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Ait Mouss K, Razki A, Hong E, Zaki B, Maaloum F, Nzoyikorera N, Belabbes H, Elmdaghri N, Zerouali K. Epidemiological profile of Neisseria meningitidis in Casablanca, Morocco: 2010-2019. Access Microbiol 2020; 2:acmi000157. [PMID: 33195986 PMCID: PMC7656187 DOI: 10.1099/acmi.0.000157] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 06/30/2020] [Indexed: 12/17/2022] Open
Abstract
Surveillance of invasive meningococcal diseases (IMD) must be carried out regularly and continuously in order to detect the emergence of strains of reduced susceptibility to antibiotics for therapeutic and prophylactic use and the appearance of new invasive clones. Molecular-typing approaches allow reliable traceability and powerful epidemiological analysis. This is an epidemiological study of Neisseria meningitidis causing meningitis in Casablanca, Morocco. The grouping was confirmed by PCR mainly on the isolates from cerebrospinal fluid (CSF). A total of 245 confirmed isolates of N .meningitidis were obtained between 2010 and 2019 of which 93 % are of group B. Overall, 24 % of all the isolates have a reduced susceptibility to penicillin G, but no resistance to penicillin G has been reported. All the isolated strains are susceptible to third-generation cephalosporins (3GCs). Genotyping by multilocus sequence typing (MLST) of a selection of 18 strains showed that the majority of isolates belong to the invasive clonal complex CC 32(9/18) followed by the CC 41/44(3/18).
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Affiliation(s)
- Khadija Ait Mouss
- Department of Microbiology, Faculty of Medicine and Pharmacy, Hassan II University of Casablanca, 19 rue Tarik Bnou Zyad, 20360, Casablanca, Morocco.,Bacteriology-Virology and Hospital Hygiene Laboratory, University Hospital Centre Ibn Rochd, 1, Rue des Hôpitaux, 20100, Casablanca, Morocco.,Institut Pasteur du Maroc, 1, place louis pasteur, 20360, Casablanca, Morocco
| | - Aziza Razki
- Institut Pasteur du Maroc, 1, place louis pasteur, 20360, Casablanca, Morocco
| | - Eva Hong
- Institut Pasteur, Invasive Bacterial Infections Unit, Paris, France
| | - Bahija Zaki
- Bacteriology-Virology and Hospital Hygiene Laboratory, University Hospital Centre Ibn Rochd, 1, Rue des Hôpitaux, 20100, Casablanca, Morocco
| | - Fakhreddine Maaloum
- Department of Microbiology, Faculty of Medicine and Pharmacy, Hassan II University of Casablanca, 19 rue Tarik Bnou Zyad, 20360, Casablanca, Morocco.,Bacteriology-Virology and Hospital Hygiene Laboratory, University Hospital Centre Ibn Rochd, 1, Rue des Hôpitaux, 20100, Casablanca, Morocco
| | - Néhémie Nzoyikorera
- Department of Microbiology, Faculty of Medicine and Pharmacy, Hassan II University of Casablanca, 19 rue Tarik Bnou Zyad, 20360, Casablanca, Morocco.,Bacteriology-Virology and Hospital Hygiene Laboratory, University Hospital Centre Ibn Rochd, 1, Rue des Hôpitaux, 20100, Casablanca, Morocco
| | - Houria Belabbes
- Department of Microbiology, Faculty of Medicine and Pharmacy, Hassan II University of Casablanca, 19 rue Tarik Bnou Zyad, 20360, Casablanca, Morocco.,Bacteriology-Virology and Hospital Hygiene Laboratory, University Hospital Centre Ibn Rochd, 1, Rue des Hôpitaux, 20100, Casablanca, Morocco
| | - Naima Elmdaghri
- Bacteriology-Virology and Hospital Hygiene Laboratory, University Hospital Centre Ibn Rochd, 1, Rue des Hôpitaux, 20100, Casablanca, Morocco
| | - Khalid Zerouali
- Department of Microbiology, Faculty of Medicine and Pharmacy, Hassan II University of Casablanca, 19 rue Tarik Bnou Zyad, 20360, Casablanca, Morocco.,Bacteriology-Virology and Hospital Hygiene Laboratory, University Hospital Centre Ibn Rochd, 1, Rue des Hôpitaux, 20100, Casablanca, Morocco
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Haddad-Boubaker S, Lakhal M, Fathallah C, Mhimdi S, Bouafsoun A, Kechrid A, Smaoui H. Epidemiological study of bacterial meningitis in Tunisian children, beyond neonatal age, using molecular methods: 2014-2017. Afr Health Sci 2020; 20:1124-1132. [PMID: 33402957 PMCID: PMC7751517 DOI: 10.4314/ahs.v20i3.14] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Since the 1990s, the epidemiology of bacterial meningitis worldwide has changed thanks to vaccination. In Tunisia, the main causative pathogens were Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae serotype b (Hib). Only Hib vaccination was available during our study period. OBJECTIVES We performed a laboratory case report based-study of suspected bacterial meningitis in Northern Tunisia from January 2014 to June 2017. METHODS CSF samples obtained from children beyond neonatal age with suspicion of meningitis were tested by two real time PCRs, targeting pneumococcus, meningococcus and Hib, and conventional methods. RESULTS Using real-time PCR, 63 were positive including ten supplementary cases compared to conventional methods. A general decrease of bacterial meningitis cases was demonstrated comparing to previous data. Pneumococcus was predominant (69.84%) followed by meningococcus (28.57%) and Hib (1.59%). The main serotypes were 14, 19F, 6B and 23F for pneumococcus and serogroup B for meningococcus. Most cases occurred during cold season and children under one year were the most affected by bacterial meningitis. CONCLUSION Our study suggests the predominance of pneumococcal cases. It may provide valuable data on meningitis epidemiology before the introduction of pneumococcal vaccine, which may be useful for future evaluation.
