Stephanie Ngai

Elevated Risk for Invasive Meningococcal Disease Among Persons With HIV

Context Invasive meningococcal disease (IMD) is life-threatening. Current recommendations for receipt of meningococcal vaccine to prevent IMD do not include HIV-infected adults. Contribution HIV infection and IMD are reportable diseases in New York City. Investigators linked databases and found that, compared with the general population, people living with HIV/AIDS (PLWHA) had a relative risk for IMD of 10. Risk was greatest in persons with CD4+ counts less than 0.200109 cells/L. Serotypes in nearly 90% of IMD cases in adult PLWHA are included in current meningococcal vaccines. Implication Studies of vaccine effectiveness are needed in adult PLWHA, who may be appropriate candidates for routine immunization with meningococcal vaccine. The Editors Infection with HIV is associated with an increased risk for several bacterial infections, most notably Mycobacterium tuberculosis, Streptococcus pneumonia, nontyphoid Salmonella, Haemophilus influenzae, and Staphylococcus aureus(1, 2). Data on the relationship between HIV and Neisseria meningitidis are limited. An analysis of surveillance data from 1988 to 1993 from the 8-county metropolitan area of Atlanta, Georgia, found that HIV-infected adults aged 25 to 49 years had a nearly 24-fold increased risk for invasive meningococcal disease (IMD) (3). More recently, Cohen and colleagues reported that the incidence of IMD in HIV-infected individuals of all ages in South Africa was 11 times greater than that among HIV-uninfected individuals (4). Moreover, the Centers for Disease Control and Prevention (CDC) recently published data from its Active Bacterial Core surveillance sites indicating that the cumulative annual incidence of IMD in individuals who meet the case definition for AIDS is approximately 13 times greater than in those who do not (5). In 2005, a new tetravalent meningococcal polysaccharideprotein conjugate vaccine (MCV4) was approved and recommended for routine use in young adolescents (aged 11 to 12 years) on the basis of an increased risk for IMD in college students living in dormitories and a cost-effectiveness analysis (6). Current MCV4 recommendations, however, do not include people living with HIV/AIDS (PLWHA), other than HIV-infected adolescents (5). The absence of meningococcal vaccine recommendations in HIV-infected adults is due, in part, to insufficient data on vaccine efficacy in HIV-infected adults, the duration of immunity, and the concern over the cost-effectiveness of such recommendations. To explore the relationship between HIV and IMD in New York City (NYC), we matched population-based IMD surveillance data with HIV and vital statistics registries to calculate rates of IMD and IMD-related death from 2000 to 2011 among PLWHA and persons not known to be HIV-infected. We also analyzed the serogroup distribution among IMD cases and evaluated the effect of immune status and viral load (VL) on risk for IMD among PLWHA.An outbreak of serogroup C IMD was recognized in NYC among men who have sex with men (MSM) in the fall of 2012 after the data analysis for this article was completed (7). A total of 17 cases and 6 deaths were identified in 2012 and 2013, with 10 of the cases having occurred in PLWHA. These 17 cases were not included in the analysis. Methods Study Population Both IMD and HIV are reportable diseases in NYC. We included IMD cases in NYC that were diagnosed during 2000 to 2011, met the Council of State and Territorial Epidemiologists case definitions for confirmed or probable meningococcal disease (8), and were reported to the NYC Department of Health and Mental Hygiene (DOHMH). The IMD diagnosis date was defined as the date of the clinical specimen or findings that met the case definition. Cases of IMD from 2000 to 2011 were matched to the DOHMHs Office of Vital Statistics death registry to determine vital status and underlying cause of death. Death due to IMD was defined as death occurring within 30 days of diagnosis with a final cause consistent with meningococcal disease. When IMD was not specifically listed as the cause of death, the record was reviewed by 2 independent medical reviewers who both needed to concur that the death was due to IMD. The state of New York mandated confidential, name-based reporting of HIV-related events in 1998, with implementation in June 2000. The law requires reporting of all diagnoses of HIV and AIDS, all HIV-related illness, all positive Western blot test results for HIV antibody, all VL and CD4+ cell count values, and all HIV genotypes (914). The NYC HIV Surveillance Registry (HSR) is a population-based registry of all AIDS cases diagnosed in NYC since 1981 and all HIV cases diagnosed since 2000. The HSR is regularly matched to local and national vital statistics death registries to update vital status for PLWHA and is continuously updated with HIV-related laboratory reports. Since 2005, all CD4+ cell count and HIV VL results have been electronically reported to the HSR. Incoming laboratory reports from