Increased Risk for Meningococcal Disease Among Men Who Have Sex With Men in the United States, 2012-2015.

BACKGROUND: Several clusters of serogroup C meningococcal disease among men who have sex with men (MSM) have been reported in the United States in recent years. The epidemiology and risk of meningococcal disease among MSM is not well described. METHODS: All meningococcal disease cases among men aged 18-64 years reported to the National Notifiable Disease Surveillance System between January 2012 and June 2015 were reviewed. Characteristics of meningococcal disease cases among MSM and men not known to be MSM (non-MSM) were described. Annualized incidence rates among MSM and non-MSM were compared through calculation of the relative risk and 95% confidence intervals. Isolates from meningococcal disease cases among MSM were characterized using standard microbiological methods and whole-genome sequencing. RESULTS: Seventy-four cases of meningococcal disease were reported among MSM and 453 among non-MSM. Annualized incidence of meningococcal disease among MSM was 0.56 cases per 100000 population, compared to 0.14 among non-MSM, for a relative risk of 4.0 (95% confidence interval [CI], 3.1-5.1). Among the 64 MSM with known status, 38 (59%) were infected with human immunodeficiency virus (HIV). HIV-infected MSM had 10.1 times (95% CI, 6.1-16.6) the risk of HIV-uninfected MSM. All isolates from cluster-associated cases were serogroup C sequence type 11. CONCLUSIONS: MSM are at increased risk for meningococcal disease, although the incidence of disease remains low. HIV infection may be an important factor for this increased risk. Routine vaccination of HIV-infected persons with a quadrivalent meningococcal conjugate vaccine in accordance with Advisory Committee on Immunization Practices recommendations should be encouraged.

Meningococcal disease among men who have sex with men - United States, January 2012-June 2015.

Since 2012, three clusters of serogroup C meningococcal disease among men who have sex with men (MSM) have been reported in the United States. During 2012, 13 cases of meningococcal disease among MSM were reported by the New York City Department of Health and Mental Hygiene (1); over a 5-month period during 2012­2013, the Los Angeles County Department of Public Health reported four cases among MSM; and during May­June 2015, the Chicago Department of Public Health reported seven cases of meningococcal disease among MSM in the greater Chicago area. MSM have not previously been considered at increased risk for meningococcal disease. Determining outbreak thresholds* for special populations of unknown size (such as MSM) can be difficult. The New York City health department declared an outbreak based on an estimated increased risk for meningococcal infection in 2012 among MSM and human immunodeficiency virus (HIV)­infected MSM compared with city residents who were not MSM or for whom MSM status was unknown (1). The Chicago Department of Public Health also declared an outbreak based on an increase in case counts and thresholds calculated using population estimates of MSM and HIV-infected MSM. Local public health response included increasing awareness among MSM, conducting contact tracing and providing chemoprophylaxis to close contacts, and offering vaccination to the population at risk (1­3). To better understand the epidemiology and burden of meningococcal disease in MSM populations in the United States and to inform recommendations, CDC analyzed data from a retrospective review of reported cases from January 2012 through June 2015.

Special considerations for prophylaxis for and treatment of anthrax in pregnant and postpartum women.

In August 2012, the Centers for Disease Control and Prevention, in partnership with the Association of Maternal and Child Health Programs, convened a meeting of national subject matter experts to review key clinical elements of anthrax prevention and treatment for pregnant, postpartum, and lactating (P/PP/L) women. National experts in infectious disease, obstetrics, maternal fetal medicine, neonatology, pediatrics, and pharmacy attended the meeting, as did representatives from professional organizations and national, federal, state, and local agencies. The meeting addressed general principles of prevention and treatment for P/PP/L women, vaccines, antimicrobial prophylaxis and treatment, clinical considerations and critical care issues, antitoxin, delivery concerns, infection control measures, and communication. The purpose of this meeting summary is to provide updated clinical information to health care providers and public health professionals caring for P/PP/L women in the setting of a bioterrorist event involving anthrax.

Persistent low carriage of serogroup A Neisseria meningitidis two years after mass vaccination with the meningococcal conjugate vaccine, MenAfriVac.

