preventing meningitis: new vaccines and forthcoming changes to the immunisation programme by jamie...
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Preventing meningitis: new vaccines and
forthcoming changes to the immunisation programme Jamie Findlow
Vaccine Evaluation Unit, Health Protection Agency, Manchester, UK.
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Overview
Neisseria meningitidis. Recent epidemiology. Vaccines and protection strategies. MenB vaccines. Forthcoming schedule changes.
Streptococcus pneumoniae. Recent epidemiology. Vaccine use update.
Summary.
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Overview
Neisseria meningitidis. Recent epidemiology. Vaccines and protection strategies. MenB vaccines. Forthcoming schedule changes.
Streptococcus pneumoniae. Recent epidemiology. Vaccine use update.
Summary.
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Neisseria meningitidis- groups
Neisseria meningitidis strains are classified into 12 groups.
The polysaccharide capsule is used to identify the different groups.
B
Polysaccharide Capsule
A
W Y
C Five main groups cause the majority (95%) of all meningococcal disease around the world – A, B, C, W and Y.
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Canada
USA
Columbia
Argentina
Brazil
Europe
Saudi Arabia
AfricanMeningitis
Belt
SouthAfrica
Australia
NewZealand
Taiwan
Japan
B53%C
21%
B25%
C29%
Y37%
Y50%
B40%
B67%
B22%
B41%
B90%
B82%
B50%
B57%
B80%C
20%
C71%
C11%
W17%
W84%
W35%
Y21%
A78%
A23%
A12%
Meningococcal disease- global epidemiology
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Laboratory confirmed cases of MenC disease in England and Wales 1995 to 2012 (calendar year)
Health Protection Agency Meningococcal Reference Unit- Unpublished data
Vaccine driven decline
Clonal exp
ansion (S
T-11)
Public health impact since 1999
Prevention of > 12,000 casesPrevention of > 1200 deaths
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 (to Aug 25th)
0
100
200
300
400
500
600
700
800
900
1000
No
of
con
firm
ed c
ases
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Laboratory confirmed cases of MenB disease in England and Wales 1995 to 2012 (calendar year)
Health Protection Agency Meningococcal Reference Unit- Unpublished data
Natural fluctuation?
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 (to Aug 25th)
0
200
400
600
800
1000
1200
1400
1600
1800
No
of
con
firm
ed c
ases
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Laboratory confirmed cases of MenW disease in England and Wales 1995 to 2012 (calendar year)
Health Protection Agency Meningococcal Reference Unit- Unpublished data
Outbreak
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 (to Aug 25th)
0
20
40
60
80
100
120
140
No
of
con
firm
ed c
ases
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France: 21
Finland: 2
S. Arabia: 241
Singapore: 4USA: 4
Indonesia: 14
Morocco: 3
Sweden: 2
Norway: 1
Germany: 10
Denmark: 1
Netherlands: 9Scotland: 1
Belgium: 1
England & Wales: 50
Kuwait: 3
Oman: 18
International Hajj associated MenW outbreak 2000*
*cases Apr to Dec 2000, WHO
Burkina Faso (2002), 13,000
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Laboratory confirmed cases of MenY disease in England and Wales 1995 to 2012 (calendar year)
Health Protection Agency Meningococcal Reference Unit- Unpublished data
Clonal exp
ansion ?
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 (to Aug 25th)
0
10
20
30
40
50
60
70
80
90
100
No
of
con
firm
ed c
ases
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Emergence of MenY in Europe
Increases in disease due to MenY has been observed in a number of Countries
across Europe
Reference: EMGM May 2011
France
Sweden
Germany
Switzerland
Finland
Norway
England and Wales
Czech Republic
Gray SJ, et al. Presented at: EMGM . Ljubljana, Slovenia. May 18–20, 2011.