providers and laboratories that cannot be matched to an existing person in the registry initiate a field investigation to confirm through medical record review that the case meets surveillance definitions for HIV, AIDS, or both (15) and to record data elements to be used to establish a date of diagnosis and collect other data required for surveillance. We matched case patients with IMD to the HSR by using a deterministic automated algorithm comprising 36 keys based on combinations of first name; last name; date of birth; Social Security number; and the soundex function in SAS, version 9.2 (SAS Institute, Cary, North Carolina), which adjusts for names spelled phonetically. The algorithm was ordered hierarchically such that lower keys were considered to represent matches more likely to be true. Exact matches on keys 1 to 7 were accepted as true matches without further review. Matches on keys 8 to 36 prompted a manual review by 2 independent reviewers with access to additional information about potentially matching pairs of case patients, such as residential address (16). To account for the W-shaped age distribution of IMD (17) and control for the confounding effect of age on the relative risk (RR) for IMD in PLWHA, we excluded case patients younger than 15 years and older than 64 years from the study population. The primary IMD syndrome was determined by clinical and laboratory findings per the following hierarchy if multiple syndromes existed: meningococcemia > meningitis > bacteremia > other (for example, joint or pneumonia). The IMD serogroup was determined by slide agglutination at the NYC Public Health Laboratory or by polymerase chain reaction at the Wadsworth Center State Public Health Laboratory. Statistical Analysis The number of PLWHA was estimated as the product of age-specific HIV prevalence rates (calculated from HSR data as persons diagnosed with HIV in NYC and reported to DOHMH by 30 September 2012) and intercensal population estimates for persons aged 15 to 64 years and was then averaged for 2000 to 2011. Populations for 3-year intervals were similarly estimated. The population of HIV-uninfected persons aged 15 to 64 years was calculated as the difference between the average total NYC populations and the interval-specific PLWHA population estimates. Descriptive statistics and the chi-square test were used to compare case patients with IMD on categorical variables by HIV status and also to test for trend in the proportion of patients with IMD who were HIV-infected over time. Means and SDs were used to compare continuous variables by HIV status. The average annual incidence rate of IMD per 100000 persons was computed for the 12-year period (20002011) and by 3-year intervals (20002002, 20032005, 20062008, and 20092011) among both PLWHA and HIV-uninfected persons. The RRs for IMD among PLWHA and 95% CIs were calculated for the 12- and 3-year intervals. The RR for IMD was also stratified by 3 age categories (15 to 24, 25 to 44, and 45 to 64 years) and by sex over the entire interval. Cigarette smoking frequently appears in the literature as a risk factor for IMD (1821). Questions on smoking were added to IMD case investigations in 2006, and data were available for three quarters of IMD cases during this period (cases with missing data were excluded). We used population-based estimates of smoking prevalence from the NYC Community Health Survey for 2006 and 2007 (39.6% among respondents self-reporting HIV infection and 18.8% among those self-reporting no HIV/AIDS) (22) to estimate the smoking prevalence among individuals without IMD in order to stratify the RR for IMD in PLWHA by smoking status. A sensitivity analysis of HIV ascertainment was also conducted using data from a serosurvey of undiagnosed HIV infection. The RR was recalculated by adding 14% to the PLWHA population with no additional cases of IMD (23). To compare the IMD case-fatality ratio (CFR) among patients with IMD and HIV and those with IMD only, we divided the CFR among the former for 2000 to 2011 by the CFR among the latter. A multivariate logistic regression model was used to obtain an age-adjusted odds ratio (OR) of death in case patients with IMD and HIV. The proportion of IMD cases potentially preventable by MCV4 vaccination (serogroups A, C, Y, and W) was compared by HIV status. To explore whether immune suppression and lack of HIV viral suppression were associated with higher IMD risk in PLWHA, we performed separate casecontrol analyses of the odds of IMD by CD4+ cell count and HIV VL among a subset of case patients with IMD and HIV. People living with HIV/AIDS with CD4+ cell counts and VL from the HSR in 2005 or later and test dates within 91 days of the IMD diagnosis date were eligible for selection (before 2005, only low CD4+ cell counts and detectable VL were reportable). All persons without IMD in the HSR who had CD4+ cell counts and VL were eligible to serve as control patients. For the 2 analyses, case patients w

Meningococcal disease among men who have sex with men - United States, January 2012-June 2015.

