University of Oregon outbreak highlights collaboration between public health and clinical care

By Michelle Forman, senior specialist, media, APHL

University of Oregon outbreak highlights collaboration between public health and clinical care | www.APHLblog.org

In mid-January, a University of Oregon student was diagnosed with Neisseria meningitidis serogroup B, a rare but serious disease. Within one month, three additional students were diagnosed with the same disease, one of whom died. “I was the first assistant on that autopsy,” said Patrick F. Luedtke MD, MPH, senior public health officer and medical director of the Lane County Department of Health & Human Services Community & Behavioral Health clinics. (He’s also a past APHL president.) “The bacteria were everywhere. Neisseria meningitidis takes over the body and wins every battle.”

College campuses like the University of Oregon are perfect breeding grounds for meningococcal disease. Young adults ages 16-21 have higher rates than others, and it is transmitted through close or lengthy contact such as living in close quarters or kissing. So, yeah… meningococcal disease can make its way across a college campus if it isn’t stopped quickly. In fact, there were similar outbreaks at Princeton University and at University of California, Santa Barbara in 2013.

Meningococcal disease is rare, but if a person gets it they are likely to become very sick. Once it is suspected, clinical laboratories can do a test to confirm meningococcal disease and doctors can quickly begin antibiotic treatment. (Oftentimes prophylactic antibiotic treatment is given anyone who had close contact with the sick individual.) But even with quick and proper treatment, approximately 20% of people will have long-term disabilities and 10-15% of people die. The best way to prevent severe illness is to prevent illness all together – decrease the number of people who can get meningococcal disease in the first place – with vaccines. Here’s the kicker, though… Kids in the US receive a quadrivalent meningococcal vaccine at age 11. However, that vaccine only protects kids from serogroup A, C, Y or W-135. What about B, the serogroup found at the University of Oregon?

In October 2014, the FDA approved the first ever N. meningitidis serogroup B vaccine for use in people 10-25 years of age as a three-dose series. In January 2015, the FDA approved another N. meningitidis serogroup B vaccine for use in the same age group as a two-dose series. Neither vaccine has been recommended for routine use yet, but it has been recommended for controlling outbreaks like the one at the University of Oregon. In order to implement a massive campaign to vaccinate all 22,000 students, CDC needed to know that there had been at least three confirmed serogroup B cases within a three month period. The clinical test that confirmed meningococcal disease in each of the four patients wasn’t enough, though. Not only are clinical laboratories often without the capabilities to serotype meningococcal disease, the serogroup doesn’t affect clinical care. Whether the meningococcal disease was serogroup A, B, C, Y or W-135 didn’t change how they cared for the sick individuals. Further testing was needed to show that all four cases had the exact same strain of serogroup B meningococcal disease.

That was a task for the Oregon State Public Health Laboratory; in an outbreak, it is the public health laboratory’s role to show cases are truly linked. As each case was determined to be meningococcal disease, the public health laboratory was contacted and serotyping began. While the public health lab’s confirmation that the patients were sick with group B meningococcal disease was enough information for CDC to green-light the vaccination effort, the Oregon State Public Health Laboratory dug even deeper. With Neisseria meningitidis cases such as the ones at the university, the Oregon state lab routinely uses pulsed-field gel electrophoresis (PFGE) to isolate the DNA fingerprint of each strain to show that everyone got the disease from the same source. That information could help epidemiologists identify the index case. “Using PFGE to fingerprint meningococcus is considered very risky, and it is very expensive, so many laboratories don’t do it,” explained Robert Vega, general microbiology manager at the Oregon state lab. “The risk associated with this is very real to us. Our staff is vaccinated against groups A, B, C, Y and W-135; we are well equipped and I have highly proficient staff.”

Once it was confirmed that the cases were group B meningococcal disease, CDC approved the Lane County Health Department and the University of Oregon to implement a massive effort to quickly vaccinate 22,000 students. The vaccination effort began on March 2 and within one week over 10,000 students had received the first dose of the vaccination. “We still have more students to reach, but we are working hard to make sure everyone is vaccinated,” said Dr. Luedtke. Quick treatment from clinical care providers and fast, accurate testing by the public health lab will hopefully mean that this is the beginning of the end of this outbreak.

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