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Published Date: 2017-12-08 11:04:46
Subject: PRO/EDR> Meningitis, meningococcal - Australia (06): (VI) MSM, sg C, vaccine, alert
Archive Number: 20171208.5491258
MENINGITIS, MENINGOCOCCAL - AUSTRALIA (06): (VICTORIA) MEN WHO HAVE SEX WITH MEN, SEROGROUP C, VACCINE, ALERT
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Date: Thu 7 Dec 2017
From: Finn Romanes <finn.romanes@dhhs.vic.gov.au> [edited]


An outbreak of invasive meningococcal disease (serogroup c) amongst men who have sex with men in Victoria, Australia
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Introduction
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The Victoria Department of Health and Human Services is responding to an outbreak of invasive meningococcal disease (IMD) due to a closely related strain of serogroup C affecting men who have sex with men (MSM) across Melbourne, Victoria, Australia. All gay and bisexual men and men who have sex with men in the state are being offered free quadrivalent ACWY vaccine against invasive meningococcal disease in order to respond to this outbreak.

Risk assessment and descriptive epidemiology
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A confirmed outbreak case was defined as:
- a confirmed case of IMD according to the national surveillance case definition (http://www.health.gov.au/casedefinitions); AND
- where the isolate was typed by the Microbiological Diagnostic Unit Public Health Laboratory in Victoria as _Neisseria meningitidis_ serogroup C; AND
- who was notified in Victoria during 2017 or was notified in another jurisdiction but is normally resident in Victoria.

A total of 8 confirmed serogroup C cases were identified, with 2 cases becoming ill in May 2017, and 1 each in July, August, September, and October. Onset in the most recent 2 cases occurred in the last week of November. Whole genome sequencing on isolates has demonstrated marked relatedness in all confirmed outbreak cases.

All cases were hospitalised, and presentations ranged from meningitis (2 cases), sepsis (2 cases), meningitis and sepsis (3 cases), and pneumonia (1 case). The age range of cases was 28 to 43 years, and all cases were male, with almost all reporting MSM sexual activity. Local transmission appears likely with no identified links between cases and only 1 case reported overseas travel in the ten days preceding illness onset. None of the cases are known to be HIV positive.

The Department has estimated that the attack rate in MSM is high in this outbreak at around 9.8 to 13.3 per 100 000 MSM population, compared to a baseline annual notification rate of IMD in the Victorian population of 1.4 per 100 000.

In Victoria between 2012-2016 inclusive there were 3 confirmed cases of IMD caused by serogroup C. In 2016 there were a total of 3 serogroup C cases notified across Australia.

Public health response including control measures
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A Chief Health Officer Alert was issued on 7 Dec 2017 (https://www2.health.vic.gov.au/about/key-staff/chief-health-officer). This alert advised that gay and bisexual men and MSM who have not received a vaccine against meningococcal serogroup C in the previous 5 years are at increased risk in this outbreak. The Department is providing free 4vMenCV (Menactra) for all gay and bisexual men and MSM, from [Mon 11 Dec 2017 until 30 Jun 2018]. Health professionals were also reminded about other groups who are recommended for meningococcal vaccination under national guidelines (http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home), which includes all children aged 12 months, travellers to sites of current overseas epidemics, and people with selected other specific medical conditions listed in that guidance.

The Department has also called on clinics to bulk-bill consultations when providing this vaccine, which means patients are not charged a consultation fee, as this may make the public health initiative more accessible for some patients recommended for vaccination.

On [30 Sep 2016] the Australian Government expanded an existing national immunisation register to become a whole of life immunisation register for all Australians, intending to capture all vaccines received across the life course. In the management of this outbreak, the Department is requesting all ACWY vaccinations provided to gay and bisexual men and other MSM to be recorded on this expanded Australian Immunisation Register (AIR), so that uptake can be estimated and the AIR can be as complete as possible.

Communication with health professionals and the public about the outbreak
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Health professionals and health services in Victoria receive urgent public health advice through subscribing by email to Chief Health Officer Alerts and Advisories on the Department's website (https://www2.health.vic.gov.au/about/key-staff/chief-health-officer).