Since 2012, three clusters of serogroup C meningococcal disease among men who have sex with men (MSM) have been reported in the United States. During 2012, 13 cases of meningococcal disease among MSM were reported by the New York City Department of Health and Mental Hygiene (1); over a 5-month period during 2012–2013, the Los Angeles County Department of Public Health reported four cases among MSM; and during May–June 2015, the Chicago Department of Public Health reported seven cases of meningococcal disease among MSM in the greater Chicago area. MSM have not previously been considered at increased risk for meningococcal disease. Determining outbreak thresholds* for special populations of unknown size (such as MSM) can be difficult. The New York City health department declared an outbreak based on an estimated increased risk for meningococcal infection in 2012 among MSM and human immunodeficiency virus (HIV)–infected MSM compared with city residents who were not MSM or for whom MSM status was unknown (1). The Chicago Department of Public Health also declared an outbreak based on an increase in case counts and thresholds calculated using population estimates of MSM and HIV-infected MSM. Local public health response included increasing awareness among MSM, conducting contact tracing and providing chemoprophylaxis to close contacts, and offering vaccination to the population at risk (1–3). To better understand the epidemiology and burden of meningococcal disease in MSM populations in the United States and to inform recommendations, CDC analyzed data from a retrospective review of reported cases from January 2012 through June 2015.

Advancing the Use of Emergency Department Syndromic Surveillance Data, New York City, 2012-2016:

Introduction: The use of syndromic surveillance has expanded from its initial purpose of bioterrorism detection. We present 6 use cases from New York City that demonstrate the value of syndromic surveillance for public health response and decision making across a broad range of health outcomes: synthetic cannabinoid drug use, heat-related illness, suspected meningococcal disease, medical needs after severe weather, asthma exacerbation after a building collapse, and Ebola-like illness in travelers returning from West Africa. Materials and Methods: The New York City syndromic surveillance system receives data on patient visits from all emergency departments (EDs) in the city. The data are used to assign syndrome categories based on the chief complaint and discharge diagnosis, and analytic methods are used to monitor geographic and temporal trends and detect clusters. Results: For all 6 use cases, syndromic surveillance using ED data provided actionable information. Syndromic surveillance helped detect a rise in synthetic cannabinoid-related ED visits, prompting a public health investigation and action. Surveillance of heat-related illness indicated increasing health effects of severe weather and led to more urgent public health messaging. Surveillance of meningitis-related ED visits helped identify unreported cases of culture-negative meningococcal disease. Syndromic surveillance also proved useful for assessing a surge of methadone-related ED visits after Superstorm Sandy, provided reassurance of no localized increases in asthma after a building collapse, and augmented traditional disease reporting during the West African Ebola outbreak. Practice Implications: Sharing syndromic surveillance use cases can foster new ideas and build capacity for public health preparedness and response.

Completeness of Neisseria meningitidis reporting in New York City, 1989–2010

SUMMARY Invasive meningococcal disease (IMD) completeness of reporting has never been assessed in New York City (NYC). We conducted a capture–recapture study to assess completeness of reporting, comparing IMD reports made to the NYC Department of Health and Mental Hygiene (DOHMH) and records identified in the New York State hospital discharge database [Statewide Planning and Research Cooperative System (SPARCS)] by ICD-9 codes from 1989 to 2010. Reporting completeness estimates were calculated for the entire study period, and stratified by year, age group, clinical syndrome, and reporting system. A chart review of hospital medical records from 2008 to 2010 was conducted to validate hospital coding and to adjust completeness estimates. Overall, 2194 unique patients were identified from DOHMH (n = 1300) and SPARCS (n = 1525); 631 (29%) were present in both. Completeness of IMD reporting was 41% [95% confidence interval (CI) 40–43]. Differences in completeness were found by age, clinical syndrome, and reporting system. The chart review found 33% of hospital records from 2008 to 2010 had no documentation of IMD. Removal of those records improved completeness of reporting to 51% (95% CI 49–53). Our data showed a low concordance between what is reported to DOHMH and what is coded by hospitals as IMD. Additional guidance to clinicians on IMD reporting criteria may improve completeness of IMD reporting.

