College campus outbreaks require timely public health response
After the ninth case of serogroup B invasive meningococcal disease, linked to a Princeton University outbreak, claimed the life of a student in March 2014, CDC officials reported the attack rate of disease on the Princeton campus to be 134 per 100,000 students — 1,400 times greater than the national average.
Since the outbreak at Princeton University in 2013, there have been three other college outbreaks of serogroup B meningococcal disease: the University of Southern California Santa Barbara, which involved 5 cases, Providence College, Rhode Island in 2015, which involved 2 cases, and University of Oregon, which involved 7 cases.
Also during 2015, another common vaccine-preventable disease – mumps – has caused a number of outbreaks of the disease on U.S. campuses; the University of Virginia reported cases of mumps in February and the University of Texas’ Austin campus reported another six cases in July. However, none of those compared with the largest and most recent outbreak at the University of Illinois, Urbana-Champaign, where there were 101 confirmed cases of mumps.
Source:University of Virginia
Living conditions and behaviors on college campuses compound in such a way that residential students are made susceptible by lax vaccination requirements and enforcement, according to James C. Turner, MD, professor of internal medicine at the University of Virginia. State laws govern vaccine enforcement by college administrations, and many jurisdictions do little to support college enforcement beyond legislatively established standards, which in some cases are inadequate, he said.
“The living, learning and social density on college campuses increases the opportunity for pathogens to be passed from person to person,” Turner told Infectious Diseases in Children. “Particularly with introductory courses, there are large classes with several hundred students packed into hot, dry lecture halls, where coughing and sneezing can easily pass pathogens from one person to another.”
Infectious Diseases in Children spoke with several infectious disease and college health experts about the heightened risk for vaccine-preventable outbreaks on college campuses and the best strategies for university staff and students to employ in order to deter future outbreaks.
Campuses represent ideal setting for pathogenic transmission
According to the CDC, meningococcal disease is transmitted by direct contact with respiratory and throat secretions from carriers infected with Neisseria meningitidis bacteria. Likewise, the mumps virus is spread through direct contact with saliva or mucus from an infected person’s mouth, nose and throat.
“One of the key things that happens on college campuses is an intense mixing of students, combined with behaviors of visiting bars and exchanging respiratory secretions when people are partying,” Jessica MacNeil, MPH, epidemiologist for the division of bacterial diseases at CDC, told Infectious Diseases in Children. “It’s really the behavior of college students and their social activities that put them at increased risk.”
MacNeil noted that these transmission characteristics, coupled with the intimate close contact between students away at universities, make college campuses the perfect environment for outbreaks of meningococcal disease to occur.
“Schools, in general, are places where infectious diseases can quickly be spread, but more so at college campuses where students have close contact, but also close intimate contacts,” Angela Vassallo, MPH, MS, director of infection prevention and epidemiologist at Providence Saint John’s Health Center in California, told Infectious Diseases in Children. “Students eat together and often share food and drinks, so there are many ways when you live in a close-contact environment that infectious diseases can be spread.”
According to the CDC, meningococcal disease presents itself with a sudden onset of fever, headache, stiff neck, rapid breathing, vomiting or rash. The average fatality rate for patients infected with serogroup B meningococcal disease is 11.2%. Three of the seven students that were part of the Princeton University outbreak reported long-term symptoms, including unilateral hearing loss, neurocognitive deficits and chronic headaches.
Seven students were affected by serogroup B meningococcal disease during outbreaks on the campuses of UCSB and Providence College. While none of these cases proved to be fatal, the attack rates of serogroup B meningococcal disease among students were 22.1 per 100,000 students at UCSB and 44 per 100,000 students at Providence; that was 234 times and 500 times, respectively, greater than the incidence rate for persons aged 17 to 22 years in the general U.S. population.
One of the students in the UCSB outbreak was forced to undergo bilateral foot amputations due to complications related to meningococcemia.
Mumps is also a dangerous disease, leading to long-term health problems and even death. In 2015, the University of Illinois at, Urbana-Champaign reported upwards of 100 cases of mumps connected to their campus, noting symptoms of mumps infection include flu-like symptoms, swollen salivary glands, puffy cheeks and swollen jaw.
“Whenever you have sororities, fraternities, sports teams and people in very close quarters to each other over extended periods of time, it is fertile ground for passing on and creating epidemics,” Sheldon Howard Jacobson, PhD, director of the Simulation and Optimization Laboratory at the University of Illinois, Urbana-Champaign, told Infectious Diseases in Children. “Which is basically what we could experience here with mumps.”
Identifying groups at greatest risk
Turner pointed to the residential aspects of college life as a major risk factor for the spread of rare diseases like measles, mumps and meningococcal disease.
According to the CDC, all of the cases of meningococcal disease among Princeton University students recorded during the outbreak were students who lived in six of the 50 undergraduate dormitories on campus. In addition, every case associated with Princeton, UCSB, and Providence, occurred in undergraduate students, while no cases were reported in graduate students, faculty, staff, local community members or family members of infected students.