BACKGROUND: The conjugate vaccine against serogroup A Neisseria meningitidis (NmA), MenAfriVac, is currently being introduced throughout the African meningitis belt. In repeated multicentre cross-sectional studies in Burkina Faso we demonstrated a significant effect of vaccination on NmA carriage for one year following mass vaccination in 2010. A new multicentre carriage study was performed in October-November 2012, two years after MenAfriVac mass vaccination. METHODS: Oropharyngeal samples were collected and analysed for presence of N. meningitidis (Nm) from a representative selection of 1-29-year-olds in three districts in Burkina Faso using the same procedures as in previous years. Characterization of Nm isolates included serogrouping, multilocus sequence typing, and porA and fetA sequencing. A small sample of invasive isolates collected during the epidemic season of 2012 through the national surveillance system were also analysed. RESULTS: From a total of 4964 oropharyngeal samples, overall meningococcal carriage prevalence was 7.86%. NmA prevalence was 0.02% (1 carrier), significantly lower (OR, 0.05, P = 0.005, 95% CI, 0.006-0.403) than pre-vaccination prevalence (0.39%). The single NmA isolate was sequence type (ST)-7, P1.20,9;F3-1, a clone last identified in Burkina Faso in 2003. Nm serogroup W (NmW) dominated with a carriage prevalence of 6.85%, representing 87.2% of the isolates. Of 161 NmW isolates characterized by molecular techniques, 94% belonged to the ST-11 clonal complex and 6% to the ST-175 complex. Nm serogroup X (NmX) was carried by 0.60% of the participants and ST-181 accounted for 97% of the NmX isolates. Carriage prevalence of serogroup Y and non-groupable Nm was 0.20% and 0.18%, respectively. Among the 20 isolates recovered from meningitis cases, NmW dominated (70%), followed by NmX (25%). ST-2859, the only ST with a serogroup A capsule found in Burkina Faso since 2004, was not found with another capsule, neither among carriage nor invasive isolates. CONCLUSIONS: The significant reduction of NmA carriage still persisted two years following MenAfriVac vaccination, and no cases of NmA meningitis were recorded. High carriage prevalence of NmW ST-11 was consistent with the many cases of NmW meningitis in the epidemic season of 2012 and the high proportion of NmW ST-11 among the characterized invasive isolates.

Impact of the serogroup A meningococcal conjugate vaccine, MenAfriVac, on carriage and herd immunity.

BACKGROUND: The conjugate vaccine against serogroup A Neisseria meningitidis (NmA), MenAfriVac, was first introduced in mass vaccination campaigns of 1-29-year-olds in Burkina Faso in 2010. It is not known whether MenAfriVac has an impact on NmA carriage. METHODS: We conducted a repeated cross-sectional meningococcal carriage study in a representative portion of the 1-29-year-old population in 3 districts in Burkina Faso before and up to 13 months after vaccination. One district was vaccinated in September 2010, and the other 2 were vaccinated in December 2010. We analyzed 25 521 oropharyngeal samples, of which 22 093 were obtained after vaccination. RESULTS: In October-November 2010, NmA carriage prevalence in the unvaccinated districts was comparable to the baseline established in 2009, but absent in the vaccinated district. Serogroup X N. meningitidis (NmX) dominated in both vaccinated and unvaccinated districts. With 4 additional sampling campaigns performed throughout 2011 in the 3 districts, overall postvaccination meningococcal carriage prevalence was 6.95%, with NmX dominating but declining for each campaign (from 8.66% to 1.97%). Compared with a baseline NmA carriage prevalence of 0.39%, no NmA was identified after vaccination. Overall vaccination coverage in the population sampled was 89.7%, declining over time in 1-year-olds (from 87.1% to 26.5%), as unvaccinated infants reached 1 year of age. NmA carriage was eliminated in both the vaccinated and unvaccinated population from 3 weeks up to 13 months after mass vaccination (P = .003). CONCLUSIONS: The disappearance of NmA carriage among both vaccinated and unvaccinated populations is consistent with a vaccine-induced herd immunity effect.

High post-exposure prophylaxis (PEP) uptake among household contacts of pertussis patients enrolled in a PEP effectiveness evaluation - United States, 2015-2017.

BACKGROUND: Post-exposure prophylaxis (PEP) for pertussis is recommended for household contacts of pertussis cases in the United States within 21 days of exposure, but data on PEP effectiveness for prevention of secondary cases in the setting of widespread pertussis vaccination are limited. We implemented a multi-state evaluation of azithromycin PEP use and effectiveness among household contacts. METHODS: Culture- or PCR-confirmed pertussis cases were identified through surveillance. Household contacts were interviewed within 7 days of case report and again 14-21 days later. Interviewers collected information on exposure, demographics, vaccine history, prior pertussis diagnosis, underlying conditions, PEP receipt, pertussis symptoms, and pertussis testing. A subset of household contacts provided nasopharyngeal and blood specimens during interviews. RESULTS: Of 299 household contacts who completed both interviews, 12 (4%) reported not receiving PEP. There was no evidence of higher prevalence of cough or pertussis symptoms among contacts who did not receive PEP. Of 168 household contacts who provided at least one nasopharyngeal specimen, four (2.4%) were culture or PCR positive for B. pertussis; three of these received PEP prior to their positive test result. Of 156 contacts with serologic results, 14 (9%) had blood specimens that were positive for IgG anti-pertussis toxin (PT) antibodies; all had received PEP. CONCLUSIONS: Very high PEP uptake was observed among household contacts of pertussis patients. Although the number of contacts who did not receive PEP was small, there was no difference in prevalence of pertussis symptoms or positive laboratory results among these contacts compared with those who did receive PEP.

