MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH GUIDE TO SURVEILLANCE, REPORTING, AND CONTROL
Invasive Meningococcal Disease

Section 1 
ABOUT THE DISEASE

A. Etiologic Agent

Invasive meningococcal infections are caused by the encapsulated bacterium Neisseria meningitidis (the meningococcus), a gram-negative diplococcus with at least 13 serogroups based on capsular type.  Strains belonging to groups A, B, C, Y, and W are implicated most commonly in invasive disease worldwide. Other serogroups such as X and Z are also known to cause invasive disease in humans. 

B. Clinical Description

Invasive infection with N. meningitidis usually results in meningitis, bacteremia, or both. Symptoms of meningitis (infection of the meninges: the membrane covering the central nervous system) typically include the sudden onset of stiff neck, high fever, headache, nausea, vomiting, sensitivity to light and/or mental confusion.  A rash may be present. Meningococcemia (infection of the blood) typically presents with the abrupt onset of fever, chills, malaise, prostration, and rash (urticarial [hives], maculopapular [spots and bumps], purpuric [bruises], or petechial [“flea bites”]). Fulminant disease presents with purpura (bleeding into the skin), abnormal blood clotting, shock, and/or coma, and may lead to loss of fingers, toes, or limbs and to death within hours despite appropriate therapy. The case-fatality rate for meningococcal meningitis and meningococcemia is about 10–15%, even with appropriate antibiotic treatment. Persons with immune compromise due to terminal complement component deficiency (including treatment with the drug eculizumab which interferes with late complement components to treat certain disorders) are prone to recurrent disease, and persons without a functioning spleen are more susceptible to bacteremic illness.

C. Vectors and Reservoirs

Humans are the only known reservoir of N. meningitidis.

D. Modes of Transmission

The principal mode of transmission of N. meningitidis is person-to-person spread through direct contact with oral or nasal secretions. This can occur through such activities as kissing, sharing water bottles, sharing eating/drinking utensils, or sharing cigarettes (including e-cigarettes or marijuana cigarettes) with someone who is infected; or being within 3-6 feet of someone who is infected and is coughing or sneezing.  
 
E. Incubation Period

The incubation period is 1–10 days but is usually < 4 days.

F. Period of Communicability or Infectious Period

Cases remain infectious as long as meningococci are present in their oral secretions. Meningococci usually disappear from the nasopharynx within 24 hours after initiation of effective antibiotic treatment. 

G. Epidemiology

Meningococcal disease is found worldwide, with the highest incidence of disease found in the ‘meningitis belt’ of sub-Saharan Africa. In this region, major epidemics occur every 5 to 12 years with attack rates reaching 1,000 cases per 100,000 population. Seasonal variations occur in these epidemics, with peaks of illness usually occurring in the dry, hot season. The prevalent serotypes of N. meningitidis vary over time and by geography. Other regions of the world experience lower overall rates of disease and occasional outbreaks, with annual attack rates of around 0.3 to 3 per 100,000.

Meningococcal disease is becoming much less common in the US.  Over the past 20 years, the overall incidence of meningococcal disease in the US has declined 10-fold.  Twenty years ago, in Massachusetts, there were 80-100 cases of meningococcal disease per year.  In contrast, for the past decade the average is approximately 12 cases per year.  Declining rates of meningococcal disease may be due in part to the administration of meningococcal vaccines prior to college entry and the introduction of meningococcal conjugate vaccines (for serogroups A, C, Y, and W135) in 2005 (recommended routinely for adolescents aged 11-12 years and unvaccinated college freshmen living in residence halls) as well as other factors such as the decline in cigarette smoking, which may impact susceptibility to this disease.

Meningococcal Carriage

N. meningitidis typically colonizes the nose and the throat of 5–15% of the general population at any given time. These carriers are generally asymptomatic, and carriage of the bacteria may act as an immunizing exposure, protecting the carrier from future infections by that particular strain. Carriers act as vectors, spreading the bacteria to others through saliva and respiratory secretions. As contacts of cases with invasive disease are at most risk (the attack rate for household contacts of cases with invasive disease is 500-800 times the rate for the general population), the contacts of cases and not contacts of carriers are prophylaxed. 

