Surveillance Open Access
Like 0



Despite progress in the management of invasive meningococcal disease (IMD) it causes significant mortality and sequelae.


This study aims to describe the epidemiology and clinical characteristics of IMD in Cyprus and discuss the current immunisation programmes.


This is a retrospective study of all cases of IMD notified to the Ministry of Health between 2004 and 2018. Demographic, epidemiological, clinical and microbiological data were collected when a new case was notified. Risk factors associated with mortality were investigated using univariable logistic regression.


54 cases of IMD were recorded, an overall incidence of 0.4 cases per 100,000 population. The incidence rate was highest among infants (7.2/100,000) and adolescents (1.4/100,000). Case fatality rate was 10.4%. Serogroup B accounted for 24 of 40 cases caused by known serogroup. Serogroups W and Y comprised nine cases and were responsible for most fatal cases. Serogroup C was the cause in only four cases. There was an increase in the odds of death with increasing age, while the presence of meningitis in the clinical picture was found to be associated with lower odds of death.


Despite the low incidence of IMD in Cyprus, it remains an important cause of morbidity and mortality. Serogroup B is the most frequent serogroup, while incidence of serogroups W and Y is rising. Monitoring new cases and yearly evaluation of the immunisation programmes by the National Immunization Technical Advisory Group (NITAG) is essential for successful control of the disease.


Article metrics loading...

Loading full text...

Full text loading...



