The results for the regional surveillance data support the theory that meningococcal disease is associated with socioeconomic deprivation. Compared to the Welsh study[16] this study included more cases (451 vs. 295) over a wider area, with a total population of 5.3 million. Also, both deprivation and incidence of meningococcal disease are mapped using GIS, showing the spatial relationship of disease foci to areas of deprivation, both urban and rural. The study, in common with that from southwest England[15], also shows that this relationship holds in an area containing many rural wards, despite the problems associated with deprivation indices in rural areas[25, 26].
The analyses of the age distribution of cases and incidences suggest that there is variation between the deprivation groups. There was a significant difference between the age-specific incidence rates between the groups, and a median age difference of five years between the most and least deprived groups (non-significant). The relative risk of disease in the most deprived wards compared to the least deprived (1.97, CI 1.55 – 2.51), is greater than that observed in the northeast Thames study[14] (odds ratio 1.51 for N. meningitidis), and the southwest England study[15] (relative risk 1.76, between upper and lower quartiles), but less than that found in the Welsh study[16] (relative risk 2.4 between upper and lower quintiles). The incidence of other infections, such as infectious intestinal disease, has also been shown to vary with area socioeconomic conditions (relative risk 2.41, quintiles) [27].
All but two (25–29 years, 35–39 years) age groups experienced higher age-specific rates in the most deprived group, but the highest case numbers were seen in the under 5 age group. The increased incidence in the under fives in the most deprived group, compared to the least deprived, accounted for 68% of the total difference in age-specific incidence. This suggests that children under five are more vulnerable to meningococcal disease in the most deprived areas. The continuation of a similar pattern when case counts, percentage and age-specific incidence were considered improves the robustness of this conclusion.
Several environmental factors might contribute to the increased risk of childhood meningococcal disease in more deprived areas. Childcare arrangements, necessitated by either personal or environmental circumstances, might expose a child in a more deprived area to more potential carriers. Smoking is also known to be more common in people from disadvantaged backgrounds and a number of studies have identified passive smoking as risk factors for both nasopharyngeal carriage and meningococcal disease [3, 28–30].
An area with a relatively greater number of under fives might have a higher overall incidence rate, simply because there are more susceptible individuals. Analysis of the percentage age distribution of the populations in each deprivation group does not reveal any marked variations. There is a slight excess of 20–29 year olds in the most deprived wards compared to the other wards, but not an excess of under fives.
Mapping of the incidence rates and deprivation indices by ward definitely added value to the routine surveillance data, emphasising the focal nature of disease, and the relationship of these foci to areas of higher deprivation. Mapping incidence at ward level, rather than pinpointing individual cases as in the Welsh study[16], both considers the population at risk, and avoids potential problems with case confidentiality. The maps also suggest that, in the Eastern region, invasive meningococcal disease is largely an urban problem. Although the higher population density of urban areas might explain this, the regression model suggested that the variation was better explained by ward deprivation (term for population density non-significant, p = 0.0866). Some of the highest rates were seen in deprived urban parts of Essex. Several rural wards containing cases corresponded to more deprived areas, particularly in North Norfolk. Figure 5 shows the relationship of incidence to deprivation in close-up, and also that disease is not confined to the more deprived areas.
This is an ecological study, so the associations shown may not be valid at an individual level. Population density might still be a factor, as the regression is subject to some autocorrelation, the population variable occurring in the incidence (dependent) and population density (predictor) terms. A separate analysis, of urban and rural areas, might show whether this is the case. The paucity of cases in rural areas might make this difficult unless several more years' data were included. The north east Thames study[14] did, however, show the same relationship in an area of high population density, as have other urban studies of pertussis[31] and sexually transmitted infections[12, 21].
Geographical bias in postcoded data might have contributed toward the results, as the health authority with the lowest rate of postcode inclusion, and therefore the greatest loss of data, includes many of the more affluent parts of the region. The cases supplied by this authority only accounted for 7.4% of all cases and 4.4% of postcoded cases, so this potential bias is unlikely to have had a major effect.
Routine childhood immunisation with meningitis C conjugate vaccine started in November 1999[2], so should have had an effect on the year 2000 cases. The subset of enhanced surveillance data used for this study did not include the date of notification or the serogroup involved, so no comment can be made on the influence of the vaccine or of serogroup on the results in this paper. A breakdown of the serogroups was available for the years as a whole; of those where the group was known, 60% of cases were group B and 33% group C. Patterns of transmission may change as group C infections decline, and this might be seen with routine mapping of case data.