Meningococcal disease before and after the introduction of
               meningococcal serogroup C conjugate vaccine. Federal District, Brazil

Tauil, Márcia de Cantuária; Carvalho, Cleidiane Santos Rodrigues de; Vieira, Ataiza César; Waldman, Eliseu Alves

doi:10.1016/j.bjid.2013.11.012

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Brazilian Journal of Infectious Diseases

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Original Articles • Braz J Infect Dis 18 (4) • Jul-Aug 2014 • https://doi.org/10.1016/j.bjid.2013.11.012 copy

Meningococcal disease before and after the introduction of meningococcal serogroup C conjugate vaccine. Federal District, Brazil

Authorship SCIMAGO INSTITUTIONS RANKINGS

OBJECTIVES:

To analyze the behavior of meningococcal disease in the Federal District, Brazil, from 2005 to 2011, and to assess the direct impact of the meningococcal serogroup C conjugate vaccine.

METHODS:

A descriptive study of cases of meningococcal disease among residents of the Federal District. We included in the study confirmed cases of meningococcal disease reported to the local surveillance. To reduce underreporting we compared data to the Brazilian Mortality Database and the Public Health Laboratory Database. We studied sociodemographic, clinical, and pathogen-related variables. For the assessment of the impact of meningococcal serogroup C conjugate vaccine, which was introduced in 2010 for children under two years of age, we compared the incidence of meningococcal disease before and after vaccine introduction in the recommended age groups for vaccination.

RESULTS:

We identified 309 cases of meningococcal disease, of which 52.1% were males. The average case fatality rate was 20.7%, the median age was three years and there was a predominance of serogroup C (70.2%) and C:23:P1.14-6 phenotype throughout the study period. In 2005-2009, 2010 and 2011, the incidence rates of meningococcal disease were 2.0, 1.8 and 0.8/100,000 inhabitants/year, while mortality rates were 0.4, 0.4 and 0.2/100,000 inhabitants/year, respectively. In the first and last periods, the incidence in poorer and more affluent areas were, respectively, 2.0 and 0.8, and 0.9 and 0.0/100,000 inhabitants/year. Comparing 2009 (the year prior to the introduction of meningococcal serogroup C conjugate vaccine) and 2011, there was 85% reduction in the incidence of serogroup C meningococcal disease in children under four years of age, from 9.0 to 1.3/100,000 (p < 0.01).

CONCLUSIONS:

The meningococcal serogroup C conjugate vaccine strategy implemented in Brazil proved highly effective and had a strong direct impact on the target population. However, case fatality rates of meningococcal disease remain high with a wide gap in the risk of disease between poor and affluent areas, pointing to the need to reexamine the current strategy on a regular base.

Meningococcal disease; Epidemiology; Control

Variables	2005-2009					2010					2011
	Cases N = 243 ^a		Deaths N = 50 ^a		Fatality rate	Cases N = 45 ^a		Deaths N = 9 ^a		Fatality rate	Cases N = 21 ^a		Deaths N = 5 ^a		Fatality rate
	N (%)	Rate^b	N (%)	Rate^b	%	N (%)	Rate^b	N (%)	Rate^b	%	N (%)	Rate^b	N (%)	Rate^b	%
Gender
Male	126 (51.9)	2.2	21 (42)	0.4	16.7	23 (51.1)	1.9	6 (66.7)	0.5	26.1	12 (57.1)	1.0	2 (40)	0.2	16.7
Female	117 (48.1)	1.8	29 (58)	0.5	24.8	22 (48.9)	1.6	3 (33.3)	0.2	13.6	9 (42.9)	0.7	3 (60)	0.2	33.3

Total	243 (100)	2.0	50 (100)	0.4	20.6	45 (100)	1.8	9 (100)	0.4	20.0	21 (100)	0.8	5 (100)	0.2	23.8

Age (years)
<1	66 (27.2)	30.6	14 (28)	6.5	21.2	5 (11.1)	13.3	4 (44.4)	10.6	80.0	5 (23.8)	13.1	0 (0.0)	0.0	0.0
1-2	31 (12.8)	14.4	6 (12)	2.8	19.4	4 (8.9)	10.8	1 (11.1)	2.7	25.0	1 (4.8)	2.7	0 (0.0)	0.0	0.0
2-5	56 (23.0)	8.7	9 (18)	1.4	16.1	10 (22.2)	8.8	1 (11.1)	0.9	10.0	6 (28.6)	5.2	0 (0.0)	0.0	0.0
5-15	42 (17.3)	1.9	4 (8)	0.2	9.5	13 (28.9)	3.1	2 (22.2)	0.5	15.4	4 (19.0)	0.9	2 (40.0)	0.5	50.0
15-30	25 (10.3)	0.7	6 (12)	0.2	24.0	4 (8.9)	0.5	1 (11.1)	0.1	25.0	3 (14.3)	0.4	1 (20.0)	0.1	33.3
≥30	23 (9.5)	0.4	11 (22)	0.2	47.8	9 (20)	0.7	0 (0.0)	0.0	0.0	2 (9.5)	0.2	2 (40.0)	0.2	100

Total	243 (100)	2.0	50 (100)	0.4	20.6	45 (100)	1.8	9 (100)	0.4	20.0	21 (100)	0.8	5 (100)	0.2	23.8