  1. Cartwright KA, Stuart JM, Jones DM, Noah ND. The Stonehouse survey: nasopharyngeal carriage of meningococci and Neisseria lactamica. Epidemiol Infect. 1987;99(3):591-601.  https://doi.org/10.1017/S0950268800066449  PMID: 3123263 
  2. Public Health England (PHE). Meningococcal: the green book, chapter 22. London: PHE; 2016. Available from: https://www.gov.uk/government/publications/meningococcal-the-green-book-chapter-22
  3. Pace D, Pollard AJ. Meningococcal disease: clinical presentation and sequelae. Vaccine. 2012;30(Suppl 2):B3-9.  https://doi.org/10.1016/j.vaccine.2011.12.062  PMID: 22607896 
  4. Harrison LH, Trotter CL, Ramsay ME. Global epidemiology of meningococcal disease. Vaccine. 2009;27(Suppl 2):B51-63.  https://doi.org/10.1016/j.vaccine.2009.04.063  PMID: 19477562 
  5. Whittaker R, Dias JG, Ramliden M, Ködmön C, Economopoulou A, Beer N, et al. The epidemiology of invasive meningococcal disease in EU/EEA countries, 2004-2014. Vaccine. 2017;35(16):2034-41.  https://doi.org/10.1016/j.vaccine.2017.03.007  PMID: 28314560 
  6. European Centre for Disease Prevention and Control (ECDC). Invasive meningococcal disease. In: ECDC. Annual epidemiological report for 2017. Stockholm: ECDC; 2019. Available from: https://www.ecdc.europa.eu/sites/default/files/documents/AER_for_2017-invasive-meningococcal-disease.pdf
  7. Kirsch EA, Barton RP, Kitchen L, Giroir BP. Pathophysiology, treatment and outcome of meningococcemia: a review and recent experience. Pediatr Infect Dis J. 1996;15(11):967-78, quiz 979.  https://doi.org/10.1097/00006454-199611000-00009  PMID: 8933544 
  8. Trotter CL, Chandra M, Cano R, Larrauri A, Ramsay ME, Brehony C, et al. A surveillance network for meningococcal disease in Europe. FEMS Microbiol Rev. 2007;31(1):27-36.  https://doi.org/10.1111/j.1574-6976.2006.00060.x  PMID: 17168995 
  9. Darton T, Guiver M, Naylor S, Jack DL, Kaczmarski EB, Borrow R, et al. Severity of meningococcal disease associated with genomic bacterial load. Clin Infect Dis. 2009;48(5):587-94.  https://doi.org/10.1086/596707  PMID: 19191644 
  10. Cohn AC, MacNeil JR, Harrison LH, Hatcher C, Theodore J, Schmidt M, et al. Changes in Neisseria meningitidis disease epidemiology in the United States, 1998-2007: implications for prevention of meningococcal disease. Clin Infect Dis. 2010;50(2):184-91.  https://doi.org/10.1086/649209  PMID: 20001736 
  11. Sadarangani M, Scheifele DW, Halperin SA, Vaudry W, Le Saux N, Tsang R, et al. Outcomes of invasive meningococcal disease in adults and children in Canada between 2002 and 2011: a prospective cohort study. Clin Infect Dis. 2015;60(8):e27-35.  https://doi.org/10.1093/cid/civ028  PMID: 25605282 
  12. Campbell H, Andrews N, Borrow R, Trotter C, Miller E. Updated postlicensure surveillance of the meningococcal C conjugate vaccine in England and Wales: effectiveness, validation of serological correlates of protection, and modeling predictions of the duration of herd immunity. Clin Vaccine Immunol. 2010;17(5):840-7.  https://doi.org/10.1128/CVI.00529-09  PMID: 20219881 
  13. Trotter CL, Andrews NJ, Kaczmarski EB, Miller E, Ramsay ME. Effectiveness of meningococcal serogroup C conjugate vaccine 4 years after introduction. Lancet. 2004;364(9431):365-7.  https://doi.org/10.1016/S0140-6736(04)16725-1  PMID: 15276396 
  14. Maiden MC, Stuart JM, UK Meningococcal Carraige Group. Carriage of serogroup C meningococci 1 year after meningococcal C conjugate polysaccharide vaccination. Lancet. 2002;359(9320):1829-31.  https://doi.org/10.1016/S0140-6736(02)08679-8  PMID: 12044380 
  15. Bröker M, Bukovski S, Culic D, Jacobsson S, Koliou M, Kuusi M, et al. Meningococcal serogroup Y emergence in Europe: high importance in some European regions in 2012. Hum Vaccin Immunother. 2014;10(6):1725-8.  https://doi.org/10.4161/hv.28206  PMID: 24608912 
  16. Krone M, Gray S, Abad R, Skoczyńska A, Stefanelli P, van der Ende A, et al. Increase of invasive meningococcal serogroup W disease in Europe, 2013 to 2017. Euro Surveill. 2019;24(14).  https://doi.org/10.2807/1560-7917.ES.2019.24.14.1800245  PMID: 30968827 
  17. Cohn AC, MacNeil JR, Clark TA, Ortega-Sanchez IR, Briere EZ, Meissner HC, et al. Prevention and control of meningococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2013;62(RR-2):1-28. PMID: 23515099 