Association of childhood pertussis with receipt of 5 doses of pertussis vaccine by time since last vaccine dose, California, 2010.

CONTEXT: In 2010, California experienced its largest pertussis epidemic in more than 60 years; a substantial burden of disease was noted in the 7- to 10-year-old age group despite high diphtheria, tetanus, and acellular pertussis vaccine (DTaP) coverage, indicating the possibility of waning protection. OBJECTIVE: To evaluate the association between pertussis and receipt of 5 DTaP doses by time since fifth DTaP dose. DESIGN, SETTING, AND PARTICIPANTS: Case-control evaluation conducted in 15 California counties. Cases (n = 682) were all suspected, probable, and confirmed pertussis cases among children aged 4 to 10 years reported from January through December 14, 2010; controls (n = 2016) were children in the same age group who received care from the clinicians reporting the cases. Three controls were selected per case. Vaccination histories were obtained from medical records and immunization registries. MAIN OUTCOME MEASURES: Primary outcomes were (1) odds ratios (ORs) for the association between pertussis and receipt of the 5-dose DTaP series and (2) ORs for the association between pertussis and time since completion (<12, 12-23, 24-35, 36-47, 48-59, or ≥60 months) of the 5-dose DTaP series. Logistic regression was used to calculate ORs, accounting for clustering by county and clinician, and vaccine effectiveness (VE) was estimated as (1 - OR) × 100%. RESULTS: Among cases and controls, 53 (7.8%) and 19 (0.9%) had not received any pertussis-containing vaccines, respectively. Compared with controls, children with pertussis had a lower odds of having received all 5 doses of DTaP (OR, 0.11; 95% CI, 0.06-0.21 [estimated VE, 88.7%; 95% CI, 79.4%-93.8%]). When children were categorized by time since completion of the DTaP series, using an unvaccinated reference group, children with pertussis compared with controls were less likely to have received their fifth dose within the prior 12 months (19 [2.8%] vs 354 [17.6%], respectively; OR, 0.02; 95% CI, 0.01-0.04 [estimated VE, 98.1%; 95% CI, 96.1%-99.1%]). This association was evident with longer time since vaccination, with ORs increasing with time since the fifth dose. At 60 months or longer (n = 231 cases [33.9%] and n = 288 controls [14.3%]), the OR was 0.29 (95% CI, 0.15-0.54 [estimated VE, 71.2%; 95% CI, 45.8%-84.8%]). Accordingly, the estimated VE declined each year after receipt of the fifth dose of DTaP. CONCLUSION: Among children in 15 California counties, children with pertussis, compared with controls, had lower odds of having received the 5-dose DTaP series; as time since last DTaP dose increased, the odds increased, which is consistent with a progressive decrease in estimated vaccine effectiveness each year after the final dose of pertussis vaccine.

Pneumococcal Serotype 5 Colonization Prevalence Among Newly Arrived Unaccompanied Children 1 Year After an Outbreak-Texas, 2015.

In 2014, an acute respiratory illness outbreak affected unaccompanied children from Central America entering the United States; 9% of 774 surveyed children were colonized with Streptococcus pneumoniae serotype 5. In our 2015 follow-up survey of 475 children, serotype 5 was not detected, and an interim recommendation to administer 13-valent pneumococcal conjugate vaccine to all unaccompanied children was discontinued.

Pertussis Vaccine Effectiveness in the Setting of Pertactin-Deficient Pertussis.

