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Red Book Online Outbreaks: Meningococcal Disease in Florida

August 17, 2022

Overview

There is a large, ongoing outbreak of serogroup C meningococcal disease in Florida, primarily among gay, bisexual, and other men who have sex with men, including those living with HIV. This outbreak is mostly affecting people who live in Florida but has also affected some people who have traveled to Florida. Leon County, FL, has also reported a cluster of serogroup B meningococcal disease among college and university students. This cluster has only been reported to affect people living in Florida. Meningococcal Outbreaks | CDC

 

Clinical Guidance

  • Presentation: Bacterial meningitis symptoms include sudden onset of fever, headache, and stiff neck, often accompanied by nausea, vomiting, photophobia, and altered mental status. Meningococcal bloodstream infection (septicemia or meningococcemia) may present with fever, chills, malaise, limb pain, prostration, and a rash that initially can be macular or maculopapular but typically becomes petechial or purpuric within hours. Newborns and infants may not have the classic symptoms but instead may be slow, inactive, or irritable; or have poor feeding, bulging fontanelle, and abnormal reflexes. Typically, symptoms develop within 3 to 7 days after exposure.
  • Diagnosis: Cultures of blood and cerebrospinal fluid (CSF) should be collected from patients with suspected invasive meningococcal disease.
  • Populations at highest risk: For the serogroup C outbreak, adolescents and/or men who are gay, bisexual, and other men who have sex with men (with or without HIV). For the serogroup B outbreak, college and university students, students living in on-campus housing, and those who participate in a fraternity or sorority in Leon County, FL (Notice from the Leon County Health Department). This cluster has only been reported to affect people living in Florida.
  • Complications: Sequelae associated with meningococcal disease occur in up to 20% of survivors and include hearing loss, neurologic disability, digit or limb amputations, and skin scarring. In addition, patients may experience subtle long-term neurologic deficits, such as impaired school performance, behavioral problems, and attention deficit disorder.
  • Precautions: Regardless of immunization status, close contacts, including household contacts of all people with invasive meningococcal disease (see Red Book Table 3.35), whether endemic or in an outbreak situation, are at high risk of infection and should promptly receive chemoprophylaxis. Chemoprophylaxis should be provided even if the close contact has received meningococcal vaccine. The decision to give chemoprophylaxis to other contacts is based on risk of contracting invasive disease related to specific exposure to the secretions from the infected patient. Throat and nasopharyngeal cultures are not recommended because these cultures are of no value in deciding who should receive chemoprophylaxis.
  • Risk mitigation: Promote vaccination with recommended meningococcal vaccines to eligible patients. In the United States, 3 meningococcal vaccines are licensed and available for use in children and adults against serogroups A, C, W, and Y (MenACWY), and 2 vaccines are licensed for people 10 through 25 years of age against serogroup B (MenB). All 3 MenACWY vaccines are protein conjugate vaccines, while the 2 MenB vaccines are protein-based developed using 2 different technologies. The Red Book Table 3.37 (p 526) and Table 3.38 (p 528) provide recommendations on meningococcal vaccines.
  • Treatment and prophylaxis
    • Ceftriaxone or cefotaxime are recommended first-line agents for empiric treatment of meningococcal disease.
    • Detection of geographically diverse cases caused by penicillin-resistant and ciprofloxacin-resistant Neisseria meningitidis serogroup Y (NmY meningococcal disease) in the United States has implications for treatment and prophylaxis of meningococcal disease.
      • Healthcare providers should ascertain susceptibility of meningococcal isolates to penicillin before switching to penicillin or ampicillin for treatment.
      • In states that have experienced meningococcal disease cases caused by ciprofloxacin-resistant strains during the past 1-2 years, clinicians and public health staff should consider antimicrobial susceptibility testing (AST) on meningococcal isolates to inform prophylaxis decisions.
      • Antimicrobial susceptibility testing should not delay the initiation of prophylaxis.
      • Recommended prophylaxis for close contacts of persons with meningococcal disease includes either a 2-day course of rifampin, a single injection of ceftriaxone, or a single dose of ciprofloxacin (see Red Book Table 3.36). Ciprofloxacin should not be used if fluoroquinolone-resistant strains of Nm have been identified in the community.
      • Azithromycin may be considered for prophylaxis in the setting of concern for ciprofloxacin resistance, and challenges exist with rifampin and ceftriaxone use. However, data are limited and minimum inhibitory concentrations at the limit of susceptibility have been detected in some meningococcal isolates tested from a carriage study.
    • Reporting and assistance
      • State and territorial health departments should continue to submit all meningococcal isolates to the CDC for AST and whole genome sequencing (WGS).
      • States that conduct their own AST, β-lactamase screening, or WGS should share results and sequences with the CDC.
      • Although the COVID-19 pandemic may create challenges for submitting meningococcal isolates and collecting epidemiologic data, this information is important for understanding the complete geographic and temporal distribution of these penicillin- and ciprofloxacin-resistant meningococci.
      • For cases with isolates determined to be β-lactamase screen-positive or ciprofloxacin-resistant, jurisdictions are requested to complete a supplemental case report form (available on request from meningnet@cdc.gov); forms can be submitted to CDC via secure email (meningnet@cdc.gov) or FTP site.

 

Resources

 

Pediatric Practice Tools and Info

CDC: Meningococcal Vaccination | For Providers

 

Public Health Resources

CDC: Guidance for the Evaluation and Public Health Management of Suspected Outbreaks of Meningococcal Disease (cdc.gov)

CDC: Meningitis

CDC: Meningococcal Vaccination

 

Infection Prevention and Control Resources

AAP: Project Firstline

 

Information for Patients and Caregivers

CDC: Serogroups A, C, W, and Y Meningococcal Disease: What Gay and Bisexual Men Need to Know

AAP HealthyChildren.org: Meningococcal Disease: Information for Teens and College Students - HealthyChildren.org | In Spanish: Enfermedad meningocócica: información para adolescentes y estudiantes universitarios - HealthyChildren.org

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