Invasive meningococcal disease in Northland, New Zealand

Invasive meningococcal diseaseis a serious illness commonly presenting as a meningitis and/or septicaemia. The case fatality rate in New Zealand over the last decade has varied from 4 to 10%, with higher rates for group C disease.1From 10 July 2011 to 16 November 2011, 13 confirmed cases of invasive meningococcal disease were notified in Northland; the initial 10 cases within 3 months. Four were group B, and unusually, 9 were group C. There have been 3 deaths (all group C). There were no epidemiological linkages between the cases in Northland. Of the 9 group C cases, all except one (an 82-year-old female) were aged 1-18 years; three were M ori and the remainder P keh (New Zealand European).The rate for Group C cases in under 20-year-olds meets the definition of a ccommunity outbreakd that is, cthree or more confirmed cases of the same serogroup and serotype within a 3-month period, and an age-specific incidence or specific community population incidence of >10/100,000 where there is no link between the cases.d2The rates in Northland in the <20 year population for group C meningococcal disease are currently27.6/100,000 in the Whangarei District, and DHB-wide 18.2/100,000. Outbreaks of group C may take 1-3 years to resolve.2From July 2011, the public health strategy for meningococcal C disease control followed a classical approach: Communication and messaging to the public about risks, symptoms and signs; Low threshold for diagnosis and referral, and heightened health professional awareness, including advice on pre-hospital transfer administration of antibiotics; Antibiotic prophylaxis and vaccination (meningococcal C conjugate vaccine) for close contacts. As cases increased, and given the high mortality rate, expert advice was sought from the Immunisation Technical Forum and Ministry of Health. This resulted in the decision to implement a DHB-wide mass vaccination strategy using the meningococcal C conjugate vaccine, targeting all children and youth from 1 year up to 20 years in order to control the outbreak.The aim is to vaccinate >85% of this population in a 12-week period. The programme began in schools on 27 September 2011 following a 10-day planning period, and then rolled out to primary care. Remaining schools are being completed in term 4. As of 25 November 2011, over 25,000 children and youth had been vaccinated (approximately 65% of our target). The programme ends on 16 December 2011.Significant challenges in implementing the programme included initial insecurity of vaccine supply (only 80 doses were available in country in mid-September), lack of central government funding support, inadequate numbers of authorised vaccinators for a rapid mass campaign, traditionally low immunisation coverage rates and persistent socio-economic and health inequities in our region.Poor geographical access to primary care and the challenges of engaging young adults were also important issues to address. There is also some public confusion about meningococcal groups and an illusion of protection from the previous MeNZB vaccination.However, there has been excellent collaboration across the health sector and with Education partners, and a multi-pronged public communications strategy is in place. This is critical given the ambitious target and short time period involved. It includes traditional media (M ori and mainstream), Facebook and Internet, local cchampionsd and regular communications through a wide range of networks, from early child centres to St Johns and other community organisations, Runanga (a traditional M ori assembly or tribal gathering), community meetings and hui. Graph: Meningococcal C vaccination coverage at 22 Nov 2011 (Target 85% of 1-<20year olds, 37,500 children and youth) The school programme is achieving about 60% coverage of children in school (58% M ori and 62% non-M ori). As of 22 November 2011, primary care has reached only 50% of under 5-year-olds, a very low proportion of the 17-19yr age group, and inequities in M ori-non-M ori coverage are significant. To address these inequities and access barriers, cwalk ind community and mobile clinics staffed by public health nurses, kaimahi and health promoters have been implemented since mid-October. These are being utilised in greater numbers by Maori wh nau, and youth. Now in the last 3 weeks, a final ccountdownd is underway, aiming to achieve the target coverage. Clair Mills Medical Officer of Health Northland District Health Board Whangarei, New Zealand