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Laboratory confirmed cases of MenY disease in England and Wales by age group and year
Ladhani et al., Emerg Infect Dis 2012;18:63-70
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Laboratory confirmed cases of meningococcaldisease in England and Wales in2012 (calendar year)
Health Protection Agency Meningococcal Reference Unit- Unpublished data
B82%
C3%
W3%
Y10%
other2%
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1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 (to Aug 25th)
0
500
1000
1500
2000
2500
3000
No
of
con
firm
ed c
ases
Laboratory confirmed cases of meningococcal disease (all groups) in England and Wales 1995 to 2012 (calendar year)
Health Protection Agency Meningococcal Reference Unit- Unpublished data
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Average annual number of laboratory confirmed cases of meningococcal disease in children <2 years of age by capsular group and age (2006/2007 to 2009/2010)
Average annual number of laboratory confirmed cases of all Meningococcal disease in under-2s by serogroup and month of age (2006-07 to 2009-10)
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23Age (months)
Nu
mb
er o
f re
po
rts
Other groups
Ungrouped
ACWY
B
~54% of disease <1 year of age is within the first 6 months
Ladhani et al., Vaccine 2012;30:3710-6
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0
50
100
150
200
250
300
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24Age (years)
Nu
mb
er o
f re
po
rts
ACWY
Ungrouped
Other groups
B
Average annual number of invasive meningococcal disease cases by capsular group in children and young adults in England and Wales (2006/07 to 2009/10)
Ladhani et al., Vaccine 2012;30:3710-6
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Overview
Neisseria meningitidis. Recent epidemiology. Vaccines and protection strategies. MenB vaccines. Forthcoming schedule changes.
Streptococcus pneumoniae. Recent epidemiology. Vaccine use update.
Summary.
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Meningococcal conjugate vaccine production
Vaccine
IsolationPurified polysaccharide Carrier protein
Conjugation
Polysaccharide capsule
B
A WYC
C
A
1999
2010
2010
?
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Infants
How do we use meningococcal vaccines to achieve optimal protection?
Adolescents
Immunise
(direct protection)
Immunise
(direct protection)
Indirect protection
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Meningococcal conjugate vaccines
Vaccine Active constituents
Manufacturer Carrier protein
Mengitec C Pfizer CRM197
Menjugate C Novartis CRM197
NeisVac-C C Baxter Tetanus toxoid
Menactra A, C, W + Y Sanofi Pasteur Diphtheria toxoid
Menveo A, C, W + Y Novartis CRM197
Nimenrix A, C, W + Y GSK Tetanus toxoid
Menitorix C + Hib GSK Tetanus toxoid
MenHibrix C + Y + Hib GSK Tetanus toxoid
MenAfriVax A Serum Institute of India
Tetanus toxoid
No licensed MenB vaccine available
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Overview
Neisseria meningitidis. Recent epidemiology. Vaccines and protection strategies. MenB vaccines. Forthcoming schedule changes.
Streptococcus pneumoniae. Recent epidemiology. Vaccine use update.
Summary.
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Why is there currently no MenB vaccine available?
MenB polysaccharide is polysialic acid, a compound identical to that found on the surface of human neuronal cells.
Consequently;
(i) Poorly immunogenic.
(ii) Potential to induce an autoimmune response.
Downside of approach = Diversity
Use subcapsular antigens, which are;
(i) Surface exposed.
(ii) Conserved.
(iii) Induce bactericidal activity.
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Development of subcapsular antigen vaccines has broadly followed two pathways-
Subcapsular approaches
Purified OMVs Blebbing
Purified or recombinant outer membrane proteins
Used successfully to combat single clone epidemics of MenB disease.
Immune response is primarily directed against the PorA protein, resulting in limited cross-protection.
(i) Outer membrane vesicles (OMVs)
(ii) Individual proteins
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The Pfizer Investigational MenB vaccine rLP2086
Investigational vaccine based upon rLP2086, a surface-exposed lipoprotein of N. meningitidis.
Discovered by traditional vaccine development procedure (fractionation, protein purification and proteomic steps).
LP2086 has since been renamed as factor H binding protein (fHBP).
fHBP is important for survival of the organism in vivo.
The gene is present in all meningococcal MenB disease isolates examined.
fHBP also a component of the Novartis vaccine.
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fHBP
Variant or family groups
Novartis Pfizer
Variant 1 Family B
Variants 2 & 3 Family A
Intra-family cross-reactivity good.
Inter-family cross reactivity poor.
10
Variant 1
Variant 2
Variant 3
Family A
Family B
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The vaccine is composed of two recombinant LP2086/fHBP proteins, one from each family.
Promising results have been achieved in three phase I/II trials in young adults and adolescents, and support continued development:
(i) Acceptable safety profile.(ii) Robust serum bactericidal antibody (SBA) response rates.
Clinical development of the Pfizer investigational MenB vaccine
Anderson AS, Jansen KU & Eiden J. Expert Rev Vaccines 2010;10:617-34.
Current situation
Evaluation continuing through later phase trials.
Will be targeted for an adolescent indication.
