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February 5, 1997, Vol 277, No. 5 >
ARTICLE | February 5, 1997

School-Based Clusters of Meningococcal Disease in the United States: Title and subTitle BreakDescriptive Epidemiology and a Case-Control Analysis FREE

Kenneth M. Zangwill, MD; Anne Schuchat, MD; Francis X. Riedo, MD; Robert W. Pinner, MD; Denise T. Koo, MD, MPH; Michael W. Reeves, PhD; Jay D. Wenger, MD
[+] Author Affiliations

Corresponding author: Anne Schuchat, MD, Childhood and Respiratory Diseases Branch, National Center for Infectious Diseases, Mailstop C-09, Centers for Disease Control and Prevention, 1600 Clifton Rd, Atlanta, GA 30333.


JAMA. 1997;277(5):389-395. doi:10.1001/jama.1997.03540290041030
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Article
References

Objective.  —To evaluate the epidemiologic features and risk factors for multiple cases of meningococcal disease in schools.

Design.  —Population-based prospective evaluation and case-control study of clusters of meningococcal disease that occurred in schools from January 1989 to June 1994.

Setting.  —Surveillance conducted through state health departments in the United States.

Main Outcome Measures.  —Descriptive epidemiology of school-based clusters of meningococcal disease and determinants of their occurrence.

Results.  —We identified 22 clusters of meningococcal disease in 15 states. The estimated incidence of secondary meningococcal disease among schoolchildren aged 5 to 18 years was 2.5 per 100 000 population, a relative risk of 2.3 (95% confidence interval [CI], 1.6-3.3). The median number of students per cluster was 2 (range, 2-4). Of 30 subsequent cases, 10 (33%) occurred 2 or fewer days after the index case, and 22 (73%) occurred 14 or fewer days after the index case. Among the 8 schools with 2 or more cases, 50% of the additional cases occurred 2 or more days after the second case. Secondary schools (grades 7 through 12) accounted for 15 (75%) of 20 cluster schools compared with 9 (45%) of 20 matched control schools (P<.05). In 16 (73%) of 22 clusters, interaction between case patients was noted. The index patient in cluster schools was more likely than the controls to have participated in a school-based group activity 14 or fewer days before illness (matched odds ratio, 7.0; 95% CI, 0.9-57).

Conclusions.  —Three quarters of the school clusters occurred in secondary schools, with over 70% of subsequent cases occurring within 2 weeks of the index case. Rapid initiation of a chemoprophylaxis program after 2 cases of meningococcal disease in a school would have potentially prevented 50% of subsequent cases in the clusters described.

