Meningococcal Vaccine Recommendations for HIV+ Men Who Have Sex with Men

Abstract & Commentary

By Mary-Louise Scully M.D.

Director, Travel and Tropical Medicine Center, Samsun Clinic, Santa Barbara, California.

Dr. Scully reports no financial relationships to this field of study.

Synopsis: A cluster of cases of invasive meningococcal disease among men who have sex with men (MSM) in New York City since September 1, 2012 prompts expanded recommendations for meningococcal vaccination in HIV-infected MSM patients felt to be at increased risk.

Source: New York City Department of Health and Hygiene. Alert # 28, 2012. Update: Meningococcal Vaccine Recommendations for HIV infected Men Who Have Sex With Men. https://a816-health29ssl.nyc.gov/sites/NYCHAN/WebPages/home.aspx Accessed Nov. 10, 2012.

Massachusetts Department of Public Health. Health Advisory. Meningococcal Vaccine Recommendations for Men Who have Sex With Men, October 25, 2012. http://www.mass.gov/eohhs/docs/dph/cdc/immunization/alerts-meningococcal-msm.pdf Accessed Nov. 10, 2012

There was 1 case in 2010, 4 cases in 2011, and now 9 cases in 2012. Nine of 14 total cases were HIV-infected, and 3 of the 4 deaths that occurred were also in HIV-infected patiThere have been 14 cases of invasive Neisseria meningitidis infection among men who have sex with men (MSM) in the New York City (NYC) area since 2010.ents. Serogroup C Neisseria meningitidis was the predominant serogroup responsible for disease. The median age was 32 with a range from 21-59 years. Six cases lived in Brooklyn, 3 in Manhattan, 2 in the Bronx, 2 in Queens, and one was undomiciled. The estimated annual incidence rate of invasive meningococcal disease (IMD) in MSM is 5.9 per 100,000 compared to a rate in all other New Yorkers of 0.25 per 100,000.

In October, the New York Department of Health and Hygiene issued a recommendation to administer meningococcal vaccination to HIV-infected men who are NYC residents and who had intimate contact with a man met either through an online website, smart phone application, bar, or party since September 1, 2012. On October 25, 2012 the Massachusetts Department of Health followed up with a recommendation to immunize MSM, especially those infected with HIV, if their travel or travel plans included visiting NYC with expected close social interaction with other MSM, or if such social interaction with men from NYC occurs on a regular basis.

Commentary

Invasive meningococcal disease (IMD) remains a feared disease both among the lay population and heath care workers, as the disease is known for its rapid progression and high morbidity and mortality if there is a delay in diagnosis and initiation of treatment. IMD can begin with non-specific flu-like symptoms, but can progress quickly to severe headache, stiff neck, photophobia, nausea, vomiting, altered mental status, and sepsis. All ill patients should be closely examined for the presence of a petechial or purpuric rash, which is often present with meningococcemia. However, in the early stages of illness the rash may be maculopapular and blanch. In addition, severe muscle pain, usually in the extremities or back, or severe abdominal pain may be an early clue to the diagnosis.

Three quadrivalent meningococcal vaccines are available in the United States and include protection against the four serogroups of N. meningitidis (A, C, W135, and Y). Serogroup B is not included in any of the vaccines. Serogroups B, C, and Y cause the majority of disease in the United States, whereas serogroup A, C, and W-135 are associated with outbreaks within the classic meningitis belt of sub-Saharan Africa.1 In patients 55 years of age and younger, a meningococcal conjugate vaccine (MCV4) should be used. HIV- infected adolescents and HIV-infected patients under age 55 who meet criteria for immunization should receive two doses of MCV4 separated by 8 weeks. For patients 56 years and older polysaccharide vaccine (MPSV4) is the approved vaccine for use and only one dose is needed. However, health care providers have the option to administer MCV4 off-label to older patients with the same 2-dose schedule used in younger patients. Influenza vaccine can be administered at the same time as either MCV4 or MPSV4.

At the present time, meningococcal vaccine is not universally recommended for all HIV-infected patients, though the lesson learned from this outbreak is that MSM and in particular HIV-infected MSM are at higher risk for invasive meningococcal disease and death. So in light of this report, in my own practice I plan to discuss and offer meningococcal vaccination to all my HIV-infected MSM patients since as Ben Franklin once said wisely "an ounce of prevention is worth a pound of cure."

References

  1. CDC. Meningococcal Disease http://www.cdc.gov/meningococcal/clinical-info.html Accessed November 10, 2012.