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Abstract & Commentary
Synopsis: College freshmen who live in dormitories have an elevated risk of developing meningococcal disease when compared with other college students. Administering currently available vaccines could reduce the risk of a meningococcal disease.
Source: Bruce MG, et al. JAMA. 2001;286:688-693.
Neisseria meningitidis causes an estimated 2400 cases of invasive meningococcal disease each year in the United States with a fatality rate of 10-15%. Although only 2-3% of cases occur on college campuses, recent outbreaks have attracted widespread media attention. These outbreaks have led the American College Health Association to recommend that college students should consider receiving meningococcal vaccine.
This study, by Bruce and associates, sought to determine the rates of meningococcal disease among American college students and to identify risk factors for the disease. They reviewed all cases of meningococcal disease among college students from Sept. 1, 1998, through Sept. 1, 2000, and then matched these cases with similar control students without a history of meningococcal vaccination. Interviews with case patients were conducted by telephone within 2 weeks of receiving a case report. Surrogates were used for case patients who died. Case-controls were similarly interviewed with information collected about demographics, class level, housing, active and passive smoking, drug and alcohol use, medical history, and exposure to large groups of people.
Ninety-six cases of meningococcal disease were identified for an incidence of 0.7 cases per 100,000 vs. 1.4 per 100,000 for the general population (P < .001) Freshmen living in dormitories had the highest incidence with a rate of 5.1 per 100,000. Of the case-patients, 68% were from vaccine preventable serogroups.
The finding that students are at no greater overall risk for meningococcal disease than noncollege students of similar age groups matches the results reported in a companion study in the same issue by Harrison and colleagues.1 However, Bruce et al did find a significant increased incidence among freshman college students residing in dormitories. They speculate that crowding may account for the increased rates. Subsequent, lower rates after the first year may be due to the development of protective antibodies among the freshman who become asymptomatic carriers. The study also identified a recent upper respiratory infection (URI) as a risk factor, similar to previous reports. Students exposed to radiator heat were also at higher risk, but most likely this is a marker for dormitory residence.
Among the 96 cases, 28% were due to serotype B but the majority of cases were due to serotypes that are potentially vaccine preventable. The current available polysaccharide vaccine has an 85-95% efficacy against serogroups A,C,Y, and W-135, which could reduce meningococcal cases among this age group by approximately 70% in the college community.
Comment by Martin Lipsky, MD
This summer, virtually all of the students going away to college that I saw for school physicals wanted the meningococcal vaccine. This study supports administering the vaccine to this group of new freshman that will be living on campus. Although from a societal perspective, it may not be cost effective to administer the vaccine to all college freshman, this study supports immunizing those individuals who request it. Although Bruce et al acknowledge that a cost-effectiveness analysis might not support routine vaccination, they also point out that this type of analysis does not take into consideration the anxiety, disruption of campus life, and tragedy of a young person suffering meningococcal disease.
In an accompanying editorial, Dr. Jay Wenger states that developing an effective long-lasting meningococcal vaccine that can be administered in childhood is clearly the best long-term solution.2 Recently, a serotype C vaccine was introduced for use in Europe and appears to be safe and effective when given with other routine childhood immunizations. Further development of a Y and W135 conjugated vaccine and an effective vaccine against serotype B will be necessary to offer extended protection.
In the meantime, the prudent thing seems to be to offer this vaccine to college students. If parents ask me what I would do for my child, I say that I would vaccinate. It is safe with minimal side effects. Its downsides are its expense and that it does not protect against all meningococcal disease.
1. Harrison LH, et al. JAMA. 2001;286:694-699.
2. Wenger J. JAMA. 2001;286:720-721.
Dr. Lipsky, Professor and Chair, Department of Family Medicine, Northwestern University Medical School, Chicago, IL, is Associate Editor of Internal Medicine Alert.