Published Date: 2013-05-20 10:59:28 Subject: PRO/EDR> Meningitis, meningococcal - USA (02): (New York City) fatal, MSM, vaccination Archive Number: 20130520.1725339
MENINGITIS, MENINGOCOCCAL - USA (02): (NEW YORK CITY) FATAL, MEN WHO HAVE SEX WITH MEN, VACCINATION *************************************************************************************************** A ProMED-mail post http://www.promedmail.org ProMED-mail is a program of the International Society for Infectious Diseases http://www.isid.org
Epidemiologists puzzled over NYC's [New York City's] meningitis outbreak: "What is concerning is that it is largely restricted to men who have sex with men. So we don't really understand why that is." Have you been vaccinated?
-- Communicated by: ProMED-mail from HealthMap Alerts <promed@promedmail.org>
At around 4 on a Saturday morning, a time when most of the gay bars in New York have closed and locked their doors, a steady stream of young and middle-aged men, almost all shirtless and some stripped down to their boxer briefs, have found their way down a dark stairwell and into a maze of basement rooms, where the decor can best be described as fallout-shelter chic. They have come to Paddles, an after-hours sex club in Chelsea, not yet ready to end their evening.
Demetre Daskalakis, a doctor and gay activist has come to spread the message that a new health threat has emerged among the city's gay population and that he is there to stop it. "Have you been vaccinated?" he asks.
A new, casually transmittable infection -- a unique strain of bacterial meningitis -- has cast a pall over the gay nightlife and dating scene, with men wondering whether this is AIDS, circa 1981, all over again. To date, 7 men have died in New York City, about a third of diagnosed cases, since 2010. And in the last few months, the contagion seemed to be accelerating. It has targeted gay and bisexual men, and nobody knows exactly why.
The city's best hope to curb the outbreak is to vaccinate as many at-risk men as possible, focusing on those most in danger: men who regularly hook up with other men whom they meet at parties, bars, clubs, and through apps like Grindr. Dr Don Weiss, the director of surveillance for the city's Bureau of Communicable Disease, has called it "Russian roulette sex," because "sooner or later, you are going to come across this organism and be exposed."
The health department's own vaccination efforts at several gay bars have had limited success. Men out partying want to have fun, not be told that they may fall prey to a lethal disease by doing so. Hence Dr Daskalakis's early-morning club crawl, medical bag in hand. Being a nonthreatening gay man who does not wear a white coat helps. So does his empathy and sense of humor.
Every half-hour or so, the owner of Paddles, Michael Aulito, makes a public-service announcement: "If you haven't gotten a shot, please go talk to Dr Demetre." Dr Daskalakis hands the men a consent form and asks the threshold question: "Do you have an illness more serious than a cold?" "Will it hurt?" they ask.
"I'm hitting more than 700 today, my injections have gotten really good," he says, grinning proudly. "Can I get it from having sex?" "Maybe," he says, "but not just from sex. You can get it from being close, like kissing or cuddling." Dr Daskalakis stabs them in the arm with a needle, applies a Band-Aid and sends them on their way. All over Paddles, men are happily sucking on the lollipops he is handing out as a reward. "Dr Demetre told me every person who gets a shot saves 4 other people," Mr. Aulito says. "If he gives 700 shots, that's 2800 people that he saved, an amazing number." Mr Aulito has been vaccinated, as has his wife.
Peter DeMartino, 40, the head of an AIDS organization, AIDS/HIV Services Group, in Charlottesville, Virginia, says that he is so excited at finding medical care in a sex club that he feels like waking up his traveling companion, who is from Philadelphia, to get inoculated, too. "It's New York, right?" Mr DeMartino says. "We know our populations are very -- migratory is not the right word -- but it's not much to have a weekend in New York. If there's an outbreak in New York, how soon before it's up and down the 95 [interstate I-95] corridor?"
A 38-year-old events coordinator from Bensonhurst, Brooklyn, said that he got his shot the week before from his doctor, but he is grateful that, for men who are not insured, Paddles is an option. "I go out quite a bit," he says. "You don't have to have sex with someone to get meningitis. You go out to a bar on Friday night, you're in contact with hundreds of men, and you're not going to know. You're going to think, 'Oh, I'm hung over.' "
The bacterium [that causes meningococcal meningitis] is carried in the nose and mouth. Though not as contagious as a cold or flu, it can be spread through kissing, sneezing, or sharing a spoon. (Sharing cigarettes is also bad, but there is a theory in the literature that this is not because of the exchange of saliva but because smoking irritates the mucous membranes and facilitates bacterial invasion.)
