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Systematic Review of the Effect of Antibiotics And/Or Vaccination in Preventing Subsequent Disease Among Household Contacts of Cases of Meningococcal Disease

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Systematic Review of the Effect of Antibiotics And/Or Vaccination in Preventing Subsequent Disease Among Household Contacts of Cases of Meningococcal Disease Systematic review of the effect of antibiotics and/or vaccination in preventing subsequent disease among household contacts of cases of meningococcal disease Report for the WHO Meningitis Guideline Revision May 2014 Dr. L. Telisinghe Current position: The WHO control of epidemic meningococcal disease; practical guidelines 2nd edition 1998 (http://www.who.int/csr/resources/publications/meningitis/WHO_EMC_BAC_98_3_EN/en/) states that 1) Vaccination – mass vaccination campaigns can halt epidemics PICO4 – preliminary results V1.7- 16th April 2014 1 2) Chemoprophylaxis – of contacts of cases of meningitis is not recommended during epidemics. In non- epidemic settings, chemoprophylaxis is recommended to close contacts of a case including household contacts. However, recently during a large outbreak of serogroup W meningococcal meningitis in the Gambia, ciprofloxacin was administered as chemoprophylaxis to close contacts of cases of meningococcal disease. In addition with the use of the serogroup A polysaccharide-tetanus toxoid conjugated vaccine, the scale and frequency of serogroup A meningococcal disease outbreaks in the meningitis belt is likely to decrease. Given these, the WHO recommendation for the use of chemoprophylaxis and vaccination for the region needs to be reviewed and updated, to ensure up to date, evidence based practice in the region. Recommendation question: Should prophylaxis (antibiotics and/or vaccination) be recommended for household contacts of cases of meningococcal meningitis in epidemic and non-epidemic settings? PICO question: Among household contacts of a case, what is the risk of meningococcal meningitis during the month after disease onset among close contacts given and not given prophylaxis? Populations: Household contacts of cases of meningococcal meningitis Intervention: Prophylaxis to household contacts Comparator: No prophylaxis to household contacts Outcome: Attack rate among household contacts within one month after disease onset in index case Aim: To determine the effect of antibiotics and/or vaccination, in preventing subsequent meningococcal disease in household contacts of cases of meningococcal meningitis, in epidemic and non-epidemic settings. Objectives: 1) Conduct a systematic review of the literature using an appropriate search strategy. 2) Determine a combined estimate of the effect of appropriate antibiotics on the risk of subsequent meningococcal disease among household contacts of cases of meningococcal disease at 30 days and 1 year following the index case. 3) Determine a combined estimate of the effect of appropriate vaccination on the risk of subsequent meningococcal disease among household contacts of cases of meningococcal disease at 30 days and 1 year following the index case. PICO4 – preliminary results V1.7- 16th April 2014 2 4) Determine a combined estimate of the effect of appropriate antibiotics and vaccination on the risk of subsequent meningococcal disease among household contacts of cases of meningococcal disease at 30 days and 1 year following the index case. 5) Determine the number needed to treat with antibiotics, vaccination, and, antibiotics and vaccination to prevent one subsequent case of meningococcal disease among household contacts of cases of meningococcal disease at 30 days and 1 year. 6) Explore drug resistance in isolates of Neisseria meningitidis from subsequent cases of meningococcal disease given chemoprophylaxis. 7) Explore the proportion of household contacts given prophylaxis (both antibiotics and vaccination), who develop side effects due to prophylaxis. th Methods: See protocol v1.6; 7 March 2014 for details of the study methods. Where methods differ from proposed methods in the protocol – this is indicated in the document. PICO4 – preliminary results V1.7- 16th April 2014 3 Results Systematic review search Figure 1: Search for systematic reviews (undertaken by LT, TW and JS) Records identified through database search N=906 Records remaining after Number of duplicates removed duplicates removed n=718 n=188 Number of records excluded Titles screened n=718 following title screen n=522 Number of records excluded Abstracts screened n=196 following abstract screen n=128 Additional articles reviewed Unable to find articles n=16 3rd For full text screen n=68+12=80 based on reference search review by RJS n=12 Excluded Full texts screened n=64 Not SR (i.e. reviews only) n=58 Older version of SR n=2 Number of articles considered n=4 *n=27(39.7%) had no abstracts; SR=systematic review PICO4 – preliminary results V1.7- 16th April 2014 4 Table 1: Methodological quality