Last Friday night my wife and I were enjoying the company of some friends whose sons go to school with ours. The T.V. was on, but no one was really watching as we were deep in conversation. ABC’s 20/20 came on and had a segment on meningococcal infections that had devastated some college students. This attracted my attention, but I was not in a position to watch it as closely as I would have liked.
I did manage to catch glimpses of horrendous scenes of patients in an intensive-care setting, literally on the verge of death...and the same patient months later in a wheel chair after having a limb amputated from the devastation caused by the infection.
I regretted not being able to see the segment for I was certain that there would be a flood of questions and concerns regarding this when I went to the office the next day (since I was on call that particular weekend, I would be in the office all day seeing patients). After making rounds at the hospital, I arrived at the office around 10:30 AM.. No sooner had I walked in the door, our office manager was waiting for me and in an anxious voice asked if I had “seen it” referring to the 20/20 show. She said it scared her to death and was wondering if her daughter who was attending college in New York should get the vaccine for meningococcus that the show talked about. “It was just horrible!”, she exclaimed. She then went on to inform me that we already had three calls about the show. Oh, the power of the media.
When a story like this comes up, and it happens quite often, it is important to look at ALL the facts objectively before making a logical conclusion. First of all, what is meningococcal disease? Nisserea meningitides is a bacteria that is acquired through the respiratory tract (sneezing, coughing etc.). After the bacteria colonize our nose and throat, it can spread through the bloodstream and go to virtually any organ in the body (meningococcemia). It causes flu-like symptoms such as fever, headaches, muscle and joint aches and a rash. The patient is usually quite ill and can go on to develop meningitis (infection of the covering of the brain), shock and even death. It can disrupt the body’s blood clotting capabilities which can lead to hemorrhaging, tissue necrosis, and loss of limbs. It is clearly a devastating disease which carries an 11.5% mortality rate. This increases to 13% if the patient has meningitis.
N. meningitis is now the leading cause of bacterial meningitis in children and young adults in the U.S. with close to 2,600 annual cases. The highest incidence of meningococcal disease is by far in children 3-12 months of age (around ten per ten thousand). This steadily drops thereafter, such that the incidence in 10-year-olds is around one per one hundred thousand.
There are 13 different sero-types of N. meningitides but groups A,B,C,Y and W-135 account for most of the infections. Group B is responsible for 46% of the cases in the U.S., group C for 45%, and group Y, W-135 and other non-typable groups account for the rest. Group A is extremely rare in this country, although it is very prevalent in Asia and Africa. This data is from a multi-state survey conducted in 1989-1991.
A vaccine against N. meningitides is currently available in this country. This vaccine has sero-types A,C,Y and W-135 in it. It is licensed for patients 2 years of age and older (which means it cannot be given to the most “at risk” group). After receiving the vaccine, detectable levels of protection are seen within 10-14 days. These levels drop dramatically after 2-3 years so the protection is limited. Side effects include fever, redness at the injection sight, and allergic reactions (9.2/100,000 shots given). It is important to recognize that sero-type B, which is the most common type in the U.S., is not in the vaccine. There is a vaccine for sero-type B, however it’s effectiveness is lacking. One study conducted in Norway showed that protective levels were achieved in only 56.2% of all recipients.
Current recommendations for the vaccine are as follows: 1) it should not be used routinely 2) it should be used in epidemics or in endemic areas provided that the sero-type that is causing the outbreak is one of the 4 in the vaccine 3) it should be considered in patients whose immune status is compromised, or patients who do not have a spleen, and 4) it should be given to travelers to countries where epidemics are known to exist, or travel to the “meningitis belt” which is a band that extends across Africa from Mauritania in the west, to Ethiopia in the east.
One means of limiting the spread of this devastating disease is through the use of “prophylactic” antibiotics. When a patient is diagnosed with meningococcal disease, it is standard care to give antibiotics to all household contacts, day-care contacts, or anyone who has come into contact with the patient's oral secretions (such as a dentist, dental hygienist or respiratory therapist). The rate of secondary disease in one of these groups is highest in the first few days, so the antibiotics must be started AS SOON AS POSSIBLE. The antibiotic of choice is Rifampin which is given twice a day, for two days. It cannot be given to pregnant women, however there are alternative antibiotics that are equally protective in eradicating the presence of the organism from the naso-pharynx of the contact host.
This is a brief overview of N. meningitides, the disease it causes, the vaccine that is currently available, and the preventive measures used when it occurs. In next month's article, I plan to look at the studies that generated the 20/20 segment as it relates to college students and the role the vaccine might...or might not play in this select population.