Vaccine 30S (2012) B63–B66 Contents lists available at SciVerse ScienceDirect Vaccine jou rn al h om epa ge: www.elsevier.com/locate/vaccine Can we defeat meningococcal disease in low and middle income countries? Brian Greenwood a,∗ , Emiliano Chiarot b , Calman A. MacLennan c , Miguel O’Ryan d a Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, Keppel St., London WC1E 7HT, UK b Novartis Vaccines and Diagnostics, Siena, Italy c Novartis Vaccines Institute for Global Health, Siena, Italy d University of Chile, Santiago, Chile a r t i c l e i n f o Article history: Received 14 October 2011 Received in revised form 10 December 2011 Accepted 13 December 2011 Keywords: Meningococcus Vaccines Control a b s t r a c t The development of multivalent conjugate and protein-based meningococcal vaccines may make global control of meningococcal disease possible. However, achieving control of meningococcal disease in low and middle income countries will be challenging. In low income countries whose vaccination programmes receive financial support from the Global Alliance for Vaccination and Immunisation, the main challenge is lack of sufficient epidemiological information to allow rational decisions on vaccine introduction to be made and, in these countries, enhanced surveillance is needed. In middle income countries, financial chal- lenges predominate. These could be met by demonstration of the cost effectiveness of new meningococcal vaccines and through the introduction of a tiered-pricing system. © 2011 Elsevier Ltd. All rights reserved. 1. Introduction The advent of polyvalent meningococcal conjugate vaccines [1], a serogroup A meningococcal conjugate vaccine for Africa [2] and recent progress in the development of safe and potentially broadly protective serogroup B meningococcal protein-based vaccines [3,4] now makes control of meningococcal disease a feasible objective. It is uncertain whether it will be possible to eliminate Neisseria meningitidis entirely, but it may be possible to eliminate the major pathogenic serogroups, a topic discussed in another paper in this supplement [5]. However, it should be possible to contain meningo- coccal disease throughout the world so that its incidence is reduced to such a low level that it is no longer a significant public health problem, the situation which we describe in this paper as ‘control’ of meningococcal disease. Control of meningococcal disease is likely to be achieved first in wealthy, industrialised countries which have the resources needed to pay for the new, relatively expensive meningococcal vaccines that are becoming available and an effective system to deliver them. However, this traditional view of the global introduction of new vaccines may be changing as shown by recent experience with rotavirus vaccine which is being introduced at more or less the same time into the national immunisation programmes of both industri- alised and developing countries. This has been achieved through international support for vaccination for the poorest countries in ∗ Corresponding author. Tel.: +44 207 299 4707; fax: +44 207 299 4720. E-mail address: brian.greenwood@lshtm.ac.uk (B. Greenwood). the world and by the establishment of a tiered-pricing scheme for middle income countries. Achieving the level of coverage with the new vaccines required for effective control of meningococcal disease in low and middle income countries will, nevertheless, be challenging. The nature and the magnitude of these challenges will be different in low and middle income countries. The characteris- tics of these differences and how they might be met were discussed at a meeting hosted by Novartis Vaccines and Diagnostics in Siena in July 2011. A summary of the results of these discussions is pre- sented in this paper. 2. The epidemiology of meningococcal disease in low and middle income countries Meningococcal disease is likely to be a significant cause of mor- tality and morbidity throughout the developing world but, with the exception of the ‘African meningitis belt’ where the infection has been studied extensively [6], relatively little is known about the epidemiology of meningococcal infection in many of the poorest countries of the world. The epidemiology of meningococcal disease in sub-Saharan Africa south of the African meningitis belt has been little studied although there is evidence that in some areas, such as the coast of Kenya and Malawi, where detailed studies have been done, that it is uncommon [7,8]. Little recent information is avail- able on the epidemiology of meningococcal disease in north Africa [9]. In South Africa outbreaks of serogroup A meningococcal dis- ease have occurred in the past and more recently a large serogroup W135 outbreak occurred in Gauteng province [10]. 0264-410X/$ – see front matter © 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.vaccine.2011.12.063