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MacLennan JM, Rodrigues CMC, Bratcher HB, Lekshmi A, Finn A, Oliver J, Wootton M, Ray S, Cameron C, Smith A, Heath PT, Bartolf A, Nolan T, Hughes S, Varghese A, Snape MD, Sewell R, Cunningham R, Stolton A, Kay C, Palmer K, Baxter D, Suggitt D, Zipitis CS, Pemberton N, Jolley KA, Bray JE, Harrison OB, Ladhani SN, Pollard AJ, Borrow R, Gray SJ, Trotter C, Maiden MCJ. Meningococcal carriage in periods of high and low invasive meningococcal disease incidence in the UK: comparison of UKMenCar1-4 cross-sectional survey results. THE LANCET. INFECTIOUS DISEASES 2021; 21:677-687. [PMID: 33482143 PMCID: PMC8064914 DOI: 10.1016/s1473-3099(20)30842-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 06/16/2020] [Accepted: 10/13/2020] [Indexed: 02/02/2023]
Abstract
Background The incidence of invasive meningococcal disease in the UK decreased by approximately four times from 1999 to 2014, with reductions in serogroup C and serogroup B disease. Lower serogroup C invasive meningococcal disease incidence was attributable to implementation of the meningococcal serogroup C conjugate vaccine in 1999, through direct and indirect protection, but no vaccine was implemented against serogroup B disease. UK Meningococcal Carriage surveys 1–3 (UKMenCar1–3), conducted in 1999, 2000, and 2001, were essential for understanding the impact of vaccination. To investigate the decline in invasive meningococcal disease incidence, we did a large oropharyngeal carriage survey in 2014–15, immediately before the changes to meningococcal vaccines in the UK national immunisation schedule. Methods UKMenCar4 was a cross-sectional survey in adolescents aged 15–19 years who were enrolled from schools and colleges geographically local to one of 11 UK sampling centres between Sept 1, 2014, and March 30, 2015. Participants provided an oropharyngeal swab sample and completed a questionnaire on risk factors for carriage, including social behaviours. Samples were cultured for putative Neisseria spp, which were characterised with serogrouping and whole-genome sequencing. Data from this study were compared with the results from the UKMenCar1–3 surveys (1999–2001). Findings From the 19 641 participants (11 332 female, 8242 male, 67 not stated) in UKMenCar4 with culturable swabs and completed risk-factor questionnaires, 1420 meningococci were isolated, with a carriage prevalence of 7·23% (95% CI 6·88–7·60). Carriage prevalence was substantially lower in UKMenCar4 than in the previous surveys: carriage prevalence was 16·6% (95% CI 15·89–17·22; 2306/13 901) in UKMenCar1 (1999), 17·6% (17·05–18·22; 2873/16 295) in UKMenCar2 (2000), and 18·7% (18·12–19·27; 3283/17 569) in UKMenCar3 (2001). Carriage prevalence was lower for all serogroups in UKMenCar4 than in UKMenCar1–3, except for serogroup Y, which was unchanged. The prevalence of carriage-promoting social behaviours decreased from 1999 to 2014–15, with individuals reporting regular cigarette smoking decreasing from 2932 (21·5%) of 13 650 to 2202 (11·2%) of 19 641, kissing in the past week from 6127 (44·8%) of 13 679 to 7320 (37·3%) of 19 641, and attendance at pubs and nightclubs in the past week from 8436 (62·1%) of 13 594 to 7662 (39·0%) of 19 641 (all p<0·0001). Interpretation We show that meningococcal carriage prevalence in adolescents sampled nationally during a low incidence period (2014–15) was less than half of that in an equivalent population during a high incidence period (1999–2001). Disease and carriage caused by serogroup C was well controlled by ongoing vaccination. The prevalence of behaviours associated with carriage declined, suggesting that public health policies aimed at influencing behaviour might have further reduced disease. Funding Wellcome Trust, UK Department of Health, and National Institute for Health Research.
