An outbreak of serogroup C (ST-11) meningococcal disease in Tijuana, Mexico

Public health management of invasive meningococcal disease outbreaks: worldwide 1973-2018, a systematic review

BACKGROUND

Infectious disease outbreaks are an ongoing public health concern, requiring extensive resources to prevent and manage. Invasive Meningococcal Disease (IMD) is a severe outcome of infection with Neisseria meningitidis bacteria, which can be carried and transmitted asymptomatically. IMD is not completely vaccine-preventable, presenting an ongoing risk of outbreak development. This review provides a retrospective assessment of public health management of IMD outbreaks.

METHODS

A systematic search was performed in PubMed and EMBASE. English-language studies reporting on IMD outbreaks and associated public health response were considered eligible. Reporting on key characteristics including outbreak size, duration, location, and public health response were assessed against Strengthening the Reporting of Observational studies in Epidemiology guidelines. A summary of lessons learned and author recommendations for each article were also discussed.

RESULTS

39 eligible studies were identified, describing 35 outbreaks in seven regions. Responses to outbreaks were mostly reactive, involving whole communities over prioritising those at highest risk of transmission. Recent responses identified a need for more proactive and targeted controls. Reporting was inconsistent, with key characteristics such as outbreak size, duration, or response absent or incompletely described.

CONCLUSION

There is a need for clear, comprehensive reporting on IMD outbreaks and their public health response to inform policy and practice for subsequent outbreaks of IMD and other infectious diseases.

Serogroup B Meningococcal Sepsis and Meningitis Associated With Meningococcal Acute Otitis Media, and Paranasal Sinusitis in an Infant: A Case Report

Meningococcal disease (MD) is a potentially lethal condition. Typically, following infection, MD manifests with high fever, with signs and symptoms of severe septicemia with or without purpura, and in more than half of cases with meningitis. Acute otitis media (AOM) caused by Neisseria meningitidis has scarcely been reported, mostly without severe MD, and there are no reports of meningococcal paranasal sinusitis (PS). We present the case of a previously healthy 11-month-old infant who started with fever and cough and further developed intense irritability and right spontaneous purulent otorrhea, with subsequent increased fever and seizures. Blood, cerebrospinal, and middle ear fluid cultures were positive for N. meningitidis serogroup B, and a CT scan showed both maxillary and ethmoidal sinusitis. Intravenous ceftriaxone was administered for eight days, and three months following discharge, no sequelae were identified. This is the first report of a patient with MD associated with sepsis, meningitis, AOM, and PS.

Association between Meningococcal Meningitis and Santa Ana Winds in Children and Adolescents from Tijuana, Mexico: A Need for Vaccination

Background: Based on previous studies (regional and national), Tijuana, Baja California, Mexico (across the border from San Diego, California, USA), has been shown to have the highest rate of meningococcal meningitis (MeM) in the country. However, the reason for this high incidence has not yet been established. To explain this regional/endemic public health problem, we aimed to evaluate whether there is a climatic association with MeM in the region. In the “African Meningitis Belt,” the Harmattan seasons are associated with MeM outbreaks; similarly, the Santa Ana winds (SAWs) seasons are characterized by hot and dry winds (similar to Harmattan seasons) that occur seasonally in Southwest California, USA, and Northwest Baja California, Mexico. Objectives: We aimed to determine a potential association of SAWs with MeM in Tijuana, Baja California, Mexico, which in turn may partially explain the high rate of this disease in the region. Methods: Based on our previously published data obtained from thirteen years of active surveillance of MeM and a 65-year review showing the seasonal occurrence of SAWs, we estimated the risk ratio (RR) for the total case numbers of MeM (51 cases of children < 16 years old) vs. bacterial meningitis not caused by Neisseria meningitidis (NMeM, 30 cases, same age group) during seasons with and without SAWs. Results: We found an association between SAWs and MeM, but not with NMeM (RR = 2.06, p = 0.02 (95% CI 1.1 to 3.8), which may partially explain the high endemicity of this deadly disease in this part of the globe. Conclusion: This study shows a new potential climatic association with MeM and provides more information that justifies universal meningococcal vaccination in Tijuana, Mexico.