assessment of systematic reviews using the AMSTAR tool Systematic review A priori study Duplicate Comprehensive Publication List of in- Characteristics of Study quality Quality Appropriate Likelihood of Conflict of design study literature search status not used and included studies assessed and assessment methods to publication bias interest selection and as inclusion excluded provided documented used in combine assessed stated data criterion* studies conclusions findings extraction Purcell 2004 Unclear Yes Yes Unclear No Yes No No Yes No No Effectiveness of chemoprophylaxis 2 independent Cochrane, HTA and Does not specify List of No formal Quality aspects data extractors national research excluded quality of studies register (UK); Medline; Did not exclude studies not assessment (including lack EMBASE; CAB heath based on provided presented. of controlling language, date, However, for Mesh terms for country information is confounders) NM; provided on the taken into chemoprophylaxis; included account when abx; HH; outbreak; tx; studies, which interpreting control enables the results in the reader to discussion Reference search assess quality. Contacted experts RISK OF BIAS = LOW (while study quality assessment was not formerly used in conclusions, this was not considered to be a critical criterion as there was duplicate study selection and data extraction and a comprehensive literature search performed, with studies not excluded based on language, country or date. Therefore the risk of bias assessment was considered low) ECDC 2010 Yes No Yes Unclear No Yes No No Yes No Yes Guidelines: Public health management Medline; EMBASE; Does not specify List of Quality of sporadic cases of Cochrane; Global excluded aspects of invasive Health studies not studies meningococcal provided (including lack disease and their Mesh terms: of controlling contacts NM; tx; outbreak; HH; for chemoprophylaxis; abx confounders) taken into Reference search account when Contacted experts interpreting results in the discussion RISK OF BIAS = NOT LOW (the risk of bias was considered as not low as duplicate study selection and data extraction was not performed) PICO4 – preliminary results V1.7- 16th April 2014 5 Systematic review A priori study Duplicate Comprehensive Publication List of in- Characteristics of Study quality Quality Appropriate Likelihood of Conflict of design study literature search status not used and included studies assessed and assessment methods to publication bias interest selection and as inclusion excluded provided documented used in combine assessed stated data criterion* studies conclusions findings extraction Hoek 2008 Unclear Yes Yes Unclear No Yes No No Yes No No Effectiveness of vaccination in Only 1 person Medline; EMBASE Does not specify List of No formal Quality addition to reviewed titles excluded quality aspects of chemoprophylaxis and abstracts. MESH terms: studies not assessment studies to prevent IMD NM; contact; HH; provided presented. (including lack among HH contacts 2 people chemoprophylaxis Results table of controlling reviewed full does however for texts Reference lists include confounders) searched information taken into Experts contacted which enables account when the reader to interpreting assess quality. results in the discussion RISK OF BIAS = LOW (quality assessment used to formulate study conclusions not considered to be a critical criterion. Therefore the risk of bias assessment was considered as low) HOWEVER – CAUTION WITH RESULTS AS ONLY 2 DATABASES WERE SEARCHED STUDY QUESTION DOES NOT ANSWER THE FULL QUESTION REGARDING VACCINATION PROPOSED BY PICO4 Zalmanovici Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 2013 Effectiveness of 2 people Cochrane, Medline, abx in preventing reviewed titles, EMBASE, LILACS secondary cases of abstracts and MD full texts MESH terms: MD; chemoprophylaxis; abx; RISK OF BIAS = LOW ONLY CONSIDERED RANDOMISED CONTROLLED TRIALS OR QUASI RANDOMISED CONTROLLED TRIALS– NO STUDIES IDENTIFIED *question reversed; IMD=invasive meningococcal disease; HH=household; abx=antibiotics; tx=transmission; NM=Neisseria meningitides; MD=meningococcal disease; Low risk of bias = comprehensive literature review performed + methods to combine studies appropriate + quality of the included studies used to formulate conclusions Purcell 2004 was chosen as the starting point for the systematic review on chemoprophylaxis as this review had a low risk of bias (although the study quality assessment was not used to formulate study conclusions this was not considered a critical criterion. A comprehensive literature review was undertaken, included randomised and non-randomised studies, with duplicate data extraction). As no prior systematic review which adequately addressed the PICO question on vaccination was identified, the search was conducted without a date limit to determine the effect of vaccination on subsequent cases of meningococcal disease. PICO4 – preliminary results
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