Outbreak of Influenza A(H7N2) Among Cats in an Animal Shelter With Cat-to-Human Transmission—New York City, 2016

We describe the first case of cat-to-human transmission of influenza A(H7N2), an avian-lineage influenza A virus, that occurred during an outbreak among cats in New York City animal shelters. We describe the public health response and investigation.

Sex Difference in Meningococcal Disease Mortality, New York City, 2008–2016

Background The case fatality rate (CFR) from invasive meningococcal disease (IMD) in New York City (NYC) is greater than national figures, with higher rates among females than males across all age groups. Methods We conducted a retrospective cohort study among 151 persons aged ≥15 years diagnosed with IMD in NYC during 2008-2016 identified through communicable disease surveillance. We examined demographic, clinical, and community-level associations with death to confirm the elevated risk of mortality among female IMD patients after adjusting for confounders and to determine factors associated with female IMD mortality. Relative risks of death were estimated using multivariable log-linear Poisson regression with a robust error variance. Results Females had a higher CFR (n = 23/62; 37%) following IMD than males (n = 17/89; 19%) (adjusted relative risk [aRR], 2.1; 95% confidence interval [CI], 1.2-3.8). Controlling for demographic and clinical factors, there was a significant interaction between sex and fatal outcomes related to meningitis: the relative risk of death for females with meningitis was 13.7 (95% CI, 3.2-58.1) compared with males. In the model restricted to females, altered mental status (aRR, 7.5; 95% CI, 2.9-19.6) was significantly associated with an increased risk of death. Conclusions Female mortality from IMD was significantly increased compared with males, controlling for other predictors of mortality. Sex-based differences in recognition and treatment need to be evaluated in cases of meningococcal disease. Our study highlights the importance of analyzing routine surveillance data to identify and address disparities in disease incidence and outcomes.

LB1.6 Neisseria meningitidis carriage among men who have sex with men – new york city, 2016–2017

Introduction There have been recent U.S. outbreaks of N. meningitidis (Nm) serogroup C among men who have sex with men (MSM). From 1/2012-6/2015, 1/3 of U.S. cases in MSM were from New York City (NYC); 65% were HIV+. Little is known about Nm carriage among MSM and potential sexual transmission of Nm. Methods We conducted a carriage study among a sample of MSM and transgender female patients at 2 NYC sexual health clinics (6/2016-2/2017). Clinicians collected oropharyngeal (OP), rectal, and urethral specimens for Nm culture and STD testing. We matched test results with patient self-administered questionnaire data on antibiotic use, meningococcal vaccine history, and sexual risk behaviours (past 30 days), and data extracted from clinic medical records and the NYC STD registry (past 3 months). We calculated carriage prevalence by serogroup (slide agglutination) and anatomic site; examined Nm-gonorrhoea (GC) co-infection; and assessed associations between patient characteristics and carriage at any site using logistic regression. Results Of 636 study patients, 146 (23%; 95% CI 20%–26%) were Nm carriers. Serogroup distribution of OP carriage (22.4%; 142/633) was: 59% non-groupable, 37% B, 1.4% C, 0.7% W, 1.4% Y. Of OP Nm carriers, 20 (14%) were OP GC-positive. Urethral (0.5%; 3/626) and anal (1%; 6/626) carriage prevalence were low. Any-site carriage was associated with: kissing (OR 3.2; 95% CI 1.1–9.3), performing oral sex (OR 2.0; 95% CI 1.1–3.6), attending bars/clubs (OR 1.6; 95% CI 1.1–2.6), and antibiotic use (OR 0.2; 95% CI 0.1–0.5); and not associated with HIV status, STD history, or vaccine status. In multivariable analyses, only antibiotic use was associated with carriage. Conclusion Nm carriage in our large patient sample did not match Nm outbreak patterns (e.g., paucity of serogroup C, no link with HIV). The OP carriage rate was similar to that in prior studies, but with higher serogroup B. Low prevalence of urethral and rectal Nm carriage and lack of association with STD risk factors suggests that sexual transmission of Nm might be uncommon in this population.