H. Bioterrorist Potential

This pathogen is not considered to be of risk for use in bioterrorism.

Section 2
REPORTING CRITERIA AND LABORATORY TESTING

A. What to Report to the Massachusetts Department of Public Health (MDPH)

Report any suspect case based on a health care provider’s impression (acute severe illness associated with signs of meningitis and/or purpuric rash) or a laboratory result from a normally sterile body site indicating N. meningitidis. This includes:

•	Gram-negative diplococci seen on a stained smear of cerebrospinal fluid (CSF) or other body fluid
•	Gram-negative diplococci isolated from a normally sterile body site (e.g., blood or CSF)
•	Detection of N. meningitidis antigen in CSF by latex agglutination
•	Detection of N. meningitidis-specific nucleic acid in a specimen obtained from a normally sterile body site (e.g., blood or CSF), using a validated polymerase chain reaction (PCR) assay
•	Isolation of N. meningitidis from a normally sterile body site (e.g., blood or CSF, or less commonly, synovial, pleural, or pericardial fluid) or from petechial or purpuric lesions

Isolates obtained from sputum, throat, or bronchoalveolar lavage cultures are not considered to come from sterile sites; therefore N. meningitidis from these sites is not, in itself, indicative of invasive disease. If a patient with culture-positive sputum has an illness compatible with invasive meningococcal disease, clinical evaluation and culture of appropriate sterile sites are needed. 

Note: See Section 3C for information on how to report a case.

B. Laboratory Testing Services Available

The Massachusetts State Public Health Laboratory (MA SPHL) will perform confirmatory testing and serogrouping on isolates of N. meningitidis. The MA SPHL requests submission of all N. meningitidis isolates from normally sterile sites for serogrouping and further testing. 

For more information about testing and specimen submission, contact the MA SPHL Microbiology Laboratory at (617) 983-6607.

Section 3
REPORTING RESPONSIBILITIES AND CASE INVESTIGATION

A. Purpose of Surveillance and Reporting

•	To rapidly identify close contacts of the case and to provide recommendations for appropriate preventive measures for close contacts so as to prevent further spread of infection and disease.
•	To provide information about the disease, its transmission, and methods of prevention.
•	To identify clusters or outbreaks of infection and to initiate appropriate prevention and control measures.

B. Laboratory and Health Care Provider Reporting Requirements

Meningococcal disease is reportable to the local board of health (LBOH). The MDPH requests that health care providers immediately report to the LBOH in the community where the case is diagnosed, all confirmed or suspected cases of meningococcal disease, as defined by the reporting criteria in Section 2A.

Laboratories performing examinations on any specimens derived from Massachusetts residents that yield evidence of N. meningitidis infection shall immediately report such evidence of infection by phone to the MDPH Division of Epidemiology and Immunization at (617) 983-6800, through secure electronic laboratory reporting (ELR) mechanisms, or other method, as defined by MDPH within 24 hours. 

C. Local Board of Health (LBOH) Reporting and Follow-Up Responsibilities

Reporting Requirements

MDPH regulations (105 CMR 300.000) stipulate that meningococcal disease is reportable to the LBOH and that each LBOH must report any case of meningococcal disease or suspect case of meningococcal disease, as defined by the reporting criteria in Section 2A. Any specimens that yield evidence of N. meningitidis infection from a sterile site should be reported directly through ELR, or other method, within 24 hours. Cases reported directly to MDPH via ELR will populate the MAVEN “Online LBOH Notification for Immediate Disease” workflow for acknowledgement by the appropriate LBOH. Cases not already in MAVEN should be reported to the Office of Integrated Surveillance and Informatics Services (ISIS) using MAVEN. Local boards of health without access to MAVEN or that do not use MAVEN regularly should report by phone and collect additional information using the MDPH Invasive Meningococcal Disease Case Report Form. Case Report Forms can be faxed to ISIS at (617) 983-6813. 
Case Investigation

A LBOH that learns of a suspected or laboratory confirmed case of invasive meningococcal disease should immediately call the MDPH Division of Epidemiology and Immunization at (617) 983-6800. Epidemiologists are available 24/7.

