title: An outbreak of pneumococcal meningitis among older children (≥5 years) and adults after the implementation of an infant vaccination programme with the 13-valent pneumococcal conjugate vaccine in Ghana.
abstract: An outbreak of pneumococcal meningitis among non-infant children and adults occurred in the Brong-Ahafo region of Ghana between December 2015 and April 2016 despite the recent nationwide implementation of a vaccination programme for infants with the 13-valent pneumococcal conjugate vaccine (PCV13).
  
  
  
  Cerebrospinal fluid (CSF) specimens were collected from patients with suspected meningitis in the Brong-Ahafo region. CSF specimens were subjected to Gram staining, culture and rapid antigen testing. Quantitative PCR was performed to identify pneumococcus, meningococcus and Haemophilus influenzae. Latex agglutination and molecular serotyping were performed on samples. Antibiogram and whole genome sequencing were performed on pneumococcal isolates.
  
  
  
  Eight hundred eighty six patients were reported with suspected meningitis in the Brong-Ahafo region during the period of the outbreak. In the epicenter district, the prevalence was as high as 363 suspected cases per 100,000 people. Over 95 % of suspected cases occurred in non-infant children and adults, with a median age of 20 years. Bacterial meningitis was confirmed in just under a quarter of CSF specimens tested. Pneumococcus, meningococcus and Group B Streptococcus accounted for 77 %, 22 % and 1 % of confirmed cases respectively. The vast majority of serotyped pneumococci (80 %) belonged to serotype 1. Most of the pneumococcal isolates tested were susceptible to a broad range of antibiotics, with the exception of two pneumococcal serotype 1 strains that were resistant to both penicillin and trimethoprim-sulfamethoxazole. All sequenced pneumococcal serotype 1 strains belong to Sequence Type (ST) 303 in the hypervirulent ST217 clonal complex.
  
  
  
