Pharmacology Consult

Preventing and responding to college campus outbreaks

Life on a college campus is synonymous with crowded academic and athletic environments, social events and dormitory residences, all of which create an ideal setting for the spread of infectious diseases. Most recently, meningococcal meningitis and mumps outbreaks have been reported from several campuses. This article will focus on the prevention and response to outbreaks of both diseases in this setting.

Leah Molloy

Meningococcal meningitis

Meningococcal meningitis, caused by the bacterium Neisseria meningitidis, is spread through close contact with respiratory droplets or saliva. Symptoms of meningococcal meningitis generally appear within 1 week after exposure. Outcomes can be severe, including long-term neurologic sequelae and death, and the disease progresses very rapidly after the onset of symptoms. College students, particularly freshmen living and socializing in close quarters, are at increased risk for spreading and contracting meningococcal meningitis. Accordingly, many states mandate meningococcal vaccination, or proof of waiver, prior to enrollment in colleges and universities. This mandate applies to the widely available and uniformly recommended 4-valent meningococcal vaccine that provides immunity against serotypes A, C, W and Y.

Outbreaks of meningococcal meningitis caused by serogroup B, not included in the routine conjugate vaccine, have occurred within college campuses in recent years. As such, there is interest in how to respond to and prevent future outbreaks. When such an outbreak occurred at Princeton University in 2013-2014, the FDA authorized use of the not-yet-licensed serogroup B meningococcal (MenB) vaccine, which was administered to over 5,000 students. No recipients of the vaccine went on to contract serogroup B meningococcal disease, suggesting a protective effect. Since then, two different brands of MenB vaccine have been approved — Trumenba (rLP2086, Pfizer) in October 2014 and Bexsero (4CMenB, Novartis) in January 2015. Trumenba is given as a three-dose series, and Bexsero a two-dose series. Trumenba is also licensed as a two-dose series, but the Advisory Committee on Immunization Practices (ACIP) recommends three doses for those at increased risk of MenB. In addition to other high-risk populations, MenB vaccine is uniformly recommended for persons at increased risk due to an outbreak.

In terms of preventing serogroup B meningococcal infection prior to potential exposure, such as a healthy teen before leaving for college, the ACIP currently provides the following Category B recommendation: “A MenB vaccine series may be administered to adolescents and young adults aged 16-23 years to provide short-term protection against most strains of serogroup B meningococcal disease. The preferred age for MenB vaccination is 16-18 years.” A Category B recommendation is made for individual clinical decision making, in contrast to Category A recommendations, which are intended to uniformly apply to all persons in an identified group.

Recommendations for antimicrobial chemoprophylaxis remain unchanged, and should be offered to close contacts of any patient with invasive meningococcal disease. Close contacts are defined as household members, child care center contacts or anyone directly exposed to the patient’s oral secretions. Adults meeting these criteria should be given a single intramuscular dose of ceftriaxone 250 mg, a single oral dose of ciprofloxacin 500 mg, or a 2-day course of oral rifampin 600 mg every 12 hours.

Mumps

Mumps is caused by a paramyxovirus which, after a 12- to 25-day incubation period, manifests in pain and swelling of the parotid glands. This is often accompanied by fever and general malaise that may appear prior to the classic parotitis presentation. While most people recover completely, rare complications including testicular pain and swelling, meningitis and encephalitis have been reported. Similar to N. meningitidis, the mumps virus is transmitted through saliva and respiratory tract secretions. Outbreaks among close contacts in universities in Iowa, Illinois and Ohio have been reported in recent years, and by the end of 2016, over 200 cases of mumps had been identified at the University of Missouri.

The measles, mumps and rubella (MMR) vaccine is recommended as a two-dose series in early childhood, but the occurrence of outbreaks despite high two-dose vaccination coverage has led authorities to consider the utility of a third dose in the setting of an outbreak. When geometric mean titers (GMTs) of mumps neutralizing antibody were studied during a 2006 university outbreak in Nebraska, GMTs were substantially lower among those vaccinated at least 15 years earlier than those vaccinated within 5 years prior to the study (97 vs. 58; P = .065), suggesting a waning immunity over time. This is important as the traditional two-dose vaccine is completed by age 6 years; therefore, many college-aged students would potentially have had their last dose more than 15 years ago. When a third dose was given to students in Nebraska, over 90% of the population seroconverted to an immune state. Similarly, attack rates dropped significantly after a third MMR dose was administered to the majority of an affected population in a 2009-2010 community outbreak. Although there is currently no recommendation for a third dose of MMR vaccine, the CDC has provided guidance for public health authorities considering its use during outbreaks. The targeted population should have already received the traditional two-dose vaccine series and have intense exposure in a setting that is likely to facilitate transmission, such as schools or living facilities, and where there is a high attack rate and evidence of ongoing transmission.

Infectious outbreaks on college campuses can be alarming for students, families and the public, especially when they occur among students who are up-to-date on currently recommended vaccines. Close attention should be paid to ensuring that all recommended vaccines have been administered prior to college attendance, and health care providers and families alike should stay abreast of new recommendations as they become available with new information and novel vaccines.

