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Meningococcal disease: An update on meningococcal B vaccination
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Meningococcal disease may be relatively rare, but it remains a serious public health concern because of the high risk for mortality and severe sequelae associated with the disease, as well as its predilection to cause outbreaks such as those at Princeton University and UC Santa Barbara last year. Although disease incidence tends to occur in cycles, it can be unpredictable, with the serogroups causing disease and the incidence changing quickly. The reasons for these changes in epidemiology or serogroup prevalence are not understood.
Maintenance of caution
Although disease rates in the United States are now low, we cannot assume that the disease is disappearing; low levels of disease have preceded peaks in activity in the past. Even with modern medical treatment and care, meningococcal disease is fatal in 10% of cases and up to 50% of survivors are left with sequelae such as limb loss, hearing loss, blindness and the need for skin grafts.
For many physicians, missing a case of meningococcal disease is one of their worst fears. The presentation is often nonspecific with fever and malaise, but can progress to shock and in extremis, with death occurring in a few hours. A case of disease in a community can fuel panic when healthy children or adolescents die without warning. Outbreaks of meningococcal disease can persist for a long time. A recent outbreak in Oregon lasted almost a decade. Why it remained localized in Oregon and why it persisted for so long is unknown.
In the United States, serogroup B causes approximately one-third of all cases of meningococcal disease and a higher proportion in infants. Meningococcal disease risk is highest in infancy, with college students and military personnel also being at increased risk.
Steven B. Black
A broad coverage meningococcal B vaccine from Novartis is licensed in Europe and other countries, but not in the United States. In response to the outbreaks at Princeton and UC Santa Barbara last year, the FDA allowed this vaccine to be used under an experimental investigational new drug (IND) protocol administered by the CDC; it has now been given to more than 10,000 students to thwart the outbreaks at these two schools. In addition, Princeton announced that it plans to offer the vaccine to all incoming freshman this fall, also under the same IND.
However, this framework for response is not sustainable given the workload it requires for the FDA and CDC. Fortunately, applications have been filed with the FDA for two different serogroup B vaccines, so there is now the potential of having one or more licensed products available to prevent individual cases and future outbreaks of the disease.
Expanding protection against MenB
A vaccine against meningococcal B disease will be a useful addition to our public health toolbox, complementing our existing efforts to control serogroups A, C, W and Y through established vaccination programs. In planning for vaccine use, it should be recognized that although its use in outbreak response is warranted, the very definition of an outbreak requires multiple cases to occur. The outbreaks at Princeton and UC Santa Barbara were associated with one death; in addition, one student had a leg amputation due to disease. Clearly, consideration should be given to the routine use of meningococcal B vaccines, especially for college students and in the military to prevent these unfortunate outcomes.
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Steven B. Black, MD, is Professor of Pediatrics and Infectious Disease in the Center for Global Health at the University of Cincinnati Children’s Hospital in Ohio. He is also a member of the Infectious Diseases in Children Editorial Board.
Disclosure: Black serves as a consultant to Novartis Vaccines and Diagnostics and on Data and Safety Monitoring Boards for GlaxoSmithKline.