Indian Pediatr 2014;51: 446-448
Preventing Meningococcal Infections in India
SK Mittal and *Vikas Manchanda
Departments of Pediatrics and *Clinical Microbiology
and Infectious Diseases, Chacha Nehru Bal Chikitsalya, Delhi, India.
Neisseria meningitidis causes invasive
diseases like meningococcemia and meningitis with a case fatality rate
of 10-15% and a disability rate of 11-19% among survivors . Although
the bacterium largely continue to be sensitive to antibiotics but rapid
course of illness and emerging antibiotic resistance warrants that the
disease be prevented as far as possible [2,3]. Currently, several
vaccines against meningococcus are available, but one has to choose
wisely to ensure maximum efficacy. At least five serotypes (A, B, C, Y
and W135) have been associated with invasive meningococcal disease (IMD)
worldwide. Polysaccharide vaccine (against 2 or 4 serotypes) have been
available for quite some time but have the inherent disadvantage of
lacking T cell response, resulting in their lack of utility in children
below 2 years of age, and also failing to confer immunological memory
. Attempts to conjugate the polysaccharide antigen with protein have
resulted in successful development of conjugated monovalent or
quadrivalent vaccines against different serotypes of meningococci.
Quadrivalent vaccine with polysaccharides of serogroup A, C, Y and W 135
conjugated to Diphtheria toxoid has been in use for adolescents (11-14
years) in USA since 2005 . Although having 80-90% protective efficacy
in first year after vaccination, the same has been found to decline to
60-65% in the fifth year, warranting a recent recommendation of a
booster dose at 16-18 years of age .
Yadav, et al. . – in a study
reported in this issue of Indian Pediatrics – have shown 90-100%
sero-efficacy of this quadrivalent vaccine in Indian children,
adolescents and adults. The authors have chosen to estimate antibodies
in rabbit serum where the protective levels are highly unpredictable and
hard to define. Generally, bactericidal titers of 1:4 in human serum
are considered protective against IMD . Titers as high as 1:128 in
rabbit serum are needed to assure that a titer of 1:4 are present, if
measured with human serum . Despite this shortcoming, the results of
this bridging study are adequately reassuring regarding efficacy and
safety of this vaccine in the Indian context.
However, before considering the introduction of this
vaccine in the National program or even in the list of ‘optional
vaccines’ of schedule recommended by Indian Academy of Pediatrics, the
potential utility of this vaccine in our country needs to be examined.
Epidemiology of meningococcal disease in India appears to be distinctly
different from that in USA. While in USA, the disease mostly occurs in a
sporadic manner with serotypes B, C and Y accounting for about 30% cases
each, occasional small outbreaks among college students are usually due
to serotype B . In contrast, all the epidemics in India since 1930
have been due to serotype A . Occasional cases of meningitis due to
serogroup B are reported but to the best of our knowledge, cases of IMD
due to serotype C, Y or W 135 have not been reported from our country
. Thus, we have predominantly serotype A IMD in our country, a
situation not very different from other Asian countries and Sub-Saharan
belt in Africa [1,10].
Different countries in the world have used different
monovalent or polyvalent polysaccharide conjugated vaccines depending on
their disease epidemiology. While USA is using the quadrivalent vaccine,
a serogroup B polysaccharide conjugated vaccine has recently been
recommended for routine use in UK for infants, and is being considered
for interrupting the ongoing epidemic in Princeton University in USA
. A serogroup C monovalent vaccine has been used successfully in
several countries of the world like Spain, Italy, Greece, France,
Canada, Australia, Brazil and Argentina . It would seem logical that
with known preponderance of serogroup A IMD in our country, a monovalent
conjugate vaccine targeted against serogroup A meningococcus will be
more useful and cost effective in our country. A novel meningococcal
serogroup A conjugated vaccine (PsA-TT, MenAfrVac) – introduced in
Burkina Faso , Mali and Niger in 2010 – resulted in 71% (hazard
ratio 0.29, 95% CI 0.28,030; P<0.0001) decline in risk of
meningitis and a 64% decline in risk of fatal meningitis. No case of
serogroup A IMD occurred in vaccinated individuals and no serotype
replacement was seen. The incidence of laboratory confirmed serogroup A
meningococcal meningitis dropped to 0.1 per 100,000 representing a 98.6%
Obviously, we must know the size of shoe that is
likely to fit us, before ordering it or even trying it on! Wrong size
shoe cannot even be an option!
Funding: None; Competing interest: None
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