Meningococcal disease in North America: Updates from the Global Meningococcal Initiative

This review summarizes the recent Global Meningococcal Initiative (GMI) regional meeting, which explored meningococcal disease in North America. Invasive meningococcal disease (IMD) cases are documented through both passive and active surveillance networks. IMD appears to be decreasing in many areas, such as the Dominican Republic (2016: 18 cases; 2021: 2 cases) and Panama (2008: 1 case/100,000; 2021: <0.1 cases/100,000); however, there is notable regional and temporal variation. Outbreaks persist in at-risk subpopulations, such as people experiencing homelessness in the US and migrants in Mexico. The recent emergence of β-lactamase-positive and ciprofloxacin-resistant meningococci in the US is a major concern. While vaccination practices vary across North America, vaccine uptake remains relatively high. Monovalent and multivalent conjugate vaccines (which many countries in North America primarily use) can provide herd protection. However, there is no evidence that group B vaccines reduce meningococcal carriage. The coronavirus pandemic illustrates that following public health crises, enhanced surveillance of disease epidemiology and catch-up vaccine schedules is key. Whole genome sequencing is a key epidemiological tool for identifying IMD strain emergence and the evaluation of vaccine strain coverage. The Global Roadmap on Defeating Meningitis by 2030 remains a focus of the GMI.

Economic burden of meningococcal disease in children and adolescents in Tijuana, Mexico

Invasive meningococcal disease (IMD) is an uncommon but serious and potentially fatal condition mainly affecting children and adolescents. Active surveillance between 2005 and 2016 at Tijuana General Hospital, Mexico, indicated that the incidence of IMD in Tijuana was higher than previously thought, at 2.69 per 100,000 population aged <16 years. The objective of this study was to estimate the economic burden associated with 51 IMD cases in children aged <16 years identified over the 11 years of active surveillance at Tijuana General Hospital, Mexico. Healthcare resource usage for the IMD cases was obtained from the hospital database and combined with unit costs from the hospital purchasing department or national databases to estimate total healthcare costs over a follow-up period of 3 months. Societal costs were represented by the value of lost wages for parents or guardians. All costs were expressed in US$. Over the 11-year study period there were 51 IMD cases, of which 13 (25%) were fatal. The total cost for all 51 cases over the 11-year study period was US$1,054,499 (average per case US$20,676), of which direct healthcare costs comprised US$1,029,948 (average per case US$20,195) and societal costs US$24,551 (average per case US$481). Extrapolated to the population of Tijuana region aged <16 years, the estimated annual economic burden of IMD was US$268,794. The major cost driver was the cost of hospitalization. These data illustrate the significant economic burden associated with IMD in Tijuana, and will be useful in assessing optimal vaccination programs against meningococcal disease in Mexico.

Meningococcal Disease Outbreaks: A Moving Target and a Case for Routine Preventative Vaccination

Outbreaks of invasive meningococcal disease (IMD) are unpredictable, can be sudden and have devastating consequences. We conducted a non-systematic review of the literature in PubMed (1997-2020) to assess outbreak response strategies and the impact of vaccine interventions. Since 1997, IMD outbreaks due to serogroups A, B, C, W, Y and X have occurred globally. Reactive emergency mass vaccination campaigns have encompassed single institutions (schools, universities) through to whole sections of the population at regional/national levels (e.g. serogroup B outbreaks in Saguenay-Lac-Saint-Jean region, Canada and New Zealand). Emergency vaccination responses to IMD outbreaks consistently incurred substantial costs (expenditure on vaccine supplies, personnel costs and interruption of other programmes). Impediments included the limited pace of transmission of information to parents/communities/healthcare workers; issues around collection of informed consents; poor vaccine uptake by older adolescents/young adults, often a target age group; issues of reimbursement, particularly in the USA; and difficulties in swift supply of large quantities of vaccines. For serogroup B outbreaks, the need for two doses was a significant issue that contributed substantially to costs, delayed onset of protection and non-compliance with dose 2. Real-world descriptions of outbreak control strategies and the associated challenges systematically show that reactive outbreak management is administratively, logistically and financially costly, and that its impact can be difficult to measure. In view of the unpredictability, fast pace and potential lethality of outbreak-associated IMD, prevention through routine vaccination appears the most effective mitigation tool. Highly effective vaccines covering five of six disease-causing serogroups are available. Preparedness through routine vaccination programmes will enhance the speed and effectiveness of outbreak responses, should they be needed (ready access to vaccines and need for a single booster dose rather than a primary series).