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Novel antigens discovered by reverse vaccinology
expressionand
purification
purified proteins
immunisations
~350 proteins successfully expressed in E.coli, purified, and used to immunise mice
Based on the genome sequence of MC58, 570 ORFs that potentially encoded novel surface
exposed or exported proteins were identified
100,000
200,000
300,000
400,000
500,000
600,000
700,000
800,000
900,000
1,000,0001,100,0001,200,000
1,300,000
1,400,000
1,500,000
1,600,000
1,700,000
1,800,000
1,900,000
2,000,000
2,100,000
2,200,000IHT-A
IHT-B
IHT-C
1
28 novel protein
antigens identified
Sera used to confirm surface exposure of
novel proteins
Slide provided by Novartis Vaccines
Bexsero®
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http://www.inpharm.com/news/101223/novartis-meningococcal-vaccine-bexsero
Bexsero (previously known as 4CMenB or rMenB+OMV) contains 4 main antigens.
Novartis investigational MenB 4CMenB vaccine(Bexsero®)
PorA (presented as
part of an OMV)
NadAfHBP (Variant 1)
NHBA
OMVs from the New Zealand outbreak strain (NZ 98/254).
Three recombinant proteins discovered by reverse vaccinology.
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Bexsero (Novartis Vaccines)clinical program
Phase 3 studies in infant, toddlers and adolescents complete. Over 5000 infants/toddlers and 2000 adolescents/adults
vaccinated.
Acceptable safety and tolerability profile in all age groups.
Co-administered infant vaccines elicit expected immune responses when given with Bexsero.
Bai X, Findlow J & Borrow R. Expert Opin Biol Ther 2011;11:969-85.
Current situation
Novartis has submitted for marketing approval (licensure) to European regulators (EMA).
Decision is predicted during 2012.
Ongoing trial in English University students to investigate any impact on carriage (herd protection).
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Alternative MenB vaccine approaches
Pre-clinical
Numerous approaches using other surface exposed antigens mostly in the form of OMVs.
Walter Reed Army Institute of Research (WRAIR)
Three genetically modified strains used to produce native OMVs.
Genes responsible for three reactogenic components have been “knocked out”. Each OMV has an extra gene for a different PorA inserted (therefore each OMV has two
different PorA proteins). Increased expression of selected proteins including fHBP (Family A and B), OpcA, and
NadA.
Early phase trials have been successfully undertaken which have demonstrated good immunogenicity with a good safety profile.
Novartis Vaccines
Combined vaccine of Bexsero and Menveo (ClinicalTrials.gov Identifier: NCT01210885).
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Overview
Neisseria meningitidis. Recent epidemiology. Vaccines and protection strategies. MenB vaccines. Forthcoming schedule changes.
Streptococcus pneumoniae. Recent epidemiology. Vaccine use update.
Summary.
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<6
mth
s
6-1
1 m
ths
1-4
yrs
5-9
yrs
10
-14
yrs
15
-19
yrs
20
-24
yrs
25
-34
yrs
35
-44
yrs
45
-54
yrs
55
-64
yrs
65
+ y
rs
0
10
20
30
40
50
60
70
80
90
100
1996-99
% w
ith S
BA
titr
e >
=8
2009
Proportions of sera with MenC SBA titres ≥8 by age in England & Wales, pre and post-introduction of MCC vaccines
1996-9 data: Trotter CL et al., Clin Vaccine Immunol 2008;15:1694-8. 2009 data: Ishola D et al., Clin Vaccine Immunol 2012;19:1126-30
Consequently, need to introduce a booster dose for MenC to
(i) Provide direct protection
(ii) Maintain herd protection
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“The committee noted that clinical trial data shows that a single dose of meningococcal C vaccines (NeisvacC® or Menjugate®) provided sufficient immunity in infancy until the booster dose of Hib/MenC at 12 months of age. Given this evidence and the advice from the sub-committee that a dose of meningococcal C should be considered in adolescence to maintain individual and herd protection, the committee advised that a cost-neutral approach could be to remove a dose from the infant schedule and replace it with an adolescent dose of meningococcal C vaccine.JCVI asked that its adolescent sub-committee look at options for the timing of an adolescent dose of meningococcal C vaccine.
Action: committee and sub-committee to consider the timing of an adolescent dose of meningococcal C vaccine.”
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“the meningococcal C immune response of quadrivalent meningococcal ACWY vaccine was uncertain and may be inferior to the monovalent vaccine. In the absence of carriage data the impact of use of quadrivalent vaccine on meningococcal Y carriage is also uncertain. For these reasons the sub-committee agreed with the advice of the JCVI meningococcal sub-committee that the monovalent meningococcal C vaccine should be used as a booster dose”
“noting that there is uncertainty about when the expected increase in meningococcal C disease may arise, considered that a booster dose should be introduced as soon as practicable on precautionary grounds. It was noted that the suggested use was outside of the current market authorisations for the vaccines.”