"How long is it good?" [someone] wants to know. "It takes 7 to 10 days to take effect and provides up to 5 years of immunity," Dr Daskalakis says. Often, men ask him, "What are my chances of getting this?" "Minuscule," he replies. The idea, he explains, is to confer herd immunity by vaccinating as many at-risk men as possible. "It could have picked another social network," he says. "It picked gay men. It's like thinking of the community as a large dorm without walls."
Knowing that Dr Daskalakis has entree where government apparatchiks do not, the city supplies him with free vaccine. A week ago, he vaccinated men at a house party in Brooklyn, in a location he did not want to be disclosed, where the host set the mood by dressing in drag as a platinum-blond nurse. "The department of health loves that we're here -- loves, loves, loves," he says, at Paddles.
Meningitis can be treated with antibiotics if caught in time. The vaccine will prevent someone from getting it, and possibly reduce the ability of a carrier to spread it. The current strain was first detected among drug users in Brooklyn in 2006. In that outbreak, 23 people were infected and 7 died. After the city conducted a vaccination drive at drug treatment centers and soup kitchens, there was a three-year lull. Then there was 1 case in 2010, 4 in 2011, 13 in 2012 and 4 so far this year [2013], all among gay and bisexual men living in New York City. Of the 22, 7 have died. (City officials say there has been a 23rd case in a man who lived elsewhere in New York State but frequented the city.) Half of the men have been black, 18 percent Hispanic. Often, they are not out about their sexual activity, making it difficult for the health department to reach them. There have been 10 cases in Brooklyn, 7 in Manhattan, 2 in Queens and 2 in the Bronx. One man was homeless. Of the 22, 12 were HIV-positive, a possible risk factor because of their compromised immune systems. The last confirmed case was [15 Feb 2013].
Epidemiologists are puzzled as to why the latest outbreak is attacking men but not women. "We don't have any evidence that it's different in some biological way, we just know that it's different," says Dr Jay Varma, the city's deputy health commissioner for disease control. "And what is concerning is that it is largely restricted to men who have sex with men. So we don't really understand why that is."
Last month [April 2013], [the death of] a West Hollywood, California, lawyer fueled concerns that the outbreak had spread west. Los Angeles County health authorities and the Centers for Disease Control and Prevention have since confirmed that the strain of meningitis that killed [the lawyer] was different enough from the one in New York that it is unlikely that is how he was exposed. But the CDC has asked state health departments nationwide to be on the alert for cases among gay men.
In one positive sign, the number of vaccinations in the city has been rising sharply, to 10 200 as of [13 May 2013]. "We have our fingers crossed," Dr Varma said. "One of the reasons we can't be 100 percent confident is that there are a number of Gay Pride events coming up, where there are a lot of people coming into the city, a lot of people interacting together, so we want to get through that period before we are really celebrating controlling it."
[The news releases above are updates on the outbreak of invasive meningococcal disease among men who have sex with men (MSM) in New York City (NYC) that was reported in 2 prior ProMED-mail posts, Meningitis, meningococcal - USA (02): (NY) fatal, MSM 20120929.1315676 and Meningitis, meningococcal - USA: (New York City) fatal, MSM, alert 20130308.1576590.
The following is extracted in part from moderator ML's comments in ProMED-mail post Meningitis, meningococcal - USA: (New York City) fatal, MSM, alert 20130308.1576590:
_Neisseria meningitidis_, the cause of invasive meningococcal disease (meningitis and sepsis), is transmitted from person to person via droplets of respiratory secretions mostly from asymptomatic nasopharyngeal carriers of the microorganism. It is estimated that between 10 to 25 per cent of the population carry _N. meningitidis_ at any given time, and the carriage rate may be much higher in epidemic situations. Close and prolonged contact (such as kissing, sneezing, and coughing on someone), living in close quarters or dormitories (military recruits, students), sharing eating or drinking utensils, etc. facilitates the spread of the disease. The average incubation period for meningococcal meningitis is 4 days, ranging between 2 and 10 days (http://www.who.int/mediacentre/factsheets/fs141/en/). Invasive meningococcal disease carries a high mortality rate if untreated. Even with early and appropriate treatment, patients can die within 24-48 hours.