The most important thing in investigating a report of a case of meningococcal disease is to quickly collect information about the case to determine whether or not the patient actually has a high likelihood of having the infection, insofar as it is possible to make this determination.
Using MAVEN
Administrative Question Package 
Open the Administrative Question Package (QP) and under the “Local Health and Investigation” section, answer the first question “Step 1 - LBOH acknowledged” by selecting “Yes”.   The “LBOH acknowledged date” will then auto populate to the current day.  Completing this first step will move the event out of this workflow and into your “Online LBOH notified but Case Report Forms (CRF) are pending” workflow. Note the date you started your investigation by answering “Step 2 – Investigation started” as “Yes” and then note the date where shown.  Record your name, agency, and phone numbers where shown in “Step 3 - LBOH/Agency Investigator.”

Demographic Question Package
Accurately record the case’s demographic information, collecting as much information about the case as possible, including address, place of work, and occupation. If the patient is unemployed or a student or daycare worker, it can be noted under occupation. There is also a section on unique address conditions where it can be indicated if a patient is in college, homeless or perhaps incarcerated.  

Clinical Question Package
Record all relevant clinical information, with particular attention to the symptoms and symptom onset date. Symptom onset date will help determine who is a close contact and symptoms experienced by the case, such as coughing or sneezing, may help to identify who may have been exposed. 

Vaccine Question Package
Determine and enter in the question package if the case has ever been vaccinated for meningococcal disease. If yes, indicate which vaccination was received and for what reason.  

Risk/Exposure/Control& Prevention Question Package
Record all information requested in this question package including travel history, sexual preference, and attendance in supervised care settings such as assisted living, correctional facilities, drug treatment facilities, daycare centers, long term care facilities, shelters, etc. 

Completing your Investigation

1.	If you are finished with your case investigation and follow-up is complete, mark “Step 4 – Case Report Form Completed” as “Yes” and then choose Local Board of Health (LBOH) –Ready for MDPH review for the “Completed by” variable. 
2.	If you have made several attempts to obtain case information but have been unsuccessful (e.g., the case or health care provider does not return your calls or respond to a letter, or the case refuses to divulge information or is too ill to be interviewed), please complete “Step 4 - Case Report Form Completed” as “No” and then choose a primary reason why the case investigation was not completed from the choices provided in the primary reason answer variable list. 
3.	If you are not on MAVEN, you may submit a paper IMD Case Report Form.  After completing the form, attach laboratory report(s) and fax or mail (in an envelope marked “Confidential”) to ISIS. The confidential fax number is (617) 983-6813. Call ISIS at (617) 983-6801 to confirm receipt of your fax.

The mailing address is:
MDPH, Office of Integrated Surveillance and Informatics Services (ISIS)
305 South Street, 5th Floor
Jamaica Plain, MA 02130
Fax: (617) 983-6813

4.	Institution of disease control measures is an integral part of case investigation. It is the responsibility of the LBOH to understand, and if necessary, institute the control guidelines listed in Section 4.

Section 4
CONTROLLING FURTHER SPREAD

A. Isolation and Quarantine Requirements (150 CMR 300.200)

Minimum Period of Isolation of Patient

Cases of meningococcal disease should be on droplet precautions until 24 hours after the initiation of appropriate antibiotic therapy. 

Minimum Period of Quarantine of Contacts

Contacts of cases of meningococcal disease need to exercise personal surveillance and be given antibiotic prophylaxis, when appropriate. 