  18. European Centre for Disease Prevention and Control (ECDC). Surveillance of invasive bacterial diseases in Europe, 2012. Stockholm: ECDC; 2015. Available from: https://ecdc.europa.eu/sites/portal/files/media/en/publications/Publications/Surveillance%20of%20IBD%20in%20Europe%202012.pdf
  19. Ladhani SN, Flood JS, Ramsay ME, Campbell H, Gray SJ, Kaczmarski EB, et al. Invasive meningococcal disease in England and Wales: implications for the introduction of new vaccines. Vaccine. 2012;30(24):3710-6.  https://doi.org/10.1016/j.vaccine.2012.03.011  PMID: 22429756 
  20. Parikh SR, Andrews NJ, Beebeejaun K, Campbell H, Ribeiro S, Ward C, et al. Effectiveness and impact of a reduced infant schedule of 4CMenB vaccine against group B meningococcal disease in England: a national observational cohort study. Lancet. 2016;388(10061):2775-82.  https://doi.org/10.1016/S0140-6736(16)31921-3  PMID: 28100432 
  21. Unit for surveillance and control of communicable diseases, Medical and public health services. National Vaccination Coverage survey in toddlers 17-24 months old, 2015. Nicosia: Cyprus Ministry of Health; 2015.
  22. Unit for Surveillance and Control of Communicable Diseases, Medical and Public Health Services. National Vaccination Coverage survey in toddlers 17-24 months old, 2009. Nicosia: Cyprus Ministry of Health; 2009.
  23. European Centre for Disease Prevention and Control (ECDC). Invasive meningococcal disease, In: ECDC Annual epidemiological report for 2016, Stockholm: ECDC; 2018. Available from: https://ecdc.europa.eu/en/publications-data/invasive-meningococcal-disease-annual-epidemiological-report-2016
  24. Statistical service of Cyprus (CYSTAT) – Ministry of Finance. Demographic Report 2017. Nicosia: CYSTAT; 2018 Available from: https://www.mof.gov.cy/mof/cystat/statistics.nsf/All/77A0741D88AEB4B7C225834E003F69F2/$file/Demographic_Report-2017-EN-301118.pdf?OpenElement
  25. European Commission. Commission Implementing Decision of 8 August 2012 amending Decision 2002/253/EC laying down case definitions for reporting communicable diseases to the Community network under Decision No 2119/98/EC of the European Parliament and of the Council. 2012. Available from: https://publications.europa.eu/en/publication-detail/-/publication/10ed460f-0711-11e2-8e28-01aa75ed71a1/language-en
  26. Piscopo T, Mallia-Azzopordi C, Grech V, Muscat M, Attard-Montalto S, Mallia C. Epidemiology and prognostic factors in meningococcal disease in a small island population: Malta 1994-1998. Eur J Epidemiol. 2000;16(11):1051-6.  https://doi.org/10.1023/A:1010865315425  PMID: 11421475 
  27. Ó Maoldomhnaigh C, Drew RJ, Gavin P, Cafferkey M, Butler KM. Invasive meningococcal disease in children in Ireland, 2001-2011. Arch Dis Child. 2016;101(12):1125-9.  https://doi.org/10.1136/archdischild-2015-310215  PMID: 27566800 
  28. World Health Organization (WHO). Laboratory methods for the diagnosis of meningitis caused by Neisseria meningitidis, Streptococcus pneumoniae, and Haemophilus influenza. In: WHO Manual. 2nd ed. Chapter 7. WHO/ CDS/CSR/EDC/99.7. Geneva: WHO; 2011. Available from: https://www.cdc.gov/meningitis/lab-manual/full-manual.pdf
  29. Tzanakaki G, Tsopanomichalou M, Kesanopoulos K, Matzourani R, Sioumala M, Tabaki A, et al. Simultaneous single-tube PCR assay for the detection of Neisseria meningitidis, Haemophilus influenzae type b and Streptococcus pneumoniae. Clin Microbiol Infect. 2005;11(5):386-90.  https://doi.org/10.1111/j.1469-0691.2005.01109.x  PMID: 15819865 
  30. Drakopoulou Z, Kesanopoulos K, Sioumala M, Tambaki A, Kremastinou J, Tzanakaki G. Simultaneous single-tube PCR-based assay for the direct identification of the five most common meningococcal serogroups from clinical samples. FEMS Immunol Med Microbiol. 2008;53(2):178-82.  https://doi.org/10.1111/j.1574-695X.2008.00406.x  PMID: 18623625 
  31. Maiden MC, Bygraves JA, Feil E, Morelli G, Russell JE, Urwin R, et al. Multilocus sequence typing: a portable approach to the identification of clones within populations of pathogenic microorganisms. Proc Natl Acad Sci USA. 1998;95(6):3140-5.  https://doi.org/10.1073/pnas.95.6.3140  PMID: 9501229 