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Affiliation(s)
- Jenny M MacLennan
- Department of Zoology, Peter Medawar Building for Pathogen Research, University of Oxford, Oxford, UK
| | - Charlene M C Rodrigues
- Department of Zoology, Peter Medawar Building for Pathogen Research, University of Oxford, Oxford, UK
| | - Holly B Bratcher
- Department of Zoology, Peter Medawar Building for Pathogen Research, University of Oxford, Oxford, UK
| | - Aiswarya Lekshmi
- Meningococcal Reference Unit, Public Health England, Manchester Public Health Laboratory, Manchester Royal Infirmary, Manchester, UK
| | - Adam Finn
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
| | - Jenny Oliver
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
| | - Mandy Wootton
- Division of Public Health Wales, Temple of Peace and Health, Cardiff, UK
| | - Samantha Ray
- Division of Public Health Wales, Temple of Peace and Health, Cardiff, UK
| | - Claire Cameron
- NHS National Services Scotland, Health Protection Scotland, Glasgow, UK
| | - Andrew Smith
- Glasgow Dental School, University of Glasgow, UK; Scottish Microbiology Reference Laboratory, NHS Greater Glasgow & Clyde, Glasgow, UK
| | - Paul T Heath
- St George's Vaccine Institute, Institute of Infection & Immunity, St George's University of London, London, UK
| | - Angela Bartolf
- St George's Vaccine Institute, Institute of Infection & Immunity, St George's University of London, London, UK
| | - Tracey Nolan
- Research and Development Department, Maidstone and Tunbridge Wells NHS Trust, Maidstone, Kent, UK
| | - Stephen Hughes
- Central Manchester University Hospitals, NHS Foundation Trust, Manchester, UK
| | - Anu Varghese
- Central Manchester University Hospitals, NHS Foundation Trust, Manchester, UK
| | - Matthew D Snape
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and the National Institute for Health Research Oxford Biomedical Research Centre, Oxford, UK
| | - Richard Sewell
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and the National Institute for Health Research Oxford Biomedical Research Centre, Oxford, UK
| | - Richard Cunningham
- Department of Zoology, Peter Medawar Building for Pathogen Research, University of Oxford, Oxford, UK
| | - Alison Stolton
- Microbiology Department, University Hospitals Plymouth NHS Trust, UK
| | - Carole Kay
- Lancashire and South Cumbria NHS Foundation Trust, Preston, Lancashire, UK
| | - Karen Palmer
- Lancashire and South Cumbria NHS Foundation Trust, Preston, Lancashire, UK
| | - David Baxter
- Stockport NHS Foundation Trust, Stepping Hill Hospital, Stockport, UK
| | - Debbie Suggitt
- Stockport NHS Foundation Trust, Stepping Hill Hospital, Stockport, UK
| | - Christos S Zipitis
- Manchester Academic Health Science Centre, University of Manchester, Manchester, UK; Department of Paediatrics, Wrightington Wigan and Leigh NHS Foundation Trust, Wigan, UK
| | - Nicola Pemberton
- Clinical Trials Department, Wrightington Wigan and Leigh NHS Foundation Trust, Wigan, UK
| | - Keith A Jolley
- Department of Zoology, Peter Medawar Building for Pathogen Research, University of Oxford, Oxford, UK
| | - James E Bray
- Department of Zoology, Peter Medawar Building for Pathogen Research, University of Oxford, Oxford, UK
| | - Odile B Harrison
- Department of Zoology, Peter Medawar Building for Pathogen Research, University of Oxford, Oxford, UK
| | - Shamez N Ladhani
- Paediatric Infectious Diseases Research Group, St George's University of London, London, UK; Immunisation and Countermeasures Division, Public Health England, London, UK
| | - Andrew J Pollard
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and the National Institute for Health Research Oxford Biomedical Research Centre, Oxford, UK
| | - Raymond Borrow
- Meningococcal Reference Unit, Public Health England, Manchester Public Health Laboratory, Manchester Royal Infirmary, Manchester, UK
| | - Stephen J Gray
- Meningococcal Reference Unit, Public Health England, Manchester Public Health Laboratory, Manchester Royal Infirmary, Manchester, UK
| | - Caroline Trotter
- Disease Dynamics Unit, Department of Veterinary Medicine, University of Cambridge, Cambridge, UK
| | - Martin C J Maiden
- Department of Zoology, Peter Medawar Building for Pathogen Research, University of Oxford, Oxford, UK.