BACKGROUND: In the United States, the proportion of Bordetella pertussis isolates lacking pertactin, a component of acellular pertussis vaccines, increased from 14% in 2010 to 85% in 2012. The impact on vaccine effectiveness (VE) is unknown. METHODS: We conducted 2 matched case-control evaluations in Vermont to assess VE of the 5-dose diphtheria, tetanus, and acellular pertussis vaccine (DTaP) series among 4- to 10-year-olds, and tetanus, diphtheria, and acellular pertussis vaccine (Tdap) among 11- to 19-year-olds. Cases reported during 2011 to 2013 were included. Three controls were matched to each case by medical home, and additionally by birth year for the Tdap evaluation. Vaccination history was obtained from medical records and parent interviews. Odds ratios (OR) were calculated by using conditional logistic regression; VE was estimated as (1-OR) × 100%. Pertactin status was determined for cases with available isolates. RESULTS: Overall DTaP VE was 84% (95% confidence interval [CI] 58%-94%). VE within 12 months of dose 5 was 90% (95% CI 71%-97%), declining to 68% (95% CI 10%-88%) by 5-7 years post-vaccination. Overall Tdap VE was 70% (95% CI 54%-81%). Within 12 months of Tdap vaccination, VE was 76% (95% CI 60%-85%), declining to 56% (95% CI 16%-77%) by 2-4 years post-vaccination. Of cases with available isolates, >90% were pertactin-deficient. CONCLUSIONS: Our DTaP and Tdap VE estimates remain similar to those found in other settings, despite high prevalence of pertactin deficiency in Vermont, suggesting these vaccines continue to be protective against reported pertussis disease.

Child mortality in relation to HIV infection, nutritional status, and socio-economic background.

BACKGROUND: The aims of this study were to examine the impact of child HIV infection on mortality and to identify nutritional and sociodemographic factors that increase the risk of child mortality independent of human immunodeficiency virus (HIV) infection. METHODS: We conducted a prospective study in Dar es Salaam, Tanzania, among 687 children 6-60 months of age who were admitted to hospital with pneumonia. After discharge, children were followed up every 2 weeks during the first year and every 4 months thereafter. Sociodemographic characteristics were determined at baseline, and HIV status, haemoglobin, and malaria infection were assessed from a blood sample. During the first year of follow-up, we measured height, weight, and mid-upper arm circumference (MUAC) monthly. We estimated the risk of mortality according to HIV status and socio-economic characteristics using Cox proportional hazards models. Nutritional status variables (wasting and stunting) were examined as time-varying risk factors. RESULTS: Mean age at enrollment was 18 months. A total of 90 children died during an average 24.7 months of follow-up. HIV infection was associated with an adjusted 4-fold higher risk of mortality [relative risk (RR) = 3.92, 95% confidence interval (CI) 2.34-6.55, P < 0.0001]. Other risk factors included child's age < 24 months, stunting, low MUAC, anaemia, and lack of water supply in the household. In models with time-varying covariates, stunting and wasting during the previous month were both significant and independently related to increased risk of death. HIV infection appeared to be a stronger predictor of mortality among children who were wasted than among those who were not (P for interaction = 0.05). CONCLUSIONS: HIV infection is a strong predictor of death among children who have been hospitalized with pneumonia. Preventable conditions including inadequate water supply, child undernutrition, and anaemia contribute significantly to infant and child mortality independent of HIV infection.

Tdap vaccine effectiveness in adolescents during the 2012 Washington State pertussis epidemic.

BACKGROUND: Acellular pertussis vaccines replaced whole-cell vaccines for the 5-dose childhood vaccination series in 1997. A sixth dose of pertussis-containing vaccine, tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis, adsorbed (Tdap), was recommended in 2005 for adolescents and adults. Studies examining Tdap vaccine effectiveness (VE) among adolescents who have received all acellular vaccines are limited. METHODS: To assess Tdap VE and duration of protection, we conducted a matched case-control study during the 2012 pertussis epidemic in Washington among adolescents born during 1993-2000. All pertussis cases reported from January 1 through June 30, 2012, in 7 counties were included; 3 controls were matched by primary provider clinic and birth year to each case. Vaccination histories were obtained through medical records, the state immunization registry, and parent interviews. Participants were classified by type of pertussis vaccine received on the basis of birth year: a mix of whole-cell and acellular vaccines (1993-1997) or all acellular vaccines (1998-2000). We used conditional logistic regression to calculate odds ratios comparing Tdap receipt between cases and controls. RESULTS: Among adolescents who received all acellular vaccines (450 cases, 1246 controls), overall Tdap VE was 63.9% (95% confidence interval [CI]: 50% to 74%). VE within 1 year of vaccination was 73% (95% CI: 60% to 82%). At 2 to 4 years postvaccination, VE declined to 34% (95% CI: -0.03% to 58%). CONCLUSIONS: Tdap protection wanes within 2 to 4 years. Lack of long-term protection after vaccination is likely contributing to increases in pertussis among adolescents.

SARS preparedness checklist for state and local health officials.

A planning checklist for widespread severe acute respiratory syndrome, modeled on an Association of State and Territorial Health Officials (ASTHO) pandemic influenza planning checklist, was developed jointly by ASTHO, the National Association of County and City Health Officials, and the Centers for Disease Control and Prevention. This checklist, distributed May 2003, has been widely used.