Am Fam Physician. 2000;62(3):501-502
The Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) has modified its guidelines1 for use of the meningococcal polysaccharide vaccine in the prevention of bacterial meningitis and septicemia. The changes are particularly significant for college freshmen who live in dormitories, a group that has been found to be at a modestly increased risk of meningococcal disease compared with other college students.1
During its fall 1999 meeting, ACIP reviewed published data2–5 and data from studies recently conducted by the CDC, which identified a sixfold to sevenfold increased risk of invasive meningococcal disease among freshman dormitory residents compared with all college students.4 As a result, ACIP recommended that those who provide medical care to this group inform students and their parents about meningococcal disease and the benefits of vaccination. Vaccination should be provided for or made available to freshmen who wish to reduce their risk of disease. Other nonfreshmen undergraduate students who wish to reduce their risk for meningococcal disease may also choose to be vaccinated.1
College students are likely to be at greater risk for meningococcal disease for the same reasons that 15- to 19-year-old students have a higher incidence of endemic disease than the general population. This elevated incidence has been attributed to risk factors associated with meningococcal transmission and invasion, such as crowding, active or passive smoking, and exposure to oral secretions and strains of Neisseria meningitidis to which there was no previous exposure during early childhood.6 The risk may be increased by features of college life, such as dormitories crowded with students of diverse geographic backgrounds, frequent respiratory infections and patronage of bars or parties with students jammed into smoke-filled rooms.
Other evidence supports the potential benefit of immunization of college students. Although rare, this bacterial infection has unacceptably high rates of morbidity and mortality. Despite prompt diagnosis and treatment, the case fatality rate of invasive meningococcal disease remains unchanged at 10 percent.6 Among survivors, 3 to 15 percent suffer permanent sequelae such as skin scars, amputation, hearing loss and renal problems.7 Also, serogroup distribution has changed significantly in the past 10 years, and now 70 to 80 percent of cases among college students are potentially preventable with vaccination.3,4 Furthermore, compared with serogroup B, case fatality rates are higher among patients infected by vaccine-preventable serogroups, and permanent sequelae are more frequent as well.6,7
A compelling argument against preexposure immunization of college students can be made from a public health perspective. A cost benefit to society cannot be demonstrated because the disease is rare, protective antibodies last only three to five years, and the vaccine lacks coverage for serogroup B (which accounts for up to 30 percent of cases of disease); therefore, the cost of vaccination of college students is greater than the societal cost of disease.8 As a result, ACIP has not drafted a stronger recommendation to avoid committing limited public health resources to a meningococcal vaccination program.
However, the economic analysis has not taken into account the costs associated with long-term care (hemodialysis and renal transplantation), rehabilitation (prostheses, physical therapy), social services (disability, Medicaid), university response to the public health crisis or medicolegal consequences. It is difficult to include these factors in a cost-benefit analysis because specific data are not readily available. Interestingly, a recent report demonstrated that malpractice claims related to meningitis contribute significantly to societal costs, with nearly $92 million paid to plaintiffs between 1985 and 1997.9
A cost benefit to society will likely be realized in the future when longer lasting conjugate vaccines and an immunogenic serogroup B vaccine are successfully developed.6 In the meantime, a stronger recommendation from ACIP is unlikely and, therefore, a decision about vaccination is one of personal choice. Thus, physicians must be prepared to give college-bound students and their parents accurate information about the relative risks of meningococcal disease and the potential benefits of vaccination and must be willing to make the vaccine available on request. Physicians can anticipate that in the near future more universities will include the meningococcal recommendation on immunization forms, and more students and parents will be requesting the vaccine.
Having observed the horrific toll of meningococcal disease on college students and their families and having experienced the profound disruption and cost to a university, I welcome the ACIP recommendation as a step in the right direction. It will facilitate the education of parents and students about this rare but dreadful disease and afford them the opportunity to make informed choices about vaccination. If enough students elect to receive vaccine, many will be spared the ravages of meningococcal disease, and fewer colleges will have to deal with the public health crisis associated with one or more cases.