  32. Russell JE, Jolley KA, Feavers IM, Maiden MC, Suker J. PorA variable regions of Neisseria meningitidis. Emerg Infect Dis. 2004;10(4):674-8.  https://doi.org/10.3201/eid1004.030247  PMID: 15200858 
  33. Thompson EAL, Feavers IM, Maiden MCJ. Antigenic diversity of meningococcal enterobactin receptor FetA, a vaccine component. Microbiology. 2003;149(Pt 7):1849-58.  https://doi.org/10.1099/mic.0.26131-0  PMID: 12855736 
  34. Leber AL, Everhart K, Balada-Llasat JM, Cullison J, Daly J, Holt S, et al. Multicenter evaluation of biofire filmarray meningitis/encephalitis panel for detection of bacteria, viruses, and yeast in cerebrospinal fluid specimens. J Clin Microbiol. 2016;54(9):2251-61.  https://doi.org/10.1128/JCM.00730-16  PMID: 27335149 
  35. R Core Team. R: A language and environment for statistical computing. Vienna: R Foundation for Statistical Computing; 2018. Available from: https://www.R-project.org/
  36. Wickham H. ggplot2: Elegant graphics for data analysis. New York: Springer; 2016.
  37. Heinze G, Ploner M, Dunkler D, Southworth H. logistf: Firth's bias-reduced logistic regression. R package version 1.23. 2018. Available from: https://CRAN.R-project.org/package=logistf
  38. Heinze G, Schemper M. A solution to the problem of separation in logistic regression. Stat Med. 2002;21(16):2409-19.  https://doi.org/10.1002/sim.1047  PMID: 12210625 
  39. National Immunisation Advisory Committee . Immunisation guidelines. Chapter 13 – Meningococcal Infection. Dublin: Health Service Executive (HSE); 2019. Available from: https://www.hse.ie/eng/health/immunisation/hcpinfo/guidelines/chapter13.pdf
  40. MacNeil JR, Bennett N, Farley MM, Harrison LH, Lynfield R, Nichols M, et al. Epidemiology of infant meningococcal disease in the United States, 2006-2012. Pediatrics. 2015;135(2):e305-11.  https://doi.org/10.1542/peds.2014-2035  PMID: 25583921 
  41. Dunlop KA, Coyle P, Mitchell S, Fairley D, O’Neill H, Jackson P, et al. Molecular testing of respiratory swabs aids early recognition of meningococcal disease in children. Diagn Microbiol Infect Dis. 2011;70(4):427-34.  https://doi.org/10.1016/j.diagmicrobio.2011.03.018  PMID: 21658876 
  42. Judelsohn R, Marshall GS. The burden of infant meningococcal disease in the United States. J Pediatric Infect Dis Soc. 2012;1(1):64-73.  https://doi.org/10.1093/jpids/pir003  PMID: 23687573 
  43. European Centre for Disease Prevention and Control (ECDC). Expert opinion on the introduction of the meningococcal B (4CMenB) vaccine in the EU/EEA. Stockholm: ECDC; 2017. Available from: https://ecdc.europa.eu/en/publications-data/expert-opinion-introduction-meningococcal-b-4cmenb-vaccine-eueea
  44. American College Health Association (ACHA). Immunization recommendations for college students. Silver Spring: ACHA; 2018. Available from: https://www.acha.org/documents/resources/guidelines/ACHA_Immunization_Recommendations_Oct2018.pdf
  45. Public Health England (PHE). MenACWY: Information on vaccination for first time university entrants. London: PHE; 2015. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/443670/MenACWY_vaccination_university_letter_FINAL08_07_15.pdf
  46. Maclean IH, Bevan CE. Observations on an epidemic of cerebrospinal meningitis in Cyprus and the record of a prophylactic experiment: (Section of Epidemiology and State Medicine). Proc R Soc Med. 1939;32(12):1551-72.  https://doi.org/10.1177/003591573903201201  PMID: 19992142 
  47. Jacobs JH, Viboud C, Tchetgen ET, Schwartz J, Steiner C, Simonsen L, et al. The association of meningococcal disease with influenza in the United States, 1989-2009. PLoS One. 2014;9(9):e107486.  https://doi.org/10.1371/journal.pone.0107486  PMID: 25265409 
  48. Rameix-Welti MA, Zarantonelli ML, Giorgini D, Ruckly C, Marasescu M, van der Werf S, et al. Influenza A virus neuraminidase enhances meningococcal adhesion to epithelial cells through interaction with sialic acid-containing meningococcal capsules. Infect Immun. 2009;77(9):3588-95.  https://doi.org/10.1128/IAI.00155-09  PMID: 19528219 

Data & Media loading...

Submit comment
Comment moderation successfully completed
This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error