At least 13 serogroups, based on polysaccharide capsular antigens, have been described: 5 serogroups (A, B, C, Y, and W-135) most commonly cause human disease. Molecular epidemiology has revealed that most cases of invasive meningococcal disease are caused by only a few hypervirulent clonal lineages, whereas the genetic diversity is higher in meningococci recovered from healthy carriers (Claus H, Weinand H, Frosch M, Vogel U: Identification of the Hypervirulent Lineages of _Neisseria meningitidis_, the ST-8 and ST-11 Complexes, by Using Monoclonal Antibodies Specific to NmeDI. J Clin Microbiol. 2003; 41(8): 3873-6; available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC179822/). However, less virulent strains have been reported to cause invasive meningococcal disease in immune-compromised HIV-infected patients (Ferreira de Andrade C, Cotrim da Cunha D, Cavalcanti V, de Filippis I: Fatal meningococcal meningitis in a HIV-infected patient caused by serogroup C _Neisseria meningitidis_ belonging to the non-hypervirulent clonal complex ST-60 (cc60). Braz J Infect Dis 2011; 15 (2): 178-80; available at http://dx.doi.org/10.1590/S1413-86702011000200017).
Since 2010 there have been 22 cases in NYC. We are not told in the news reports above or in previous news reports if there is any link among the 23 cases, other than they were MSM in NYC.
It is reported elsewhere that the NYC Department of Health and Mental Hygiene stated that this outbreak was due to serogroup C (http://eziz.org/assets/docs/cdphmemo_2012_12_MeningitisAdvisoryMSM.pdf); this serogroup accounts for most US outbreaks (Woods CW, Rosenstein NE, Perkins BA: _Neisseria meningitidis_ outbreaks in the United States 1994-1997 (Abstract). In: Proceedings of Annual Meeting of IDSA. 12-15 Nov 1998. Denver, Colorado. Alexandria (VA): Infectious Disease Society of America; 1998).
We are not told the CD4 counts in the patients with HIV co-infection. Severely immunosuppressed patients with HIV infection and a low CD4 cell count of less than or equal to 200/mm3 are likely to be at greater risk of developing invasive meningococcal disease (Domingo P, Suarez-Lozano I, Torres F, et al: Bacterial meningitis in HIV-1-infected Patients in the era of highly active antiretroviral therapy. J Acquir Immune Defic Syndr. 2009 Aug 15; 51(5): 582-7; available at http://www.researchgate.net/publication/26279285_Bacterial_meningitis_in_HIV-1-infected_patients_in_the_era_of_highly_active_antiretroviral_therapy).
The primary method for preventing sporadic meningococcal disease is chemoprophylaxis with antibiotics, such as rifampin, ciprofloxacin, or ceftriaxone, for persons who are known to be close contacts after a case is identified. Close contacts of patients are considered to be household members, day-care center contacts, and other persons directly exposed to the patient's oral secretions. Administering chemoprophylaxis to persons who are not close contacts of patients usually is not recommended. Neither oropharyngeal nor nasopharyngeal cultures for _N. meningitidis_ are useful in deciding who should receive chemoprophylaxis.
However, in the face of multiple anonymous sexual encounters among some MSM, a mass vaccination campaign is being used to control this outbreak as detailed in the 2nd news release above. The Advisory Committee on Immunization Practices (ACIP) has released recommendations for the use of meningococcal vaccine to control outbreaks of serogroup C meningococcal disease (CDC. Control and prevention of serogroup C meningococcal disease: evaluation and management of suspected outbreaks: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 1997; 46(RR-5): 13-21; available at http://www.cdc.gov/mmwr/preview/mmwrhtml/00046237.htm).
The HealthMap/ProMED-mail interactive map of New York can be accessed at http://healthmap.org/r/1FWY. - Mod.ML]
ProMED-mail
Português
Español
Русский
Mekong Basin
Afrique Francophone
Anglophone Africa