  The occurrence of a pneumococcal serotype 1 meningitis outbreak three years after the introduction of PCV13 is alarming and calls for strengthening of meningitis surveillance and a re-evaluation of the current vaccination programme in high risk countries.
authors.affiliation: Vaccines and Immunity Theme, The Medical Research Council Unit The Gambia, P.O Box 273, Banjul, Fajara, The Gambia.
authors.forename: Brenda Anna
authors.initials: BA
authors.lastname: Kwambana-Adams
authors.affiliation: Ghana Health Service, Accra, Ghana.
authors.forename: Franklin
authors.initials: F
authors.lastname: Asiedu-Bekoe
authors.affiliation: Ghana Health Service, Accra, Ghana.
authors.forename: Badu
authors.initials: B
authors.lastname: Sarkodie
authors.affiliation: Brong Ahafo Regional Health Directorate, Sunyani, Brong Ahafo, Ghana.
authors.forename: Osei Kuffour
authors.initials: OK
authors.lastname: Afreh
authors.affiliation: Regional Hospital Sunyani, Sunyani, Brong Ahafo Region, Ghana.
authors.forename: George Khumalo
authors.initials: GK
authors.lastname: Kuma
authors.affiliation: National Public Health Reference Laboratory, Ghana Health Service, Accra, Ghana.
authors.forename: Godfred
authors.initials: G
authors.lastname: Owusu-Okyere
authors.affiliation: Vaccines and Immunity Theme, The Medical Research Council Unit The Gambia, P.O Box 273, Banjul, Fajara, The Gambia.
authors.forename: Ebenezer
authors.initials: E
authors.lastname: Foster-Nyarko
authors.affiliation: WHO Country Office Ghana, Accra, Ghana.
authors.forename: Sally-Ann
authors.initials: SA
authors.lastname: Ohene
authors.affiliation: WHO Country Office Ghana, Accra, Ghana.
authors.forename: Charles
authors.initials: C
authors.lastname: Okot
authors.affiliation: Vaccines and Immunity Theme, The Medical Research Council Unit The Gambia, P.O Box 273, Banjul, Fajara, The Gambia.
authors.forename: Archibald Kwame
authors.initials: AK
authors.lastname: Worwui
authors.affiliation: Vaccines and Immunity Theme, The Medical Research Council Unit The Gambia, P.O Box 273, Banjul, Fajara, The Gambia.
authors.forename: Catherine
authors.initials: C
authors.lastname: Okoi
authors.affiliation: Vaccines and Immunity Theme, The Medical Research Council Unit The Gambia, P.O Box 273, Banjul, Fajara, The Gambia.
authors.forename: Madikay
authors.initials: M
authors.lastname: Senghore
authors.affiliation: Vaccines and Immunity Theme, The Medical Research Council Unit The Gambia, P.O Box 273, Banjul, Fajara, The Gambia.
authors.forename: Jacob Kweku
authors.initials: JK
authors.lastname: Otu
authors.affiliation: Vaccines and Immunity Theme, The Medical Research Council Unit The Gambia, P.O Box 273, Banjul, Fajara, The Gambia.
authors.forename: Chinelo
authors.initials: C
authors.lastname: Ebruke
authors.affiliation: Brong Ahafo Regional Health Directorate, Sunyani, Brong Ahafo, Ghana.
authors.forename: Richard
authors.initials: R
authors.lastname: Bannerman
authors.affiliation: Ghana Health Service, Accra, Ghana.
authors.forename: Kwame
authors.initials: K
authors.lastname: Amponsa-Achiano
authors.affiliation: National Public Health Reference Laboratory, Ghana Health Service, Accra, Ghana.
authors.forename: David
authors.initials: D
authors.lastname: Opare
authors.affiliation: Microbiology and Infection Unit, Warwick Medical School, Warwick, UK.
authors.forename: Gemma
authors.initials: G
authors.lastname: Kay
authors.affiliation: Brong Ahafo Regional Health Directorate, Sunyani, Brong Ahafo, Ghana.
authors.forename: Timothy
authors.initials: T
authors.lastname: Letsa
authors.affiliation: WHO Country Office Ghana, Accra, Ghana.
authors.forename: Owen
authors.initials: O
authors.lastname: Kaluwa
authors.affiliation: Ghana Health Service, Accra, Ghana.
authors.forename: Ebenezer
authors.initials: E
authors.lastname: Appiah-Denkyira
authors.affiliation: Ministry of Health, Accra, Ghana.
authors.forename: Victor
authors.initials: V
authors.lastname: Bampoe
authors.affiliation: Disease Control and Elimination Theme, Medical Research Council Unit The Gambia, Fajara, The Gambia.|London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Syed M A
authors.initials: SM
authors.lastname: Zaman
authors.affiliation: Microbiology and Infection Unit, Warwick Medical School, Warwick, UK.
authors.forename: Mark J
authors.initials: MJ
authors.lastname: Pallen
authors.affiliation: Disease Control and Elimination Theme, Medical Research Council Unit The Gambia, Fajara, The Gambia.|London School of Hygiene and Tropical Medicine, London, UK.|Institute of Tropical Medicine, Antwerp, Belgium.
authors.forename: Umberto
authors.initials: U
authors.lastname: D'Alessandro
authors.affiliation: WHO Regional Office for Africa, Brazzaville, Republic of Congo.
authors.forename: Jason M
authors.initials: JM
authors.lastname: Mwenda
authors.affiliation: Vaccines and Immunity Theme, The Medical Research Council Unit The Gambia, P.O Box 273, Banjul, Fajara, The Gambia. mantonio@mrc.gm.|Microbiology and Infection Unit, Warwick Medical School, Warwick, UK. mantonio@mrc.gm.|London School of Hygiene and Tropical Medicine, London, UK. mantonio@mrc.gm.
authors.forename: Martin
authors.initials: M
authors.lastname: Antonio
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000494:pharmacology; D002648:Child; D002675:Child, Preschool; D004196:Disease Outbreaks; D005260:Female; D005869:Ghana / Q000453:epidemiology; D006193:Haemophilus influenzae / Q000302:isolation & purification / Q000472:pathogenicity; D006801:Humans; D017589:Immunization Programs; D007223:Infant; D008297:Male; D008585:Meningitis, Meningococcal / Q000453:epidemiology / Q000382:microbiology; D008586:Meningitis, Pneumococcal / Q000188:drug therapy / Q000453:epidemiology* / Q000382:microbiology*; D008826:Microbial Sensitivity Tests; D008875:Middle Aged; D009345:Neisseria meningitidis / Q000235:genetics / Q000302:isolation & purification / Q000472:pathogenicity; D022242:Pneumococcal Vaccines / Q000627:therapeutic use*; D013296:Streptococcus pneumoniae / Q000187:drug effects / Q000235:genetics / Q000302:isolation & purification / Q000472:pathogenicity; D015662:Trimethoprim, Sulfamethoxazole Drug Combination / Q000627:therapeutic use; D055815:Young Adult
chemical_list: C538862:13-valent pneumococcal vaccine; D000900:Anti-Bacterial Agents; D022242:Pneumococcal Vaccines; D015662:Trimethoprim, Sulfamethoxazole Drug Combination
keywords: Ghana; Meningitis; Meningitis belt; Outbreak; Pneumococcal conjugate vaccine (PCV); Pneumococcus; Serotype 1; West Africa