Using Neisseria meningitidis genomic diversity to inform outbreak strain identification

Meningococcal disease is a life-threatening illness caused by the human-restricted bacterium Neisseria meningitidis. Outbreaks in the USA involve at least two cases in an organization or community caused by the same serogroup within three months. Genome comparisons, including phylogenetic analysis and quantification of genome distances can provide confirmatory evidence of pathogen transmission during an outbreak. Interpreting genome distances depends on understanding their distribution both among isolates from outbreaks and among those not from outbreaks. Here, we identify outbreak strains based on phylogenetic relationships among 141 N. meningitidis isolates collected from 28 outbreaks in the USA during 2010-2017 and 1516 non-outbreak isolates collected through contemporaneous meningococcal surveillance. We show that genome distance thresholds based on the maximum SNPs and allele distances among isolates in the phylogenetically defined outbreak strains are sufficient to separate most pairs of non-outbreak isolates into separate strains. Non-outbreak isolate pairs that could not be distinguished from each other based on genetic distances were concentrated in the clonal complexes CC11, CC103, and CC32. Within each of these clonal complexes, phylodynamic analysis identified a group of isolates with extremely low diversity, collected over several years and multiple states. Clusters of isolates with low genetic diversity could indicate increased pathogen transmission, potentially resulting in local outbreaks or nationwide clonal expansions.

Outbreaks of meningococcal meningitis in non-African countries over the last 50 years: a systematic review

Background

Meningococcal disease is caused by the bacteria Neisseria meningitidis, leading to substantial mortality and severe morbidity; with serogroups A, B, C, W135, X and Y most significant in causing disease. An outbreak is defined as multiple cases of the same serogroup occurring in a population over a short time-period. A systematic review was performed to gain insight into outbreaks of meningococcal disease and to describe the temporal pattern over the last 50 years in non-African countries.

Methods

PubMed and EMBASE were searched for English-language publications on outbreaks of meningococcal disease in non-African countries between January 1966 and July 2017, with an additional grey literature search. Articles and reports were considered eligible if they reported confirmed meningococcal outbreak cases, included the region, number of cases, and the start and end dates of the outbreak. Data on outbreaks was stratified by geographical region in accordance with the World Health Organization (WHO) regional classification, and case-fatality rates (CFRs) were calculated.

Results

Of the identified publications, 3067 were screened and 73 included, reporting data from 83 outbreaks. The majority of outbreaks were identified in the regions of the Americas (41/83 outbreaks), followed by the European region (30/83 outbreaks). In each of the Western Pacific, Eastern Mediterranean, and South-East Asian regions there were <10 outbreaks reported. The predominant serogroup in the majority of outbreaks was serogroup C (61%), followed by serogroup B (29%), serogroup A (5%) and serogroup W135 (4%). Outbreaks showed a peak in the colder months of both the Northern and Southern Hemispheres. Of the 54 outbreaks where CFR was calculable for all outbreak cases, it ranged from 0%-80%.

Conclusions

These data present a retrospective view of the patterns for meningococcal disease outbreaks in non-African countries, and provide valuable data for monitoring future changes in disease epidemiology and informing preventive measures.

Pediatric meningitis due to Neisseria meningitidis, Streptococcus pneumoniae and Group B Streptococcus in Tijuana, Mexico: active/prospective surveillance, 2005-2018

Introduction

In Mexico, Neisseria meningitidis is considered to be a rare cause of bacterial meningitis (BM), however, one national publication using active surveillance has suggested the opposite. Group B Streptococcus (GBS) is also considered to be infrequent in young infants as a cause of BM in central Mexico. Streptococcus pneumoniae vaccination using the 13-valent conjugate vaccine (PCV13) started in our region in May 2012. We focused our research on whether N. meningitidis and GBS are important causes of BM, and to examine the effectiveness of PCV13 on pneumococcal BM.