B. Protection of Contacts of a Case

Prophylaxis

If the decision has been made to prophylax close contacts with antibiotics, the contacts need to be identified and referred to a health care provider for appropriate antibiotic therapy.  A close contact is defined as anyone who may have had contact with the case’s saliva and/or oral/nasal secretions within the seven day period prior to the case’s onset of illness. Consider the following:

Adults: Consider the place of employment, car pools, sports teams, parties, friends/relatives, visitors, etc. If the case is a foodhandler, consider recommending prophylaxis to co-workers. Food sharing is common in restaurant kitchens.

Children:  Consider school, daycare, after-school programs, sports teams, baby sitters, friends/relatives, visitors, parties, etc.

Health care workers who have contact with the case’s oral/nasal secretions (through unprotected mouth-to-mouth resuscitation, intubation, or suctioning) are also considered close contacts.

Airline passengers: The control measures for passengers on an airplane who are exposed to a case of meningococcal disease are determined by the symptoms of the case.
	
•	For travelers with meningococcal disease who were NOT coughing or vomiting, the contact zone is one seat on either side of the ill traveler (not crossing the aisle) and only for travel times that are greater than eight hours, “gate-to-gate”.
•	For travelers with meningococcal disease who WERE coughing or vomiting during a flight of any duration, the contact zone is expanded to one seat in any direction from the ill traveler without crossing the aisle. This is based on the assumption that droplets from coughing travel farther and that the vomiting occurred in the seat. Since the contact zone is determined based on the location of the traveler when the vomiting occurred, if the traveler vomited in the aisle, then the contact zone may cross the aisle.

C. Managing Special Situations

Daycare

A case of meningococcal illness in a daycare setting often causes anxiety in parents and in the community. Although the risk of transmission in this setting is relatively low, chemoprophylaxis for all the children in the daycare class or the daycare facility may be recommended because the interactions between young children are often very close. Daycare attendees identified as close contacts should receive prophylaxis before returning to daycare. Surveillance for additional cases of disease should also be heightened. Contact the MDPH Division of Epidemiology and Immunization to report a suspected or laboratory-confirmed case in a daycare (or any other setting). An epidemiologist will work with the LBOH to ensure all contacts are identified and notified and can provide sample letters to be used for this notification.  Surveillance for new cases of disease should continue at the facility for at least two weeks after the onset of the first case. If multiple cases occur, surveillance should continue for two weeks after the onset of the last case.

School

A case of meningococcal illness in a school often causes anxiety in parents and in the community.  Although the risk of transmission in a school is relatively low, the age of the case will determine the extent of chemoprophylaxis necessary. Because the interactions between young children are often very close, chemoprophylaxis for all the children in the case’s class may be recommended if the child is in early elementary school. A high school or college student, on the other hand, usually has a more defined group of close contacts, and chemoprophylaxis may be more targeted. Surveillance for additional cases of disease should also be heightened. In addition, contact the MDPH Division of Epidemiology and Immunization to report a suspected or laboratory-confirmed case in a school (or any other setting). An epidemiologist will work with the LBOH to ensure all contacts are identified and notified and can provide sample letters to be used for this notification. Surveillance for new cases of disease should continue at the school for at least two weeks after the onset of the first case. If multiple cases occur, surveillance should continue for two weeks after the onset of the last case.

Community Residential Program

When a case of meningococcal disease occurs in a congregate residential program, activity in the facility should be assessed to determine the level of interaction between residents. The facility may be considered a household setting and may require chemoprophylaxis of all residents, or the chemoprophylaxis may be more targeted. Contact the MDPH Division of Epidemiology and Immunization for assistance in following up on a case of invasive meningococcal disease in residential programs. In addition, surveillance for new cases of disease in the facility should continue for at least two weeks after the onset of the first case. If multiple cases occur, surveillance should continue for two weeks after the onset of the last case.