“The number one and probably most important cause of outbreaks on college campuses is dormitory living,” Aaron E. Glatt, MD, hospital epidemiologist at South Nassau Communities Hospital on Long Island, New York, and a spokesman for the Infectious Diseases Society of America, told Infectious Diseases in Children. “You have people living together, living on top of each other to a certain extent, in relatively small, not necessarily well-aerated spaces. If somebody gets sick with a mild illness, they’re going to continue on with their regular activities, and that can easily spread various viruses quickly.”
However, immediate connections in the college outbreaks between each case of serogroup B invasive meningococcal disease were difficult for officials to establish. For example, the five students involved in the UCSB outbreak had little in common, but three were involved in Greek life. The outbreak was ultimately only remotely connected to a widely attended Halloween event adjoining campus, according to the National Foundation for Infectious Diseases.
“Some students tend to aggregate in large numbers at Greek houses or private apartments, and all of these things just facilitate the passage of pathogens from one person to another,” Turner said. “Halloween is a big one, St. Patrick’s Day and Greek rush periods, either in the fall or the spring. We see a lot of issues, particularly with respiratory and gastrointestinal diseases, during those times.”
Factors compounding student life
Stress can also be a factor in facilitating the spread of infectious diseases on college campuses, Turner said. Immunodeficiency can be caused by the compounding stress or lack of sleep that is natural to college, that when coupled with the social environments of college life, make the spread of disease easier.
“Any time a person puts stress on their body due to lack of adequate sleep or worry over school pressures, this affects the immune system in subtle ways,” Angela Myers, MD, MPH, director of the infectious diseases fellowship program at Children’s Mercy Hospital, Kansas City, Missouri, told Infectious Diseases in Children. “These, and other factors, may increase the risk of getting the common cold or sometimes even more serious infections.”
The problem is multi-factorial and all of these things combined play a role, although how much of a role is hard to determine, Myers noted.
“As part of prevention messages, we always say getting sleep, being healthy, and promoting healthy behaviors are ways to just keep yourself healthy in general,” MacNeil said. “But there isn’t anything that we’ve seen in studies that shows stress as a risk for meningococcal disease.”
Glatt also cited a lapse in coverage that can occur as older adolescents go off to college and transition from a pediatrician to an adult care provider.
“Certainly if a teenager hits 18 and no longer wants to go to their pediatrician or no longer feels comfortable with a pediatrician, but they’re healthy, they may not feel it’s urgent to get care,” Glatt said. “They may say: ‘I don’t need to go to a doctor. I don’t have adult diseases or concerns’ which makes it possible that something could slip through, including meningitis vaccinations.”
In order to alleviate the risk caused by incoming students’ gap in medical coverage, colleges work to provide students with necessary medical services, according to Turner.
“My bias is that there’s not a big gap in coverage, and, in fact, college students have access to really excellent college health services that can provide continuity of care for students when they go off to college,” Turner said. “I think it’s just really important that students and families be aware of the services that are available on a college campus.”
Adequate response needed to curtail outbreak
Before the outbreaks of serogroup B meningococcal disease at Princeton and UCSB, outbreak response was limited to postexposure antibiotic chemoprophylaxis for close contacts and hygiene campaigns to educate students about transmission prevention, according to a report published by the National Foundation for Infectious Diseases.
“Since 2009, there have been seven outbreaks of serogroup B meningococcal disease on college campuses,” MacNeil said. “Some of these outbreaks have taken place over a really long period of time, which has made things challenging from a communications standpoint, because cases keep happening. Until Princeton there was nothing that we could do to really control these outbreaks, because there was no vaccine available.”
In November 2013, the FDA granted emergency investigational new drug status for Bexsero (4CMenB, GlaxoSmithKline) to be used to control the outbreak at Princeton University. This expanded-access investigational new drug status made the vaccine available to the population determined to be at risk in the outbreak, defined as any student, staff, or faculty member of Princeton University, according to CDC reports.
“[4CMenB] had been licensed in Europe at the time of the Princeton University and UCSB outbreaks, so we were able to bring it to both of those college campuses to vaccinate students in response to the outbreak,” MacNeil said. “More recently in the last couple of years, there were two additional serogroup B outbreaks, and in both of those cases, the universities vaccinated their students with a serogroup B vaccine as a response.”
According to CDC reports, the emergency vaccination campaign at Princeton University was successful in achieving high vaccine coverage in the at-risk population. Between Dec. 9, 2013 and Feb. 20, 2014, vaccine coverage of the target population was 94.9% for single dose and 89.1% for two doses of 4CMenB. Furthermore, 96.6% of undergraduate students — the most vulnerable population on campus — received at least one dose of the vaccine.