REFERENCES

1 +
Hume SE.  Mass voluntary immunization campaigns for meningococcal disease in Canada: media hysteria . JAMA . 1992;;267:1834, 1837-1838.
2 +
Jackson LA, Schuchat A, Reeves MW, Wenger JD.  Serogroup C meningococcal outbreaks in the United States: an emerging threat . JAMA . 1995;;273:383-389.
3 +
Feigin RD, Baker CJ, Herwaldt LA, Lampe RM, Mason EO, Whitney SE.  Epidemic meningococcal disease in an elementary school classroom . N Engl J Med . 1982;;307:1255-1257.
4 +
Morrow HW, Slaten DD, Reingold AL, Werner SB, Fenstersheib MD.  Meningococcal disease: risk factors associated with a school-related outbreak of serogroup C meningococcal disease . Pediatr Infect Dis J . 1990;;9:394-398.
5 +
Hudson PJ, Vogt RL, Heun EM, et al.  Evidence for school transmission of Neisseria meningitidis during a Vermont outbreak . Pediatr Infect Dis J . 1986;;5:213-217.
6 +
Harrison LH, Armstrong CW, Jenkins SR, et al.  A cluster of meningococcal disease on a school bus following epidemic influenza . Arch Intern Med . 1991;;151:1005-1009.
7 +
Jacobson JA, Camargos PAM, Ferreira JT, McCormick JB.  The risk of meningitis among classroom contacts during an epidemic of meningococcal disease . Am J Epidemiol . 1976;;104:552-555.
8 +
Jackson LA, Wenger JD.  Laboratory-based surveillance for meningococcal disease in selected areas, United States, 1989-1991 . MMWR Morb Mortal Wkly Rep . 1993;;42( (SS-2) ):21-30.
9 +
Selander RK, Caugant DA, Ochman H, Musser JN, Gilmour MN, Whittam TS.  Methods of multilocus enzyme electrophoresis for bacterial population genetics and systematics . Appl Environ Microbiol . 1986;;51:873-884.
10 +
SAS/STAT Software: Changes and Enhancements Through Release 6.11. Cary, NC: SAS Institute, Inc; 1996.
11 +
Centers for Disease Control and Prevention.  Serogroup B meningococcal disease: Oregon, 1994 . MMWR Morbid Mortal Wkly Rep . 1995;;44:121-124.
12 +
The Meningococcal Disease Surveillance Group.  Meningococcal disease: secondary attack rate and chemoprophylaxis in the United States, 1974 . JAMA . 1976;;235:261-265.
13 +
Munford RS, Taunay A, De Morais JS, Fraser DW, Feldman RA.  Spread of meningococcal infection within households . Lancet . 1994;;1:1275-1278.
14 +
De Wals P, Hertoghe L, Borlee-Grimee I, et al.  Meningococcal diease in Belgium: secondary attack rate among household, day-care nursery, and preelementary school contacts . J Infect . 1981;;3( (suppl 1) ):53-61.
15 +
Favorova LA, Sokova IN, Cherynshova TF, et al.  Results of controlled epidemiologic trial on the use of placental gamma-globulin in the foci of meningococcus infection . Zh Mikrobiol Epidemiol Immunobiol . 1975;;6:15-18.
16 +
Olivares R, Hubert B.  Clusters of meningococcal disease in France (1987-1988) . Eur J Epidemiol . 1992;;8:737-742.
17 +
Counts GW, Gregory DF, Spearman JG, et al.  Group A meningococcal disease in the U.S. Pacific Northwest: epidemiology, clinical features, and effect of a vaccination control program . Rev Infect Dis . 1984;;6:640-8.
18 +
Wang J-F, Caugant DA, Morelli G, Koumare B, Achtman M.  Antigenic and epidemiologic properties of the ET-37 complex of Neisseria meningitidis . J Infect Dis . 1993;;167:1320-1329.
19 +
Schwartz B, Moore PS, Broome CV.  Global epidemiology of meningococcal disease . Clin Microbiol Rev . 1989;;2:S118-S124.
20 +
Hoge CW, Fisher L, Connell D, et al.  Risk factors for transmission of Mycobacterium tuberculosis in a primary school outbreak: lack of racial difference in susceptibility to infection . Am J Epidemiol . 1994;;139:520-530.
21 +
Cheek JE, Baron R, Atlas H, Wilson DL, Crider RD Jr.  Mumps outbreak in a highly vaccinated school population: evidence for large-scale vaccination failure . Arch Pediatr Adolesc Med . 1995;;149:774-778.
22 +
Alexander JP, Chapman LE, Pallansch MA, Stephenson WT, Torok TJ, Anderson LJ.  Coxsackievirus B2 infection and aseptic meningitis: a focal outbreak among members of a high school football team . J Infect Dis . 1993;;167:1201-1205.
23 +
Moore PS, Hierholzer J, De Witt W, et al.  Respiratory viruses and mycoplasma as cofactors for epidemic group A meningococcal meningitis . JAMA . 1990;;264:1271-1275.
24 +
Centers for Disease Control.  Recommendation of the Immunization Practices Advisory Committee (ACIP): meningococcal vaccines . MMWR Morb Mortal Wkly Rep . 1985;;34:255-259.
25 +
Gaunt PN, Lambert BE.  Single dose ciprofloxacin for the eradication of pharyngeal carriage of Neisseria meningitidis . J Antimicrob Chemother . 1988;;21:489-496.
26 +
Schwartz B, Al-Tobaiqi A, Al-Ruwais A, et al.  Comparative efficacy of ceftriaxone and rifampicin in eradicating pharyngeal carriage of group A Neisseria meningitidis . Lancet . 1988;;2:1239-1242.