Disclosure: Molloy reports no relevant financial disclosures.

Life on a college campus is synonymous with crowded academic and athletic environments, social events and dormitory residences, all of which create an ideal setting for the spread of infectious diseases. Most recently, meningococcal meningitis and mumps outbreaks have been reported from several campuses. This article will focus on the prevention and response to outbreaks of both diseases in this setting.

Leah Molloy

Meningococcal meningitis

Meningococcal meningitis, caused by the bacterium Neisseria meningitidis, is spread through close contact with respiratory droplets or saliva. Symptoms of meningococcal meningitis generally appear within 1 week after exposure. Outcomes can be severe, including long-term neurologic sequelae and death, and the disease progresses very rapidly after the onset of symptoms. College students, particularly freshmen living and socializing in close quarters, are at increased risk for spreading and contracting meningococcal meningitis. Accordingly, many states mandate meningococcal vaccination, or proof of waiver, prior to enrollment in colleges and universities. This mandate applies to the widely available and uniformly recommended 4-valent meningococcal vaccine that provides immunity against serotypes A, C, W and Y.

Outbreaks of meningococcal meningitis caused by serogroup B, not included in the routine conjugate vaccine, have occurred within college campuses in recent years. As such, there is interest in how to respond to and prevent future outbreaks. When such an outbreak occurred at Princeton University in 2013-2014, the FDA authorized use of the not-yet-licensed serogroup B meningococcal (MenB) vaccine, which was administered to over 5,000 students. No recipients of the vaccine went on to contract serogroup B meningococcal disease, suggesting a protective effect. Since then, two different brands of MenB vaccine have been approved — Trumenba (rLP2086, Pfizer) in October 2014 and Bexsero (4CMenB, Novartis) in January 2015. Trumenba is given as a three-dose series, and Bexsero a two-dose series. Trumenba is also licensed as a two-dose series, but the Advisory Committee on Immunization Practices (ACIP) recommends three doses for those at increased risk of MenB. In addition to other high-risk populations, MenB vaccine is uniformly recommended for persons at increased risk due to an outbreak.

In terms of preventing serogroup B meningococcal infection prior to potential exposure, such as a healthy teen before leaving for college, the ACIP currently provides the following Category B recommendation: “A MenB vaccine series may be administered to adolescents and young adults aged 16-23 years to provide short-term protection against most strains of serogroup B meningococcal disease. The preferred age for MenB vaccination is 16-18 years.” A Category B recommendation is made for individual clinical decision making, in contrast to Category A recommendations, which are intended to uniformly apply to all persons in an identified group.

Recommendations for antimicrobial chemoprophylaxis remain unchanged, and should be offered to close contacts of any patient with invasive meningococcal disease. Close contacts are defined as household members, child care center contacts or anyone directly exposed to the patient’s oral secretions. Adults meeting these criteria should be given a single intramuscular dose of ceftriaxone 250 mg, a single oral dose of ciprofloxacin 500 mg, or a 2-day course of oral rifampin 600 mg every 12 hours.

Mumps

Mumps is caused by a paramyxovirus which, after a 12- to 25-day incubation period, manifests in pain and swelling of the parotid glands. This is often accompanied by fever and general malaise that may appear prior to the classic parotitis presentation. While most people recover completely, rare complications including testicular pain and swelling, meningitis and encephalitis have been reported. Similar to N. meningitidis, the mumps virus is transmitted through saliva and respiratory tract secretions. Outbreaks among close contacts in universities in Iowa, Illinois and Ohio have been reported in recent years, and by the end of 2016, over 200 cases of mumps had been identified at the University of Missouri.

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The measles, mumps and rubella (MMR) vaccine is recommended as a two-dose series in early childhood, but the occurrence of outbreaks despite high two-dose vaccination coverage has led authorities to consider the utility of a third dose in the setting of an outbreak. When geometric mean titers (GMTs) of mumps neutralizing antibody were studied during a 2006 university outbreak in Nebraska, GMTs were substantially lower among those vaccinated at least 15 years earlier than those vaccinated within 5 years prior to the study (97 vs. 58; P = .065), suggesting a waning immunity over time. This is important as the traditional two-dose vaccine is completed by age 6 years; therefore, many college-aged students would potentially have had their last dose more than 15 years ago. When a third dose was given to students in Nebraska, over 90% of the population seroconverted to an immune state. Similarly, attack rates dropped significantly after a third MMR dose was administered to the majority of an affected population in a 2009-2010 community outbreak. Although there is currently no recommendation for a third dose of MMR vaccine, the CDC has provided guidance for public health authorities considering its use during outbreaks. The targeted population should have already received the traditional two-dose vaccine series and have intense exposure in a setting that is likely to facilitate transmission, such as schools or living facilities, and where there is a high attack rate and evidence of ongoing transmission.

Infectious outbreaks on college campuses can be alarming for students, families and the public, especially when they occur among students who are up-to-date on currently recommended vaccines. Close attention should be paid to ensuring that all recommended vaccines have been administered prior to college attendance, and health care providers and families alike should stay abreast of new recommendations as they become available with new information and novel vaccines.

Disclosure: Molloy reports no relevant financial disclosures.