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Meningococcemia: Epidemiology & Prevention

Meningococcemia: Epidemiology & Prevention. Baylor College of Medicine Med-Peds Continuity Clinic Anoop Agrawal, M.D. The Cause: N. Meningitidis. Neisseria meningitidis is a commensal bacteria of the human nasopharynx, its only reservoir.

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Meningococcemia: Epidemiology & Prevention

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  1. Meningococcemia:Epidemiology & Prevention • Baylor College of Medicine • Med-Peds Continuity Clinic • Anoop Agrawal, M.D.

  2. The Cause: N. Meningitidis • Neisseria meningitidis is a commensal bacteria of the human nasopharynx, its only reservoir. • Gram negative, aerobic, diplococcus with a polysaccharide capsule • 5% to 15% of adolescents and young adults are asymptomatic carriers vs. <2% in young children.

  3. Epidemiology of Disease • Rate of disease in US: 1.5 cases per 100,000 • Incidence peaks in late winter and early spring • Highest risk groups: infants less than 1 year of age and adolescents • Most carriers develop protective antibodies to the organism.

  4. Annual incidence of meningococcal disease, US., 1999-2008 MMWR, Jan 2011/60(03);72-76

  5. Epidemiology Continued • Thirteen serogroups exist, but five serogroups account for majority of invasive disease: A, B, C, Y, W-135 • The subtype causing disease varies over time and by geographic location. • Subtype A was a common cause in US till WW II. Now is the major cause in sub-Saharan Africa (aka the”meningitis belt”). • Currently, B, C and Y are major causes in US.

  6. Epidemiology Continued • In 2001, 65% of cases in infants age 1 year or younger were caused by subtype B. • Presently, none of the meningitis vaccines offer protection for subtype B.

  7. Pathogenesis • Transmission occurs by droplet aerosolization or direct contact with secretions. • The bacteria must then cross mucosal barrier and gain access to the bloodstream - virulence factors and host defense mechanisms will determine the development of disease • Crowded living conditions, exposure to tobacco smoke are known risk factors.

  8. Disease Outcomes • Majority of cases manifested as meningitis (49%), followed by bacteremia (33%) and pneumonia (9%). • Case fatality rate of 10% to 14% • Up to 20% will have serious sequale: neurologic deficits, deafness, or limb loss.

  9. Primary Prevention • Meningococcal Vaccines - What are the two types available? • MPSV4 (polysaccharide) • MCV4 (conjugate) • Menactra (sanofi pasteur) - 2005 • Menveo (Novartis) - 2010

  10. The Vaccines

  11. Mortality • Which disease has the highest mortality? • a. meningitis • b. bacteremia • c. pneumonia • Which age group has the higher mortality? • a. infants • b. adolescents

  12. Other advantages • Conjugate vaccines can be boosted at a later date. • MCV-4 can eliminate carrier state. • MPSV-4 vaccine has decreased immune responsiveness to subsequent vaccinations.

  13. MCV4 (conjugate) • What are the recommendations for use of this vaccine for adolescents? What other persons are considered high risk and should also be vaccinated?

  14. MCV4 Vaccination Rec’s • Adolescents: • Should be administered as part of routine preventive visit at 11-12 years of age • Booster dose at age 16 years • Any adolescent requesting to reduce their risk by vaccination.

  15. MCV4 Vaccination Rec’s • Other groups that need vaccination: • College freshman living in dormitories • Microbiology lab personnel • Military recruits • Travelers headed to areas of high endemic disease • Persons with anatomic or functional asplenia, or terminal complement deficiencies

  16. Why is a booster dose now needed? • MCV-4 was expected to provide protection for persons age16 through 21 years with single administration at age 11 or 12 years. • Recent data indicate many adolescents might not be protected for more than 5 years.

  17. Case 1 • An 16 year old girl presents to your office requesting the MCV4 vaccine. She just found out she is pregnant. Can she receive the vaccine? • YES. • Does she need a booster following today’s vaccination? • No. Persons who receive first dose at or after age 16 years do not need a booster.

  18. Case 2 • An 5 year old girl with a history sickle cell and asplenia since the age of 20 months presents for a well child exam. She received the her initial MCV-4 vaccination with a booster 8 weeks later at the age of 2 years. Does she need any further boosters for MCV-4? • YES. Children whose previous booster was before their 7th birthday need boosters every 3 years. After the 7 years of age, vaccinations should be given every 5 years.

  19. Case 3 • An 17 year old girl with h/o HIV presents to your office for her annual physical. She has never received MCV-4. What is the vaccination schedule for her situation? • For children and teens ages 11-18 years with HIV, give 2 doses at least 8 weeks apart.

  20. Case 4 • An 60 year old physician is planning a vacation to northern Nigeria in January. Does this person need vaccination for meningococcal disease? If so, what will you administer? • Yes, vaccination is needed. MPSV-4 is the only option for adults older than 55 years of age.

  21. Case 5 • An 16 year old girl presents to your office for routine physical. According to her vaccination record, she received MCV-4 at age 13. When can she receive her booster dose? • Now. If primary dose was given at age 13-15 years, then booster can be given between age 16-18 years. • Reasoning: adolescents aged 14 and up are less likely to visit the doctor

  22. Summary • N. Meningitidis is found in 5-15% of asymptomatic adolescents. • The new MCV4 is recommended for all adolescents beginning at age 11 with a booster at age 16 years. • MCV-4 has now been approved to age • It protects against 2 of the 3 most common serotypes in US - C and Y, but does not protect against B. • MPSV4 may be used if MCV4 is unavailable.

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