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1 +
Hume SE.  Mass voluntary immunization campaigns for meningococcal disease in Canada: media hysteria . JAMA . 1992;;267:1834, 1837-1838.
2 +
Jackson LA, Schuchat A, Reeves MW, Wenger JD.  Serogroup C meningococcal outbreaks in the United States: an emerging threat . JAMA . 1995;;273:383-389.
3 +
Feigin RD, Baker CJ, Herwaldt LA, Lampe RM, Mason EO, Whitney SE.  Epidemic meningococcal disease in an elementary school classroom . N Engl J Med . 1982;;307:1255-1257.
4 +
Morrow HW, Slaten DD, Reingold AL, Werner SB, Fenstersheib MD.  Meningococcal disease: risk factors associated with a school-related outbreak of serogroup C meningococcal disease . Pediatr Infect Dis J . 1990;;9:394-398.
5 +
Hudson PJ, Vogt RL, Heun EM, et al.  Evidence for school transmission of Neisseria meningitidis during a Vermont outbreak . Pediatr Infect Dis J . 1986;;5:213-217.
6 +
Harrison LH, Armstrong CW, Jenkins SR, et al.  A cluster of meningococcal disease on a school bus following epidemic influenza . Arch Intern Med . 1991;;151:1005-1009.
7 +
Jacobson JA, Camargos PAM, Ferreira JT, McCormick JB.  The risk of meningitis among classroom contacts during an epidemic of meningococcal disease . Am J Epidemiol . 1976;;104:552-555.
8 +
Jackson LA, Wenger JD.  Laboratory-based surveillance for meningococcal disease in selected areas, United States, 1989-1991 . MMWR Morb Mortal Wkly Rep . 1993;;42( (SS-2) ):21-30.
9 +
Selander RK, Caugant DA, Ochman H, Musser JN, Gilmour MN, Whittam TS.  Methods of multilocus enzyme electrophoresis for bacterial population genetics and systematics . Appl Environ Microbiol . 1986;;51:873-884.
10 +
SAS/STAT Software: Changes and Enhancements Through Release 6.11. Cary, NC: SAS Institute, Inc; 1996.
11 +
Centers for Disease Control and Prevention.  Serogroup B meningococcal disease: Oregon, 1994 . MMWR Morbid Mortal Wkly Rep . 1995;;44:121-124.
12 +
The Meningococcal Disease Surveillance Group.  Meningococcal disease: secondary attack rate and chemoprophylaxis in the United States, 1974 . JAMA . 1976;;235:261-265.
13 +
Munford RS, Taunay A, De Morais JS, Fraser DW, Feldman RA.  Spread of meningococcal infection within households . Lancet . 1994;;1:1275-1278.
14 +
De Wals P, Hertoghe L, Borlee-Grimee I, et al.  Meningococcal diease in Belgium: secondary attack rate among household, day-care nursery, and preelementary school contacts . J Infect . 1981;;3( (suppl 1) ):53-61.
15 +
Favorova LA, Sokova IN, Cherynshova TF, et al.  Results of controlled epidemiologic trial on the use of placental gamma-globulin in the foci of meningococcus infection . Zh Mikrobiol Epidemiol Immunobiol . 1975;;6:15-18.
16 +
Olivares R, Hubert B.  Clusters of meningococcal disease in France (1987-1988) . Eur J Epidemiol . 1992;;8:737-742.
17 +
Counts GW, Gregory DF, Spearman JG, et al.  Group A meningococcal disease in the U.S. Pacific Northwest: epidemiology, clinical features, and effect of a vaccination control program . Rev Infect Dis . 1984;;6:640-8.
18 +
Wang J-F, Caugant DA, Morelli G, Koumare B, Achtman M.  Antigenic and epidemiologic properties of the ET-37 complex of Neisseria meningitidis . J Infect Dis . 1993;;167:1320-1329.
19 +
Schwartz B, Moore PS, Broome CV.  Global epidemiology of meningococcal disease . Clin Microbiol Rev . 1989;;2:S118-S124.
20 +
Hoge CW, Fisher L, Connell D, et al.  Risk factors for transmission of Mycobacterium tuberculosis in a primary school outbreak: lack of racial difference in susceptibility to infection . Am J Epidemiol . 1994;;139:520-530.
21 +
Cheek JE, Baron R, Atlas H, Wilson DL, Crider RD Jr.  Mumps outbreak in a highly vaccinated school population: evidence for large-scale vaccination failure . Arch Pediatr Adolesc Med . 1995;;149:774-778.
22 +
Alexander JP, Chapman LE, Pallansch MA, Stephenson WT, Torok TJ, Anderson LJ.  Coxsackievirus B2 infection and aseptic meningitis: a focal outbreak among members of a high school football team . J Infect Dis . 1993;;167:1201-1205.
23 +
Moore PS, Hierholzer J, De Witt W, et al.  Respiratory viruses and mycoplasma as cofactors for epidemic group A meningococcal meningitis . JAMA . 1990;;264:1271-1275.
24 +
Centers for Disease Control.  Recommendation of the Immunization Practices Advisory Committee (ACIP): meningococcal vaccines . MMWR Morb Mortal Wkly Rep . 1985;;34:255-259.
25 +
Gaunt PN, Lambert BE.  Single dose ciprofloxacin for the eradication of pharyngeal carriage of Neisseria meningitidis . J Antimicrob Chemother . 1988;;21:489-496.
26 +
Schwartz B, Al-Tobaiqi A, Al-Ruwais A, et al.  Comparative efficacy of ceftriaxone and rifampicin in eradicating pharyngeal carriage of group A Neisseria meningitidis . Lancet . 1988;;2:1239-1242.

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