Serotype and serosubtype distribution of strains of Neisseria meningitidis isolated in South Australia and the Northern Territory of Australia: 1971-1989

Differences in the population structure of Neisseria meningitidis in two Australian states: Victoria and Western Australia

Neisseria meningitidis is the causative agent of invasive meningococcal disease (IMD). A recombinant vaccine called Bexsero® incorporates four subcapsular antigens (fHbp, NHBA, NadA and PorA) which are used to assign a Bexsero® antigen sequence type (BAST) to each meningococcal strain. The vaccine elicits an immune response against combinations of variants of these antigens which have been grouped into specific BAST profiles that have been shown to have different distributions within geographical locations thus potentially affecting the efficacy of the vaccine. In this study, invasive meningococcal disease isolates from the western seaboard of Australia (Western Australia; WA) were compared to those from the south-eastern seaboard (Victoria; VIC) from 2008 to 2012. Whole-genome sequencing (WGS) of 131 meningococci from VIC and 70 meningococci from WA were analysed for MLST, FetA and BAST profiling. Serogroup B predominated in both jurisdictions and a total of 10 MLST clonal complexes (cc) were shared by both states. Isolates belonging to cc22, cc103 and cc1157 were unique to VIC whilst isolates from cc60 and cc212 were unique to WA. Clonal complex 41/44 represented one-third of the meningococcal population in each state but the predominant ST was locally different: ST-6058 in VIC and ST-146 in WA. Of the 108 BAST profiles identified in this collection, only 9 BASTs were simultaneously observed in both states. A significantly larger proportion of isolates in VIC harboured alleles for the NHBA-2 peptide and fHbp-1, antigenic variants predicted to be covered by the Bexsero® vaccine. The estimate for vaccine coverage in WA (47.1% [95% CI: 41.1-53.1%]) was significantly lower than that in VIC (66.4% [95% CI: 62.3-70.5%]). In conclusion, the antigenic structure of meningococci causing invasive disease in two geographically distinct states of Australia differed significantly during the study period which may affect vaccine effectiveness and highlights the need for representative surveillance when predicting potential impact of meningococcal B vaccines.

Australia's century of meningococcal disease: development and the changing ecology of an accidental pathogen

Trends in meningococcal disease (MD) over the 20th century in Australia, as in other industrialised countries, have been characterised by epidemics during the two World Wars, a transient rise in incidence in the 1950s followed by endemic disease, and in the 1980s the emergence of a sustained hypersporadic phase. Epidemics occur at times of social upheaval and among marginalised populations, and resolve when living conditions improve. Periodic serogroup A epidemics have been replaced since the 1950s by endemic disease caused mainly by serogroups B and C meningococci. The current hypersporadic plateau in Australia, as in other industrialised countries, is associated with the intercontinental spread of hypervirulent clones of meningococci. The conjugate serogroup C vaccine has reduced the incidence of MD and carriage rates of serogroup C meningococci. However, the vaccine is expensive and its long-term impact on the emergence of non-vaccine strains and on nasopharyngeal microecology is unknown. A rising incidence of MD should not be viewed as the action of a virulent microbe exploiting a vulnerable population, but as the emergence of an "accidental pathogen" from an evolving host-microbial ecology. While it is essential to monitor the impact of vaccines on this ecology, we must find ways that can optimise our coexistence with microbes.

Have South Australian isolates of Neisseria meningitidis become less susceptible to penicillin, rifampicin and other drugs? A study of strains isolated over three decades, 1971-1999

AIMS

To ascertain whether isolates of Neisseria meningitidis in South Australia (SA) have become less susceptible to antimicrobial agents. The patients studied were children and adults in SA with either meningococcal bacteraemia or meningitis or both.

METHODS

The susceptibility of meningococci to 11 antimicrobial agents, including sulphonamides, penicillin and rifampicin, was tested by agar dilution, and in the case of six of the drugs, by E test also.

RESULTS

Resistance to folate antagonists emerged in 1979 and became very common. Resistance peaked in 1995 at 76% of strains. Relative insusceptibility to penicillin was first encountered amongst strains isolated in 1985, and, while the incidence of such strains increased slightly, the overall incidence was low at 10 (5.2%) of 190 strains tested. Meningococci relatively insusceptible to rifampicin were encountered as early at 1971 and did not become more common. The incidence of such strains at 26 (13.7%) of 189 strains tested was higher than that for penicillin. For the 11-year period 1989-1999 of > or= 84 strains tested all were susceptible to ceftriaxone, chloramphenicol and ciprofloxacin; 98% were susceptible to azithromycin and 97% were susceptible to minocycline. Shifts in MIC values for these drugs were not detected.

CONCLUSIONS

Resistance was common to sulphonamides and co-trimoxazole, however >or=95% meningococci tested were susceptible to drugs commonly used in the treatment of meningococcal disease, including penicillin and ceftriaxone. Relative insusceptibility to rifampicin was more common but did not increase during the 29-year period. For all drugs tested, except rifampicin, there was good agreement between agar dilution and E test results.

Meningococcal disease in urban south western Sydney, 1990-1994

BACKGROUND

There has been a sustained increase in incidence of meningococcal disease throughout Australia since 1987. In south western Sydney the incidence is higher than the national rate and a cluster of cases occurred in 1991 resulting in a widespread vaccination programme.

AIMS

To investigate the clinical demographics of patients with meningococcal disease treated in south western Sydney, and to differentiate meningococcal strains to understand better the epidemiology in this urban setting. In addition, to investigate whether delays in diagnosis of meningococcal disease and institution of appropriate treatment were occurring.

METHODS

Retrospective classification of notified cases as meningitis, septicaemia, meningitis/septicaemia, and other syndromes. Clinical information recorded to establish patterns of disease, delays in diagnosis and appropriate treatment, and outcome. Microbiological classification of organisms isolated by serogroup, serotype and subtype.

RESULTS

Meningococcal disease primarily affects young children in winter months in south western Sydney, with a secondary peak of incidence in the 15-20 year old age group. 20.7% presented with meningitis only, 22.4% with septicaemia only, and 53.4% with meningitis/septicaemia. There was a delay in diagnosis and institution of appropriate treatment of more than two hours in 21/58 (36.2%) patients including three of the six who died. No patient had received a parenteral antibiotic prior to coming to hospital -18.9% had received an oral antibiotic. The use of antibiotics before diagnostic lumbar puncture decreased the number of positive CSF cultures. However, in all but one patient with negative cultures there was other microbiological evidence of meningococcal disease. The mortality rate was highest (30.8%) in patients with septicaemia only, 6.5% in patients with meningitis/septicaemia and 0% in patients with meningitis only. Serogroup C was the predominant organism in all age groups. The predominant serotype was 2b (80% of serogroup C isolates). Subtypes were more variable but P1.2 occurred in 66.7% of serogroup C strains.

CONCLUSIONS

There is a need for more education in our Health Area to improve the time taken to diagnose and institute appropriate treatment. The predominance of serogroup C is unusual in urban Australia where national data show serogroup B organisms predominate. Meningococci of phenotype C:2b:P1.2 have continued to cause disease in our Health Area for the past five years. This phenotype is uncommon in other areas of Australia.