“The vaccine could be given concomitantly with the current tetanus, diphtheria and polio (Td/IPV) booster. Evidence that would be discussed later in the agenda suggested that the booster would probably most effectively be delivered in schools. Whilst a booster dose at age 15 years (school year 11) may be optimal given that it may have a larger immediate impact on carriage, issues around implementation of a booster dose at that age need to be considered and would be discussed later in the agenda. An alternative strategy that would have a similar impact on carriage would be to introduce routine vaccination in younger adolescents with a time limited catch-up campaign for older ages, although this option would be more costly overall. It would also be important to review new carriage data that may be available later in the year, which may inform scheduling considerations.”
MenC booster
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“The committee noted the recent market authorisation of a new quadrivalent meningococcal ACWY conjugate vaccine (Nimenrix® produced by GSK) for children from one year of age and adults. Current Green Book guidance covers use of another quadrivalent meningococcal ACWY conjugate vaccine (Menveo® produced by Novartis) in certain risk groups and as a travel vaccine. The current market authorisation for Menveo® is for use in children from 11 years of age and adults. However, JCVI had advised that it should be used in certain younger children outside of its market authorisation. It was noted that the market authorisation for Menveo® may change in relation to use in younger children.
31. The committee agreed that Green Book guidance should be changed to specify that either Menveo® or Nimenrix® may be used in certain risk groups and as a travel vaccine in individuals from one year of age. Only Menveo® should be used in children under one year of age as there are some data on its use in that age group (there are no data on use of Nimenrix® in this age group) and the amount of tetanus toxoid in Nimenrix® could potentially give rise to greater reactogenicity in infants.
32. The committee also noted that the summary of product characteristics of both vaccines suggested a booster dose of vaccine after one year in individuals that remain at risk of exposure to serogroup A meningococci bacteria because of evidence of waning immunity against this strain. However, it was considered that the data on waning meningococcal A immunity may be unreliable due to the type of assay (human complement serum bactericidal assay) used in clinical trials. It was agreed that a booster dose after five years may be more appropriate for individuals at continued risk from serogroup A meningococci, in line with that5 of the meningococcal ACWY polysaccharide vaccines.”
Quadrivalent meningococcal vaccines
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Overview
Neisseria meningitidis. Recent epidemiology. Vaccines and protection strategies. MenB vaccines. Forthcoming schedule changes.
Streptococcus pneumoniae. Recent epidemiology. Vaccine use update.
Summary.
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Cumulative weekly number of reports of Invasive Pneumococcal Disease due to any of the six serotypes IN Prevenar13™ but not in PCV7 : Children aged < 2 years in England and Wales by Epidemiological Year: July-June (2006- To Date)
0
50
100
150
200
250 06-07 07-08 08-09 09-10 10-11 11-12
Week
Nu
mb
er
of R
ep
ort
s
Introduction of Prevenar™ BLUE LINE Week 36 2006
PCV13 introduced WHITE LINE Week 13 2010
Vaccine effectiveness of additional 6
serotypes = 80%
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Unclear whether there is an increase in non PCV13 serotypes as yet in children
Cumulative weekly number of reports of Invasive Pneumococcal Disease due to any of the serotypes NOT IN Prevenar13™ : Children aged < 2 Years in England and Wales by Epidemiological Year: July-June (2006- To Date)
26 28 30 32 34 36 38 40 42 44 46 48 50 52 1 3 5 7 9 11 13 15 17 19 21 23 250
20
40
60
80
100
120
14006-07 07-08 08-09 09-10 10-11 11-12
Week
Nu
mb
er
of R
ep
ort
s
Introduction of Prevenar™ BLUE LINE Week 36 2006
PCV13 introduced WHITE LINE Week 13 2010
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Cumulative weekly number of reports of Invasive Pneumococcal Disease due to any of the six serotypes IN Prevenar13™ but not in PCV7 : Persons aged >5 Years in England and Wales by Epidemiological Year: July-June (2006- To Date)
26 28 30 32 34 36 38 40 42 44 46 48 50 52 1 3 5 7 9 11 13 15 17 19 21 23 250
500
1000
1500
2000
2500 06-07 07-08 08-09 09-10 10-11 11-12
Week
Nu
mb
er
of R
ep
ort
s
Introduction of Prevenar™ BLUE LINE Week 36 2006
PCV13 introduced WHITE LINE Week 13 2010
Early evidence of herd protection
(within 18 months of implementation)
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Cumulative weekly number of reports of Invasive Pneumococcal Disease due to any of the serotypes NOT IN Prevenar13™ : Persons aged >5 Years in England and Wales by Epidemiological Year: July-June (2006- To Date)
26 28 30 32 34 36 38 40 42 44 46 48 50 52 1 3 5 7 9 11 13 15 17 19 21 23 250
500
1000
1500
2000
2500
3000 06-07 07-08 08-09 09-10 10-11 11-12
Week
Nu
mb
er
of R
ep
ort
s
Introduction of Prevenar™ BLUE LINE Week 36 2006
PCV13 introduced WHITE LINE Week 13 2010
Unclear whether there is an increase in non PCV13 serotypes as yet in >5 year olds
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Overview
Neisseria meningitidis. Recent epidemiology. Vaccines and protection strategies. MenB vaccines. Forthcoming schedule changes.
