brazjinfectdis2020;24(4):349–351
w w w . e l s e v i e r . c o m / l o c a t e / b j i d
The
Brazilian
Journal
of
INFECTIOUS
DISEASES
Brief
communication
Trajectory
of
serogroups
causing
Invasive
Meningococcal
Disease
in
Santa
Catarina
state,
Brazil
(2007–2019)
Ricardo
Becker
Feijo
a,∗,
Juarez
Cunha
baUniversidadeFederaldoRioGrandedoSul,FaculdadedeMedicina,DepartamentodePediatria,PortoAlegre,RS,Brazil
bSecretariaMunicipaldeSaúde,DiretoriaGeraldeVigilânciaemSaúde,UnidadedeVigilânciaEpidemiológica,PortoAlegre,RS,Brazil
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Articlehistory:
Received29September2019 Accepted13June2020 Availableonline10July2020
Keywords:
Invasivemeningococcaldisease SerogroupW
SantaCatarinastate Brazil
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The aim of this study was to compare the trajectory of serogroups causing Invasive MeningococcalDisease(IMD)intheSantaCatarina(SC)statewiththoseofwholeBrazil. AretrospectiveanalysisofallIMDcasesreportedfromJanuary2007toDecember2019was carriedout.Duringthestudyperiod,26,058IMDcaseswereregisteredinBraziland644and inSCstatealone.Overall,Brazilshowedprogressivereductionincasessince2010,whenthe meningococcalCconjugatevaccinewasintroductedonNationalImmunizationProgram, whileSCshowedanincreaseintotalcasessince2013,particularlyfromserogroupsWand C.SerogroupsdistributionwassignificantlydifferentbetweenBrazilandSC.Theemergence of serogroupWhighlights theimproved meningococcalsurveillancethroughincreased accuracyinidentificationmethodsinSCstate.Thisfindingisimportantfordiscussing rec-ommendationsofquadrivalent(ACWY)conjugatevaccinesindifferentgeographicalareas ofBrazil.
©2020SociedadeBrasileiradeInfectologia.PublishedbyElsevierEspa ˜na,S.L.U.Thisis anopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Neisseria meningitidis (N. meningitidis) causes extremely severeconditions inhumans, especiallyinvasive meningo-coccal disease (IMD) characterizedby oneor moreclinical syndromesincluding bacteremia,sepsis, ormeningitis,the latterbeingthemostcommonpresentation.1
CapsulargroupsA,B,C,W,Y,andXcausealmostallIMD.2
However,thequalityandreliabilityoftheinformationonIMD arenotuniformacrosstheworld,dueinparttodifferencesin surveillancepractices,useofdifferentdiagnosticmethodsand protocols,and application ofdifferent meningococcal case definition.3Sincelate1960scapsulargroupWhasbecomea
∗ Correspondingauthorat:RuaAttilioBilibio120/23,91530008PortoAlegre,RS,Brazil.
E-mailaddress:rfeijo@hcpa.edu.br(R.B.Feijo).
frequentcauseofIMD,4particularlyinEurope,SouthAmerica,
Australia,andsomepartsofSub-SaharanAfrica.5
ThehighestincidenceratesofIMDareobservedinchildren agedless than oneyear,6,7 but insomeregionsother
inci-dencepeaksareobservedamongadolescents(16through21 yearsofage)8,9andthoseaged≥65years.10,11InLatin
Amer-ica,theincidenceofIMDvariesfrom<0.1casesper100,000 incountriesincludingMexico,Paraguay,Peru,andBoliviato almost twocasesper 100,000inBrazil.7 InBrazil,N.
menin-gitidiswastheprimaryetiologyofacutebacterialmeningitis withserogroupCbeingthemostprevalentinthecountry.In
https://doi.org/10.1016/j.bjid.2020.06.007
1413-8670/©2020SociedadeBrasileiradeInfectologia.PublishedbyElsevierEspa ˜na,S.L.U.ThisisanopenaccessarticleundertheCC BY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).
350
braz j infect dis.2020;24(4):349–351 3000 75 50 25 0 2000 1000 0 20072008 2009 2010 2011201220132014 2015 2016 2017 2018 2019 20072008 2009 2010 2011201220132014 2015 2016 2017 2018 2019 Year of reportBrazil Santa catarina
Number of cases Serogroup B C NT Other W
Fig.1–MeningococcalDiseaseinBrazilcomparedtoSantaCatarinaState. NT,nontypeable;OTHER,Otherserogroups.
Table1–Meningococcalserogroupdistributionduringtheperiodof2007-2019.
Serogroups Total NTa B C W OTHERb Brazil 13,589(52.1%) 2608(10.0%) 8728(33.5%) 802(3.1%) 331(1.3%) 26,058(100%) SCc 291(45.2%) 106(16.5%) 136(21.1%) 101(15.7%) 10(1.6%) 644(100%) a Nontypeable. b Otherserogroups. c SantaCatarinaState.
2010,theNationalImmunizationProgram(NIP)includedthe MenCconjugatevaccineforchildrenundertwoyearsold,with nocatch-upcampaigninolderagesgroups.Basedonthe sig-nificantIMDreductionobservedonlyinthevaccinatedgroup, theMinistryofHealthdecidedtoincludeMenCvaccinefor adolescentsaged11–14yearsin2017.12
Theintroductionofmultiplexreal-timePCR(polymerase chainreaction) (RT-PCR) assay testing forS. pneumoniae,N. meningitidisandH.influenzaetypeBinsentinelhospitalsinSão Pauloincreasedthediagnosticyieldforbacterialmeningitis by52,85and20%,respectively,overculture-basedmethods.13
Sincethen,therehasbeenaprogressiveincreaseintheuseof PCRassayswithimprovementinmicrobiologicconfirmation ofbacterialmeningitisthroughoutthecountry.