In addition to recommending vaccination, the alert issued on [7 Dec 2017] advises health professionals to consider IMD in MSM who present with symptoms consistent with meningitis or septicaemia, and to notify the Department under the Public Health and Wellbeing Regulations 2009 without delay, and to provide immediate antibiotic treatment. Under those Regulations, suspected invasive meningococcal disease is a group A notifiable condition, meaning it must be called through immediately to the Department as the public health authority in the state of Victoria.

Further information has been made available, including frequently asked questions for MSM (https://www.betterhealth.vic.gov.au/health/healthyliving/meningococcal-vaccine-for-men-who-have-sex-with-men) and for health professionals (https://www2.health.vic.gov.au/public-health/immunisation/adults/meningococcal-acwy-vaccine-gbm-msm). The Department's online resource library known as the Better Health Channel (https://www.betterhealth.vic.gov.au/) also contains other information on meningitis and meningococcal disease, as well as accessible health information across a range of other topics.

Further background on invasive meningococcal disease
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From 2002 to 2015 the predominant invasive meningococcal disease serogroup in Australia was serogroup B. However, in 2016, serogroup W became the predominant meningococcal serogroup in Australia with a total of 109 cases reported to the National Notifiable Diseases Surveillance System (NNDSS).

Infection with the causative bacteria _N. meningitidis_ serogroup C can cause syndromes including meningitis and sepsis that progress rapidly and can cause death in up to 10 per cent of cases, and permanent sequelae in up to 20 per cent of survivors. Quadrivalent (A, C, W, Y) meningococcal conjugate vaccine (4vMenCV) provides effective prevention for up to five years. Meningococcal bacteria are difficult to spread and are probably only passed from person to person by close, prolonged contact.

--
Dr Finn Romanes, MBBS, MPHTM, FFPH, FAFPHM
Public Health Physician
Department of Health and Human Services,
Victoria State Government
Australia
<finn.romanes@dhhs.vic.gov.au>

[ProMED-mail thanks Dr Finn Romanes for submitting the alert above.

_Neisseria meningitidis_, the cause of invasive meningococcal disease (meningitis and sepsis), is usually transmitted from person to person via droplets of respiratory secretions, mostly from asymptomatic nasopharyngeal carriers of the microorganism. However, recent data suggest that meningococci can adapt to a urethral location (https://www.ncbi.nlm.nih.gov/pubmed/28373547) and can be transmitted by sexual activity.

Urogenital infections due to _N. meningitidis_ have been reported sporadically in the past, but in 2015, a marked increase in the incidence of meningococcal urethritis was noted in heterosexual men at 2 US sexual health clinics, one in Columbus, Ohio, and another in Oakland County, Michigan, as well as in clinics in Atlanta and Indianapolis. Oral sex was reported by almost all patients (see ProMED-mail post Urethritis, meningococcal - USA: (OH,MI) heterosex. men, oral sex trans, non-gr. 20160604.4265651.) The urethral isolates were nongroupable (nonencapsulated), ST-11 clonal complex 11 (cc11), ET-15, and clustered together phylogenetically. Urethral Nm isolates were similar by fine typing (PorA P1.5-1,10-8, PorB 2-2, FetA F3-6) and the strains grow well anaerobically (https://www.ncbi.nlm.nih.gov/pubmed/28373547, https://www.ncbi.nlm.nih.gov/pubmed/28481980, and https://www.ncbi.nlm.nih.gov/pubmed/28098538).

Outbreaks of invasive meningococcal disease (IMD) have occurred in the past several years among men who have sex with men (MSM) in Germany, Belgium, and France caused by a hypervirulent _N. meningitidis_ serogroup C strain (http://www.ecdc.europa.eu/en/publications/Publications/rapid-risk-assessment-invasive-meningococcal-disease-among-MSM.pdf). Similar outbreaks among MSM caused by _N. meningitidis_ serogroup C have also occurred in Canada and the US (see ProMED-mail posts listed below).