Reported Incidence is Higher than Usual/Outbreak Suspected

If the number of reported cases in your city/town is higher than usual for the time of year or if you suspect an outbreak, please contact the MDPH Division of Epidemiology and Immunization immediately, at (617) 983-6800. This situation may warrant an investigation of clustered cases to determine a course of action to prevent further cases. The MDPH can perform surveillance for clusters of illness across town lines, which would otherwise be difficult to identify at the local level.

D. Preventive Measures

Personal Preventive Measures/Education

To prevent additional cases:

•	Refer close contacts to health care providers ASAP for appropriate chemoprophylaxis. Chemoprophylaxis two weeks following exposure is not useful and usually not recommended.

•	Advise contacts of signs and symptoms of illness and refer them to their health care providers should they experience any symptoms compatible with meningococcal disease.

•	Provide close contacts with a Meningococcal Disease Public Health Fact Sheet, which is available from the MDPH Division of Epidemiology and Immunization or on the MDPH website at https://www.mass.gov/fact-sheets-on-infectious-diseases  

To avoid future exposures, advise individuals to:

•	Practice good hand hygiene and hand washing.

•	Avoid sharing food, beverages, eating utensils, “smokes”, or personal items like chapstick and lip gloss.

•	Consider immunization in certain circumstances (see below).

Immunization

There are 2 different meningococcal vaccines:  

Quadrivalent meningococcal conjugate vaccine (Menactra®  and Menveo®) protects against 4 serotypes (subgroups), A, C, W, and Y, of meningococcal disease. It is recommended for all children 11-12 years of age and for some younger children with certain health conditions like asplenia (including sickle cell disease), or prior to travel to certain parts of the world where meningococcal disease is common. A second dose of meningococcal conjugate vaccine is routinely recommended at 16 years of age. 

Adolescents and young adults who have not been vaccinated according to routine recommendations should talk to their healthcare provider about vaccination according to the “catch up” schedule. It is recommended that college freshmen, military recruits and other newly enrolled college students living in dormitories who are not yet vaccinated receive meningococcal conjugate vaccine. 

Meningococcal serogroup B vaccine (Bexsero®  and Trumenba®) protects against serogroup B meningococcal disease. It is recommended for people with certain relatively rare high-risk health conditions age 10 or older (examples: persons with a damaged spleen or whose spleen has been removed, those with persistent complement component deficiency (an inherited disorder), microbiologists working with N. meningitidis, and people who may have been exposed during an outbreak). 

Adolescents and young adults (16 through 23 years of age) who do not have high risk health conditions may also be vaccinated with a serogroup B meningococcal vaccine, preferably at 16 through 18 years of age, to provide short term protection for most strains of serogroup B meningococci.  

Section 5
ADDITIONAL INFORMATION

The formal CDC surveillance case definition for meningococcal disease is the same as the criteria outlined in Section 2A of this chapter. (The CDC and the MDPH use the CDC case definitions to maintain uniform standards for national reporting.) For reporting to the MDPH, always use the criteria outlined in Section 2A.

Note: The most up-to-date CDC case definitions are available on the CDC website at https://wwwn.cdc.gov/nndss/conditions/meningococcal-disease/  

REFERENCES

American Academy of Pediatrics. [Meningococcal Infections.] In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018-2021 Report of the Committee on Infectious Diseases, 31st Edition. Itasca, IL American Academy of Pediatrics; 2018: 550-561.

CDC.  Case Definitions for Infectious Conditions under Public Health Surveillance. https://wwwn.cdc.gov/nndss/conditions/meningococcal-disease/case-definition/2015/

CDC. Prevention and Control of Meningococcal Disease MMWR. Recommendations and Reports. March 22, 2013; Vol 62/No. 2

Heymann, D., ed. Control of Communicable Diseases Manual, 20th Edition. Washington, DC, American Public Health Association, 2015.

MDPH. The Comprehensive School Health Manual. MDPH, 1995.

MDPH. Regulation 105 CMR 300.000: Reportable Diseases, Surveillance, and Isolation and Quarantine Requirements. MDPH, Promulgated January 27, 2017.