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Affiliation(s)
- Sondes Haddad-Boubaker
- Laboratory of Microbiology of Bechir Hamza Children's Hospital, LR18ES39, Faculty of Medicine of Tunis, Tunis El-Manar University, Tunis, Tunisia
- Laboratory of Clinical Virology, WHO EMRO Regional Reference Laboratory for Poliomyelitis and Measles, Pasteur Institute of Tunis, Tunisia
- Research Laboratory of Virus, Vector and Host, Pasteur Institute of Tunis, Tunis El-Manar University, Tunisia
| | - Marwa Lakhal
- Laboratory of Microbiology of Bechir Hamza Children's Hospital, LR18ES39, Faculty of Medicine of Tunis, Tunis El-Manar University, Tunis, Tunisia
| | - Cyrine Fathallah
- Laboratory of Microbiology of Bechir Hamza Children's Hospital, LR18ES39, Faculty of Medicine of Tunis, Tunis El-Manar University, Tunis, Tunisia
| | - Samar Mhimdi
- Laboratory of Microbiology of Bechir Hamza Children's Hospital, LR18ES39, Faculty of Medicine of Tunis, Tunis El-Manar University, Tunis, Tunisia
| | - Aida Bouafsoun
- Laboratory of Microbiology of Bechir Hamza Children's Hospital, LR18ES39, Faculty of Medicine of Tunis, Tunis El-Manar University, Tunis, Tunisia
| | - Amel Kechrid
- Laboratory of Microbiology of Bechir Hamza Children's Hospital, LR18ES39, Faculty of Medicine of Tunis, Tunis El-Manar University, Tunis, Tunisia
| | - Hanen Smaoui
- Laboratory of Microbiology of Bechir Hamza Children's Hospital, LR18ES39, Faculty of Medicine of Tunis, Tunis El-Manar University, Tunis, Tunisia
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Ceyhan M, Ozsurekci Y, Lucidarme J, Borrow R. Characterization of invasive Neisseria meningitidis isolates recovered from children in Turkey during a period of increased serogroup B disease, 2013-2017. Vaccine 2020; 38:3545-3552. [PMID: 32199701 DOI: 10.1016/j.vaccine.2020.03.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 02/03/2020] [Accepted: 03/09/2020] [Indexed: 01/24/2023]
Abstract
Diverse Neisseria meningitidis strains belonging to various serogroups and clonal complexes cause epidemic and endemic life-threatening disease worldwide. This study aimed to investigate the genetic diversity of recent invasive meningococci in Turkey with respect to multilocus sequence type (MLST) and also meningococcal serogroup B (MenB) vaccine antigens to enable assessment of potential MenB strain coverage using the genetic Meningococcal Antigen Typing System (gMATS). Fifty-four isolates, representing 37.5% of all pediatric (ages 0-18 years) invasive meningococcal disease cases in Turkey from January 2013 to December 2017, underwent genome sequence analysis. Thirty-six (66.7%) isolates were MenB, 10 (18.5%) were serogroup W (MenW), 4 (7.4%) were serogroup A (MenA), 3 (5.6%) were serogroup Y (MenY) and 1 (1.8%) was serogroup X (MenX). The MenB isolates were diverse with cc35 (19.4%), cc41/44 (19.4%) and cc32 (13.8%) as the most prevalent clonal complexes. The MenW isolates (n = 10) comprised cc11 (n = 5), ST-2754 (cc-unassigned; n = 4) and cc22 (n = 1). gMATS was indicative of high 4CMenB coverage (72.2-79.1%) of Turkish invasive MenB strains from pediatric patients. Strain coverage of several clonal complexes differed from that seen elsewhere in Europe highlighting the importance of performing local assessments and also the use of phenotypic methods, i.e. MATS, where possible. All of the isolates possessed in-frame fhbp alleles and so were potentially covered by MenB-fHbp. Continued surveillance is essential to guide recommendations for current and future vaccines as well as understanding changes in epidemiology.
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Affiliation(s)
- Mehmet Ceyhan
- Hacettepe University, Faculty of Medicine, Department of Pediatric Infectious Diseases, Ankara, Turkey
| | - Yasemin Ozsurekci
- Hacettepe University, Faculty of Medicine, Department of Pediatric Infectious Diseases, Ankara, Turkey.
| | - Jay Lucidarme
- Meningococcal Reference Unit, Public Health England, Manchester, United Kingdom
| | - Ray Borrow
- Meningococcal Reference Unit, Public Health England, Manchester, United Kingdom
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