Meningococci isolated in Germany and France from these MSM with IMD and from MSM with urethritis/proctitis were found to have the same genotype, (serogroup C, PorA type P1.5-1,10-8, FetA type F3-6, and cc11) (http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20523 and http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=21016). Genome sequencing analysis showed that isolates from MSM with IMD clustered with urethritis and proctitis isolates collected in the 2 countries, distinct from other cc11/ET-15 isolates.

The meningococcal isolates from both MSM with IMD and urethritis were able to grow anaerobically in the presence of nitrite, as do gonococci, unlike non-MSM/urethritis meningococcal isolates. Anaerobic growth was thought to allow meningococci to survive under anaerobic and acidic pH in the urethra or rectum, leading to the clinical manifestation of urethritis/proctitis as well as the capacity for direct sexual transmission.

However, invasive isolates from MSM, but not urethritis isolates, expressed a protein that binds human factor H, a complement regulatory protein, which favors survival in the bloodstream.

These studies suggested that in the outbreak of IMD in MSM, meningococci were transmitted sexually and that reverted to a phenotype with enhanced bacterial survival in the blood, which facilitated meningococcemia and systemic dissemination.

Similar to the meningococcal vaccine program in Victoria. Australia, vaccination campaigns with a meningococcal conjugate vaccine directed against serogroup C that target MSM have been carried out in Europe and the US to control outbreaks of IMD in MSM (CDC. Control and prevention of serogroup C meningococcal disease: evaluation and management of suspected outbreaks: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 1997; 46(RR-5): 13-21; available at http://www.cdc.gov/mmwr/preview/mmwrhtml/00046237.htm).

Maps of Australia: http://www.ezilon.com/maps/images/oceania/australia-political-map.gif and http://healthmap.org/promed/p/288. Victoria, in southeastern Australia, is the country's 2nd-most populous state. Most of its population of over 5.7 million is concentrated in the area surrounding Port Phillip Bay, which includes the metropolitan area of its capital and largest city, Melbourne, Australia's 2nd-largest city http://en.wikipedia.org/wiki/Victoria_(Australia). - Mod.ML]

See Also

Meningitis, meningococcal - Australia (05): (WA) sg W, sg Y 20171121.5456199
Meningitis, meningococcal - Australia (04): (VI) vaccine, adolescents 20171103.5421941
Meningitis, meningococcal - Australia (03): (NT) sg W, Aboriginal children 20171014.5376391
Meningitis, meningococcal - Australia (02): (NT) sg W, Aboriginal children 20170928.5345825
Meningitis, meningococcal - Australia: (WA) sg Y 20170728.5211652
2016
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Meningitis, meningococcal - USA (04): (CA) fatal, MSM, sg C, vaccination 20160727.4371802
Meningitis, meningococcal - USA (03): (CA) fatal, MSM, sg C, vaccination 20160630.4314012
Meningitis, meningococcal - USA (02): (CA) fatal, MSM, vaccination, RFI 20160626.4310203
Urethritis, meningococcal - USA: (OH,MI) heterosex. men, oral sex trans, non-gr. 20160604.4265651
Meningitis, meningococcal - Europe: fatal, MSM, new sexually transmitted strain 20160513.4220814
2015
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Meningitis, meningococcal - USA (03): (MN,IL) fatal, MSM, vaccine 20150718.3520169
Meningitis, meningococcal - USA (02): (IL) fatal, MSM, vaccine, RFI 20150711.3502722
Meningitis, meningococcal - France: (Paris) serogroup C, MSM, vaccination 20150124.3116307
2014
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Meningitis, meningococcal - USA (04): (CA) fatal, MSM, vaccination, RFI 20140404.2379584
2013
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Meningitis, meningococcal - Germany: (BE) fatal, MSM, vaccination 20130725.1844122
Meningitis, meningococcal - USA (02): (New York City) fatal, MSM, vaccination 20130520.1725339
Meningitis, meningococcal - USA: (New York City) fatal, MSM, alert 20130308.1576590
2012
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Meningitis, meningococcal - USA (02): (NY) fatal, MSM 20120929.1315676
.................................................ml/mj/mpp
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