Serogroup
B	25 (20.7)	0.2	1 (7.7)	0.01	4.0	2 (11.1)	0.1	0 (0.0)	0.0	0.0	2 (20.0)	0.1	0 (0.0)	0.0	0.0
C	85 (70.2)	0.7	10 (76.9)	0.1	11.8	14 (77.8)	0.5	2 (66.7)	0.1	14.3	6 (60.0)	0.2	2 (50.0)	0.1	33.3
Y	4 (3.3)	0.03	0 (0.0)	0.0	0.0	1 (5.6)	0.04	0 (0.0)	0.0	0.0	1 (10.0)	0.04	1 (25.0)	0.04	100
W135	7 (5.8)	0.1	2 (15.4)	0.02	28.6	1 (5.6)	0.04	1 (33.3)	0.04	100	1 (10.0)	0.04	1 (25.0)	0.04	100

Total	121 (100)	1.0	13 (100)	0.1	10.7	18 (100)	0.7	3 (100)	0.12	16.7	10 (100)	0.38	4 (100)	0.15	40.0

Phenotypes
C:23:P1.14-6	47 (38.8)	0.4	4 (30.8)	0.03	8.5	8 (44.4)	0.3	1 (33.3)	0.04	12.5	6 (60.0)	0.2	2 (50.0)	0.1	33.3
C:2a:P1.5.2	19 (15.7)	0.2	1 (7.7)	0.01	5.3	0 (0.0)	0.0	0 (0.0)	0.0	0.0	0 (0.0)	0.0	0 (0.0)	0.0	0.0
C:23:NT	6 (5.0)	0.05	0 (0.0)	0.0	0.0	4 (22.2)	0.2	1 (33.3)	0.04	25.0	0 (0.0)	0.0	0 (0.0)	0.0	0.0
C: Other Pt^c	13 (10.7)	0.1	5 (38.5)	0.04	38.5	2 (11.1)	0.1	0 (0.0)	0.0	0.0	0 (0.0)	0.0	0 (0.0)	0.0	0.0
B:4,7:P1.19,15	15 (12.4)	0.1	0 (0.0)	0.0	0.0	0 (0.0)	0.0	0 (0.0)	0.0	0.0	1 (10.0)	0.04	0 (0.0)	0.0	0.0
B: Other Pt^c	10 (8.3)	0.08	1 (7.7)	0.01	10.0	2 (11.1)	0.1	0 (0.0)	0.0	0.0	1 (10.0)	0.04	0 (0.0)	0.0	0.0
Y/W135^d	11 (9.1)	0.09	2 (15.4)	0.02	18.2	2 (11.1)	0.1	1 (33.3)	0.04	50.0	2 (20.0)	0.1	(50.0)	0.1	100

Total	121 (100)	1.0	13 (100)	0.1	10.7	18 (100)	0.7	3 (100)	0.12	16.7	10 (100)	0.38	4 (100)	0.15	40.0

Income ^e
≤2 MMWs	187 (86.2)	2.0	40 (81.6)	0.4	21.4	36 (90.0)	1.9	8 (88.9)	0.4	22.2	18 (94.7)	0.9	4 (100)	0.2	22.2
3-5 MMWs	16 (7.4)	1.3	7 (14.3)	0.6	43.8	1 (2.5)	0.3	0 (0.0)	0.0	0.0	1 (5.3)	0.4	0 (0.0)	0.0	0.0
>5 MMWs	14 (6.5)	0.8	2 (4.1)	0.1	14.3	3 (7.5)	1.0	1 (11.1)	0.3	33.3	0 (0.0)	0.0	0 (0.0)	0.0	0.0

Total	217 (100)	1.8	49 (100)	0.4	22.6	40 (100)	1.6	9 (100)	0.4	22.5	19 (100)	0.8	4 (100)	0.2	21.1

Age	All cases			Serogroup C			Serogroup B
	2009 Rate^a (cases)	2011 Rate^a (cases)	Variation %	2009 Rate^a (cases)	2011 Rate^a (cases)	Variation %	2009 Rate^a (cases)	2011 Rate^a (cases)	Variation %
<2	23.6 (21)	7.9 (6)	-66.5	12.4 (11)	2.6 (2)	-79.0	2.2 (2)	2.6 (2)	+18.2
2	13.5 (6)	2.7 (1)	-80.0	6.8 (3)	0.0 (0)	-100	0 (0)	0.0 (0)	-
3	9.0 (4)	7.8 (3)	-13.3	4.5 (2)	0.0 (0)	-100	2.3 (1)	0.0 (0)	-100
4	15.9 (7)	5.0 (2)	-68.5	13.6 (6)	2.5 (1)	-81.6	0 (0)	0.0 (0)	-
5-19	1.6 (11)	0.8 (5)	-50.0	0.1 (1)	0.3 (2)	+200	0.1 (1)	0.0 (0)	-100
≥20	0.9 (15)	0.2 (4)	-77.8	0.2 (4)	0.1 (1)	-50.0	0 (0)	0.0 (0)	-
Total	2.5 (64)	0.8 (21)	-68.0	1.0 (27)	0.2 (6)	-80.0	0.2 (4)	0.1 (2)	-50.0

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[1] * Corresponding author. E-mail address: mctauil@yahoo.com.br (M.d.C. Tauil).