Streptococcus pneumoniae. Recent epidemiology. Vaccine use update.
Summary.
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“The committee agreed with the sub-committee that it would not be effective nor cost effective to introduce a programme in the UK to offer PCV13 to those in clinical risk groups or to older adults given the evidence of accumulating indirect protection of the population from the childhood immunisation programme. However, certain groups with a greatly increased risk of death from IPD from PCV13 serotypes would continue to benefit, but only in the short-term, from PCV13 given under the supervision of a secondary care physician. Given the expected disappearance of PCV13 serotypes within a small number of years, use of PCV13 outside of the routine childhood immunisation programme would become ineffective even in these groups. It was noted that several medical professional bodies had recommended use of PCV13 in certain clinical risk groups. Action: the committee and sub-committee to produce a more detailed statement with this advice.
18. In addition, the committee also accepted the advice of the sub-committee: • to revise the definition of chronic kidney disease for the purposes of pneumococcal vaccination; • that there should be no changes currently to guidance on the use of pneumococcal polysaccharide vaccine (PPV23); • the use of PPV23 should be reviewed within two years to determine whether it remains effective and cost effective in light of the changing epidemiology of invasive pneumococcal disease and further analysis of the accumulating UK data on the effectiveness of PPV23.”
Pneumococcal vaccines
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Overview
Neisseria meningitidis. Recent epidemiology. Vaccines and protection strategies. MenB vaccines. Forthcoming schedule changes.
Streptococcus pneumoniae. Recent epidemiology. Vaccine use update.
Summary.
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Meningococcal epidemiology
In England and Wales we are currently in a period of comparatively lower meningococcal disease incidence.
The number of MenY disease cases has risen over recent years and is associated with pneumonia in older age groups. MenB is currently responsible for ~85% of meningococcal disease in and is currently unpreventable by vaccination.
The peak incidence of MenB disease is at 5 months of age.
Vaccination strategies can be designed to provide indirect protection in addition to direct protection.
Summary (1)
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MenB vaccines There are two MenB vaccines in the later stages of development.
Bexsero (Novartis Vaccines) is currently being reviewed by the EMA. If licensed this would result in the first broad coverage vaccine for MenB becoming available.
Licensure of Bexsero does not necessarily equate to recommendation/implementation into the UK schedule which is based upon multiple considerations.
It is probable that other broad coverage MenB vaccines will subsequently become available over the next decade.
Summary (2)
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Future schedule changes (meningococcal vaccines)
We will be changing from a two dose MCC priming schedule to a single dose priming schedule in the near future.
In a “cost neutral” approach, this MCC dose will re-scheduled to become an adolescent booster.
A second quadrivalent meningococcal polysaccharide vaccine (Nimenrix, GSK) has been recently licensed by the EMA.
The “Green book” will be updated shortly to include Nimenrix.
Summary (3)
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Pneumococcal epidemiology and vaccination
Excellent direct impact of PCV13 in targeted age groups, with overall vaccine effectiveness of the additional 6 serotypes covered by PCV13 ~80%.
Early evidence of rapid herd protection with PCV13 (within 18 months) despite no catch up.
The JCVI have recommended no changes to the use of PPV23 in clinical at-risk groups (except those with a very high risk of contracting disease).
Summary (4)
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10th June 2011 or 2013?
What the papers say
30th Sept 20122012
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Vaccine Evaluation Unit, HPA, Manchester
Ray Borrow.
Meningococcal Reference Unit, HPA, Manchester
Ed Kaczmarski, Steve Gray and Tony Carr.
Immunisation Department, HPA, Colindale
Liz Miller, Pauline Kaye, Shamez Ladhani and Rashmi Malkani.
Acknowledgements