The Boston Public Health Commission (BPHC) has received reports of three confirmed cases of meningococcal disease in the Boston adult homeless community since the end of January; each presented with meningococcemia. One case developed fulminant disease and died. Close contacts of each case have been chemoprophylaxed. Given the number of cases, and the temporal and geographic clustering of cases in a distinct population cohort, vaccine targeting the Boston homeless community is currently being offered by Boston Health Care for the Homeless Program and other community partners in conjunction with BPHC. Serogrouping was performed on all three isolates. Two isolates were determined to be serogroup C, and additional testing showed they are genetically similar. The third isolate is serogroup Y, with genetic characterization pending. Menactra (which covers serogroups A, C, W-135, and Y) will be used for vaccination.
Healthcare providers, particularly emergency department clinicians, should consider meningococcal disease in the differential diagnosis of any homeless individual residing in Boston who presents with a clinically compatible illness. Healthcare providers in Boston are reminded that all cases of suspected or confirmed meningococcal disease must be immediately reported to the Boston Public Health Commission at (617) 534-5611. Additionally, all meningococcal isolates must be submitted to the Hinton State Laboratory Institute for serogrouping and genetic characterization.
EPIDEMIOLOGY: Between 2011 and 2015, twelve cases of meningococcal disease were identified in Boston residents (range 1-5 cases/year). They were sporadic, with no clustering noted by age, gender, or geographical location. In the U.S., outbreaks of invasive meningococcal disease occur most frequently in crowded conditions (e.g., military bases, college dormitories). Cases of invasive meningococcal disease in the U.S. are most often caused by serogroups B, C, and Y (each accounting for approximately 30% of reported cases), although other serogroups are seen sporadically. Epidemics of invasive disease are most commonly associated with serogroups B, C and Y.
The incubation period is usually 2–4 days, but it can range from 1–10 days. Cases remain infectious as long as meningococci are present in their oral secretions. Meningococci usually disappear from the nasopharynx within 24 hours after initiation of effective antibiotic treatment. The overall case-fatality rate, including in cases who are treated with appropriate antimicrobials, is 10-15%. Long term sequelae including hearing loss, digit or limb amputations, and neurologic disability occur in 11-19% of survivors.
SYMPTOMS AND DIAGNOSIS: All three cases presented with meningococcemia. Invasive infection can result in meningitis, bacteremia, or both. Presentation with pneumonia is typically associated with serogroup Y. Onset may be nonspecific but abrupt, with fever, chills, malaise, limb pain, and a rash that can be macular, maculopapular, papular, petechial, or purpuric. Fulminant disease may present with purpura, disseminated intravascular coagulation, limb ischemia, pulmonary edema, shock, and coma. Healthcare providers should consider meningococcal disease in the differential diagnosis of any homeless resident residing in Boston who presents with signs of meningococcal disease. A confirmed diagnosis is made by identifying meningococci from any normally sterile site. Starting antimicrobial treatment before collection of any appropriate specimen (e.g., blood or CSF) may decrease the sensitivity of culture.
PREVENTION: Vaccination against meningococcal disease is routinely recommended for specific subgroups (e.g., college students). It is also indicated in well defined settings and subgroups when a cluster has been identified and the associated serogroup is included in an available vaccine.
REPORTING: City and State regulations require that healthcare providers and institutions report immediately any clinically suspected or confirmed case of meningococcal disease diagnosed in Boston to BPHC. All meningococcal isolates must be submitted to the Hinton State Laboratory Institute for serogrouping and genetic characterization.
Reporting forms for healthcare providers and for laboratories are available at: http://www.bphc.org/cdc
Communicable Disease Control Division Boston Public Health Commission 1010 Massachusetts Avenue Boston, MA 02118
Tel. (617) 534-5611, Fax. (617) 534-5905 http://www.bphc.org/cdc
What is meningococcus?
A deadly bacterial infection. Go to the CDC web page to read about it.
When should I consider meningococcus in my differential diagnosis?
When a patient (homeless or not), comes in febrile and ill.
What should I do?
Follow your hospital’s isolation procedures. Get blood cultures before antibiotics. Call your infectious diseases service. Start appropriate antibiotics. Do a spinal tap. Look at the gram stain immediately.
What do you think about the situation of the homeless in Boston/Cambridge?
For one of the richest cities in the world, home to Harvard and MIT and a number of other universities and corporations, the situation of the homeless in Boston/Cambridge is a travesty. Why did we close the Long Island shelter and where did those people end up? Why don’t we have adequate housing and health care for everyone? It’s simple. We don’t care about poor people. We don’t want to spend money on vitally important social services.
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