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Carr J, Plested E, Aley P, Camara S, Davis K, MacLennan JM, Gray S, Faust SN, Borrow R, Christensen H, Trotter C, Maiden MCJ, Finn A, Snape MD. 'Be on the TEAM' Study (Teenagers Against Meningitis): protocol for a controlled clinical trial evaluating the impact of 4CMenB or MenB-fHbp vaccination on the pharyngeal carriage of meningococci in adolescents. BMJ Open 2020; 10:e037358. [PMID: 33093030 PMCID: PMC7583083 DOI: 10.1136/bmjopen-2020-037358] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
INTRODUCTION Capsular group B Neisseria meningitidis (MenB) is the most common cause of invasive meningococcal disease (IMD) in many parts of the world. A MenB vaccine directed against the polysaccharide capsule remains elusive due to poor immunogenicity and safety concerns. The vaccines licensed for the prevention of MenB disease, 4CMenB (Bexsero) and MenB-fHbp (Trumenba), are serogroup B 'substitute' vaccines, comprised of subcapsular proteins and are designed to provide protection against most MenB disease-causing strains. In many high-income countries, such as the UK, adolescents are at increased risk of IMD and have the highest rates of meningococcal carriage. Beginning in the late 1990s, immunisation of this age group with the meningococcal group C conjugate vaccine reduced asymptomatic carriage and disrupted transmission of this organism, resulting in lower group C IMD incidence across all age groups. Whether vaccinating teenagers with the novel 'MenB' protein-based vaccines will prevent acquisition or reduce duration of carriage and generate herd protection was unknown at the time of vaccine introduction and could not be inferred from the effects of the conjugate vaccines. 4CMenB and MenB-fHbp may also impact on non-MenB disease-causing capsular groups as well as commensal Neisseria spp. This study will evaluate the impact of vaccination with 4CMenB or MenB-fHbp on oropharyngeal carriage of pathogenic meningococci in teenagers, and consequently the potential for these vaccines to provide broad community protection against MenB disease. METHODS AND ANALYSIS The 'Be on the TEAM' (Teenagers Against Meningitis) Study is a pragmatic, partially randomised controlled trial of 24 000 students aged 16-19 years in their penultimate year of secondary school across the UK with regional allocation to a 0+6 month schedule of 4CMenB or MenB-fHbp or to a control group. Culture-confirmed oropharyngeal carriage will be assessed at baseline and at 12 months, following which the control group will be eligible for 4CMenB vaccination. The primary outcome is the carriage prevalence of potentially pathogenic meningococci (defined as those with genogroups B, C, W, Y or X), in each vaccine group compared separately to the control group at 12 months post-enrolment, that is, 12 months after the first vaccine dose and 6 months after the second vaccine dose. Secondary outcomes include impact on carriage of: genogroup B meningococci; hyperinvasive meningococci; all meningococci; those meningococci expressing vaccine antigens and; other Neisseria spp. A sample size of 8000 in each arm will provide 80% power to detect a 30% reduction in meningococcal carriage, assuming genogroup B, C, W, Y or X meningococci carriage of 3.43%, a design effect of 1.5, a retention rate of 80% and a significance level of 0.05. Study results will be available in 2021 and will inform the UK and international immunisation policy and future vaccine development. ETHICS AND DISSEMINATION This study is approved by the National Health Service South Central Research Ethics Committee (18/SC/0055); the UK Health Research Authority (IRAS ID 239091) and the UK Medicines and Healthcare products Regulatory Agency. Publications arising from this study will be submitted to peer-reviewed journals. Study results will be disseminated in public forums, online, presented at local and international conferences and made available to the participating schools. TRIAL REGISTRATION NUMBERS ISRCTN75858406; Pre-results, EudraCT 2017-004609-42.
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Affiliation(s)
- Jeremy Carr
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Emma Plested
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
- National Institute for Health Research Oxford Biomedical Research Centre, Oxford, Oxfordshire, UK
| | - Parvinder Aley
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
- National Institute for Health Research Oxford Biomedical Research Centre, Oxford, Oxfordshire, UK
| | - Susana Camara
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
- National Institute for Health Research Oxford Biomedical Research Centre, Oxford, Oxfordshire, UK
| | - Kimberly Davis
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | | | - Steve Gray
- Meningococcal Reference Unit, Public Health England, Manchester Royal Infirmary, Manchester, UK
| | - Saul N Faust
- NIHR Southampton Clinical Research Facility and NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Faculty of Medicine and Institute of Life Sciences, University of Southampton, Southampton, UK
| | - Ray Borrow
- Meningococcal Reference Unit, Public Health England, Manchester Royal Infirmary, Manchester, UK
| | - Hannah Christensen
- School of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Caroline Trotter
- Department of Veterinary Medicine, University of Cambridge, Cambridge, UK
| | | | - Adam Finn
- School of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Matthew D Snape
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
- National Institute for Health Research Oxford Biomedical Research Centre, Oxford, Oxfordshire, UK
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