IMDisassociatedwithsubstantialmorbidityandoverall casefatalityrates (CFRs)ofaround 10%(withCFRsashigh as20%reportedinsomecountries).14Meningococcaldisease
causedbyserogroupWalonehasbeenassociatedwithCFRs of>30%.15
SerogroupsBandCarecurrentlydominantinLatin Amer-ica. Nevertheless, the proportion of IMD cases including outbreaksattributabletootherserogroupshavebeenreported inseveralcountries.16 SouthernBrazil,ArgentinaandChile
witnessedthe emergence ofMenWcc11 strain asa major cause ofendemic meningococcal disease after2003.17 The
statesofParana,SantaCatarinaandRioGrandedoSulinthe southernregionofBrazilbordersthesouthernconecountries ofLatinAmerica.Infact,Wserogrouprepresented17.8%ofall invasivestrainsin2003–2005comparedto3.2%in1995–2002.18
NotificationsofIMDinBrazilareroutinelycollectedbythe MinisterofHealthtroughtheInformationSystemfor Notifi-ableDiseases(SINAN).Thisstudyisaretrospectivereviewof allIMDcasesreportedinBrazilasawholeandinSCin par-ticular,from1January2007to31December2019,usingthe SINANelectronicdatabase.19,20
ThestudyvariablesincludedthenumbertotalcasesofIMD andmeningococcalserogroups.Pearson’schisquaredtestwas usedtocomparetotalcasesandserogroupsfrequencies.For comparingdistributionsevolution,stackedbarswereusedas visualization.StatisticalsoftwareusedwasRversion3.5.2.
Totalnumberofcasesandcasesaccordingtoserogroups weredifferentbetweenBrazilandSantaCatarinastatealong thereportedyears(Fig.1).Analysisoftotalnumberofcases byyearfrom2007through2019showedstatisticallysignificant differencesbetweenBrazilandSCstate(p<0.001)(Table1).
A progressive decline of total cases and its respective serogroupsoccurred afterintroduction ofmeningococcal C vaccinationin2010inBrazil.Incontrast,therewasa dimin-ishingnumberofcasesinSCstatefrom2007to2013,witha reversaloftrendsfrom2014to2018,withareductionofthe numberofthecasesin2019.
SerogroupdistributionshowedspecificchangesinSCstate. Meningococcal disease by serogroup W increasedbetween 2016–2018,withareductionin2019.UnlikeBrazil,serogroup Cshowedanincrementofcasesafter2013inSCstate.
Ingeneral,non-identifiedcasesshoweddecreasingtrends inbothregionseventhoughtheyhaveoccurredindifferent proportions.
Differencesbetweenthenumberofcasesanddistribution of serogroups cannot be clearly explained. There are sev-eralvariablesthatcanexplainthechangesintheprevalence of individual serogroups, one of them could be the natu-rallyoccurringperiodicchangesand anothertheimpactof immunizationprograms.Anotherpossibility,consideringthat SC isaregionwithhighaffluence oftourism (mainlyfrom Argentina), isthatthesedifferencescouldbeinfluencedby tourismcarriage.
ThenotificationofSCstatepresentedacutpointat Decem-ber2nd,2019,whichmightaffecttheanalysisofthefollowing monthsoftheanalyzedperiod.
brazj infect dis.2020;24(4):349–351
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Theobservednumberofcasesandserogroupdistribution alongtimeforSCstatecomparedtoBrazil,couldimplythat healthauthorities need to reviewcurrent policies inorder tocope withexisting epidemiology, especially sincethe W serogroupisassociateddirectlywithincreasedmortalityand morbidityrates.15,16
Theemergence ofserogroupWinSChighlights the dif-ference in how health authorities have been dealing with meningococcal surveillance as the identification methods increased in accuracy. Moreover, it shows that geographi-calfeaturesshouldbeconsidered asanimportantvariable when recommending quadrivalent (ACWY) conjugate vac-cinesexceptionallyconsideringtheemergencyofastrainthat usedtobeunderrepresented.
Insummary,weshowedthatthetotalnumberofcasesand serogroupdistributioninthetimeperiodof2007through2019 inSCstatewassignificantlydifferentcomparedtoBrazil.
Funding
Sponsorshipofthisstudyandarticleprocessingchargeswere fundedbyPfizerInc.
Conflict
of
interest
TheauthorsareconsultantandspeakerPfizer,Sanofi, Glaxo-SmithKlineandMerckSharp&Dohme.
Acknowledgments
Sponsorshipofthisstudyandarticleprocessingchargeswere fundedbyPfizerInc.AllnamedauthorsmeettheInternational CommitteeofMedicalJournalEditorscriteriaforauthorship forthisarticle,takeresponsibilityfortheintegrityofthework asawhole,andhavegiventheirapprovalforthisversiontobe published.ThestatisticalanalysiswasconductedbyContent MedicineinBuenosAires,Argentina;fundingwasprovidedby PfizerInc.Thisarticleisbasedonpreviouslyconductedstudies anddoesnotcontainanystudieswithhumanparticipantsor animalsperformedbyanyoftheauthors.
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