Methods

From October 2005 to September 2018, active/prospective surveillance looking for all patients admitted with suspected BM <16 years of age was performed at the Tijuana, Mexico, General Hospital. Tijuana, Mexico to San Diego, Unites States of America (USA), is the most transited border in the world. Isolation of pathogens was by either conventional culture or Real Time-polymerase chain reaction (RT-PCR), all patients were followed during and 3 months after discharge, and a descriptive analysis was performed. The effectiveness of PCV13 was determined by comparing the proportion of cases per month on pneumococcal BM before and after its implementation.

Results

There were 86 confirmed BM cases. N. meningitidis was the leading cause (60.5%, and 61.5% caused by serogroup C), followed by S. pneumoniae (18.6%). PCV13 effectiveness on pneumococcal BM was of 64.3% and was associated with the disappearance of serotype 19A. A total of 22 infants <3 months old had BM; GBS was the leading cause at this age group (27.3%), followed by N. meningitidis (22.7%). The overall mortality was 24%.

Conclusions

BM by N. meningitidis is endemic in Tijuana, Mexico, and meningococcal vaccination should be seriously considered in the region. PCV13 is currently showing high effectiveness on pneumococcal BM, and we need to continue active surveillance to see whether maternal screening/prophylaxis for GBS should also be introduced in the region.

Meningococcal Neonatal Purulent Conjunctivitis/Sepsis and Asymptomatic Carriage of N. meningitidis in Mother's Vagina and Both Parents' Nasopharynx

Neonatal conjunctivitis is usually associated with vagina's infection by Chlamydia sp., N. gonorrhoeae, and/or other bacteria during delivery. Meningococcal neonatal conjunctivitis is an extremely rare disease. We report a case of neonatal meningococcal sepsis/conjunctivitis and asymptomatic carriage of N. meningitidis from both parents (vagina and nasopharynx). As part of our active surveillance for meningococcal disease at the Tijuana General Hospital (TGH), Mexico, we identified a 3-day-old newborn with meningococcal conjunctivitis and sepsis. The patient had a one-day history of conjunctivitis and poor feeding. Clinical examination confirmed profuse purulent conjunctival discharge, as well as clinical signs and laboratory findings suggestive of bacteraemia. Gram stain from conjunctival exudate revealed intracellular Gram negative diplococci; we presumed the baby had gonorrheal conjunctivitis; however, serogroup Y, N. meningitidis was isolated both from conjunctival exudate and blood. Additionally, isolation of serogroup Y, N. meningitidis was obtained from mother's vagina and both parents' nasopharynx. The baby was treated with 7 days of IV ceftriaxone and discharged with no sequelae.

Neisseria meningitidis and Streptococcus pneumoniae as leading causes of pediatric bacterial meningitis in nine Mexican hospitals following 3 years of active surveillance

OBJECTIVES

Meningococcal meningitis is reported as a rare condition in Mexico. There are no internationally published studies on bacterial causes of meningitis in the country based on active surveillance. This study focuses on finding the etiology of bacterial meningitis in children from nine Mexican Hospitals.

METHODS

From January 2010 to February 2013, we conducted a three years of active surveillance for meningitis in nine hospitals throughout Mexico. Active surveillance started at the emergency department for every suspected case, and microbiological studies confirmed/ruled out all potentially bacterial pathogens. We diagnosed based on routine cultures from blood and cerebrospinal fluid (not polymerase chain reaction or other molecular diagnostic tests), and both pneumococcal serotyping and meningococcal serogrouping by using standard methods.

RESULTS

Neisseria meningitidis was the leading cause, although 75% of cases occurred in the northwest of the country in Tijuana on the US border. Serogroup C was predominant. Streptococcus pneumoniae followed Neisseria meningitides, but was uniformly distributed throughout the country. Serotype 19A was the most incident but before universal implementation of the 13-valent pneumococcal conjugate vaccine. Other bacteria were much less common, including Enterobacteriaceae and Streptococcus agalactiae (these two affecting mostly young infants).

CONCLUSIONS

Meningococcal meningitis is endemic in Tijuana, Mexico, and vaccination should be seriously considered in that region. Continuous universal vaccination with the 13-valent pneumococcal conjugate vaccine should be nationally performed, and polymerase chain reaction should be included for bacterial detection in all cultures - negative but presumably bacterial meningitis cases.