Following the outbreaks at Princeton University and UCSB, both 4CMenB and Trumenba (MenB-FHbp, Pfizer) have been licensed for use in the U.S. The ACIP recommends these vaccines for individuals aged 10 years or older with certain medical conditions identified as being at increased risk for serogroup B meningococcal disease outbreaks. The ACIP also recommends both serogroup B meningococcal vaccines for individuals aged 16 to 23 years as “category B” vaccinations, defined as a vaccines for use on the basis of individual clinical decision-making, not for routine use among the recommended age group.
“Immunization offers the best line of defense at this time,” Jacobson said. “The earlier this is done, the more likely that a large-scale outbreak can be suppressed. In fact, mass immunization can be implemented proactively even before a case surfaces, to prevent such an outbreak.”
However, even though most students entering college have already been vaccinated against mumps during childhood, the disease still poses a threat on campus, according to Jacobson.
“The University of Virginia had 20 to 30 cases this past school year, and we have nearly 100% compliance with the recommended two [measles-mumps-rubella (MMR)] shots and so having two MMR shots doesn’t completely protect you from having a mumps outbreak,” Turner said. “The mumps vaccine, unfortunately, even with two shots is approximately 92% to 93% effective in preventing disease.”
Furthermore, according to the CDC, mumps vaccine protection may wane, prompting universities to consider administering booster doses in response to an outbreak.
“The mumps component of the MMR vaccine appears to be the weak link and does not provide the level of immunicity even after the second shot,” Jacobson said. “University of Illinois, Urbana-Champaign health officials are trying to add a third shot not only for students, but also for the entire community within the university.”
Averting an on-campus crisis
During the outbreak at Princeton University, a hygiene campaign was implemented that engaged students to develop disease awareness messages that resonated with their fellow students. These awareness campaigns focused on ways to reduce the burden of infectious diseases.
“Good general infection prevention practices can deter the spread of infectious disease, such as washing your hands before you eat, washing your hands after using the restroom, sharing or not sharing food,” Vassallo said. “I would recommend not to share drinks — also not to share food — but in particular not to share drinks. When someone is sharing a drink with others, saliva and bodily fluids are left on the surface or inside the drink that can help promote the spread of disease.”
Other deterrents that specialists suggested included rigorous enforcement of vaccination requirements. Proper immunization is a concern on college campuses because of the breadth of students traveling from diverse locations. Because of this, international students complicate the threat of disease on campuses due to the vagueness and unreliability of foreign vaccination records, according to Jacobson.
This same logic must also be applied to domestic students traveling abroad, Turner said, in order to ensure campuses remain free of vaccine-preventable diseases.
“We have to remember there is also a huge push by American universities to encourage study abroad and travel abroad and, as many more U.S. students travel abroad to these areas, they can potentially bring endemic diseases back,” Turner said. “We cannot forget about the domestic student traveling and then importing diseases as well.”
Turner noted that optimal vaccination coverage on college campuses is the best way to help protect against outbreaks of rare and fatal diseases. While, infectious diseases like serogroup B invasive meningococcal disease are dangerous, they are rare and can stay that way with a concerted effort from college officials, staff, faculty and, most importantly, students.
“Cases of meningococcal disease, including serogroup B, have been going down pretty steadily,” MacNeil said. “Because it is such a high-impact, devastating disease, and now that there are so few cases, each one gets a lot of media attention, and a lot of people think the disease is resurging, when in fact, there are actually fewer cases that are happening each year. Which is a really good thing because it is such a terrible disease.” – by David Costill
- Cohn AC, et al. Clinic Infect Dis J. 2015;doi:10.1086/649209.
- Cortese MM, et al. Clinic Infect Dis J. 2015;doi:10.1086/529141.
- McNamara LA, et al. Pediatrics. 2015;doi:10.1542/peds.2014-4015.
- Shaffner W, et al. National Foundation for Infectious Diseases. 2015; http://www.nfid.org/meningococcal-b. Last accessed 9/18/15
- Soeters HM, et al. MMWR. 2015;64:606-607.
- For more information:
- Aaron E. Glatt, MD, can be reached at Mercy Medical Center, 1000 North Village Ave., Rockville Centre, NY 11570.
- Sheldon Howard Jacobson, PhD, can be reached at the University of Illinois, 201 N. Goodwin Avenue (MC258), Urbana, IL 61801-2302; email: firstname.lastname@example.org twitter: @shj_analytics
- Jessica MacNeil, MPH, can be reached at email@example.com
- Angela Myers, MD, MPH, can be reached at firstname.lastname@example.org.
- James C. Turner, MD, can be reached at University of Virginia, PO Box 801094, Charlottesville, VA 22908; email: email@example.com
- Angela Vassallo, MPH, MS, can be reached at Providence Saint John’s Health Center, 2121 Santa Monica Blvd., Santa Monica, CA 90404; email: firstname.lastname@example.org
Disclosure: Glatt, Jacobson, MacNeil, Myers, Turner and Vassallo report no relevant financial disclosures.