Few infectious diseases are as frightening as meningococcus. It’s every parent’s nightmare: a healthy teenager with a few standard complaints—a little fever, maybe some headache—goes to sleep for the night and the next morning cannot be awoken. Next comes the ambulance, the ICU and the unimaginable. Meningococcus—so-called because of its propensity to involve the meninges, that thin lining surrounding the brain—preferentially attacks teens and young adults. For example, in 2009, a senior at Stuyvesant High School in New York died of the disease, but she was just one the 30–50 cases seen in NYC that and every year.
So when the New York City Department of Health and Mental Hygiene yesterday sent around an alert about recent meningococcus cases in HIV-positive homosexual men, it caused a real gasp among practitioners everywhere—this one is scary. When you see a newspaper photo of people in a town lined up for shots and pills to prevent spread of the case of meningitis, it’s meningococcus causing the problem. Its name, which is already alarming enough, actually understates its potential devastation. The meningococcus bacteria can cause two different diseases—when it’s “just” meningitis, the death rate is about 10 percent, but the more lethal sepsis form (called meningococcemia) kills about half by overwhelming the body’s blood vessels while sparing the brain’s lining. We don’t know yet which manifestation is being seen among gay men in NYC—perhaps cases of both—but the high death rate suggests the more dangerous meningococcemia.
According to the DOH report, in the last two years, 12 cases have occurred among gay men in their early thirties, including eight who were HIV-infected. More alarmingly, four of these cases have been diagnosed in the last month—each with a similar strain of the bacteria. To date, four of the 12 have died. According to the DOH, the estimated rate of severe meningococcal disease in gay men is about 20 times that of the rest of the population—a fact that has set in motion a large effort to halt the outbreak as quickly as possible.
Fortunately for meningococcus, we surely have the tools to prevent the next case. A vaccine is available to prevent almost all the cases seen in the U.S. It’s comprised of bits from four of the five strains that cause most human disease. In the usually drab world of hard-boiled science, these strains are organized by an eccentric lettering system: A, B, C, Y, and W135 (don’t ask). The current shot works against all but the B strain, which remains difficult to develop for reasons that only a vaccinologist could describe.
Indeed the vaccine is so good, and the risk to kids so distinct that, for the last decade, a two-shot series has been recommended for children at age 11 or 12 with a booster at 16. These in turn have gradually replaced the shot given to the young adult right before he or she heads off to college, where the peculiar hygienic habits and close habitation of the matriculators clearly amplifies risk.
Plus despite its brutish profile, meningococcus actually is among the most drug-susceptible infections out there—penicillin still works. Catch it early enough and it’s a kitten; wait too long and the results are tragic. A single dose of certain antibiotics in an exposed person prevents any chance of developing the disease. The difficulty is that we understand so little about how the bacteria is transmitted. According to the CDC, risks include kissing and “other intimate activities” as well risks for medical personnel working close to the patient. But even in a home where a case occurs, less than one in 25 households have a second case and almost none have a third.
These issues are particularly important right now, near next month’s hajj, the pilgrimage to Mecca that all observant Muslims make at least once in their lifetime; it is one of the five pillars of the religion. By an unfortunate confluence, a region of sub-Saharan Africa with extremely high rates of meningococcus—so high that it called the Meningococcus Belt also is home to many observant Muslims. In 2000 and 2001, large epidemics of meningococcal disease occurred among pilgrims, many of whom became ill after returning home—the perfect conditions for a global nightmare.
Since then, the Saudi government has been increasingly firm about requiring evidence of vaccination for all pilgrims making the expedition. In recent years, evidence of vaccination within the last three years has become a formal requirement. The reason is simple—the hajj is the largest meeting of people in the world, dwarfing even Woodstock, with millions making the journey each year. And the conditions for transmission of the bacteria are perfect— close, sustained proximity between pilgrims, some from the Mening Belt, others not, who are packed together around the granite Kaaba, the familiar large black cube that is at the center of Mecca—the direction toward which all Muslims face for their daily prayers.
With two extremely effective lines of control—vaccine and antibiotics—the current New York City outbreak is easy to stop, at least on paper. Yet getting people at risk to come forward is not so easy; many gay men remain in the closet. Standing in line at a public clinic designated for “gay men at high risk” surely will turn away far too many. And vaccinating the entire city is neither plausible nor sensible. Things are easier in the Kingdom of Saudi Arabia, where a decree is not subject to interpretation or parsing by a local clutch of pundits. In one of the odd twists that rule the world of public health, free choice sometimes gets in the way of disease control. Without rooting too hard or too long, once in a while one wishes for life in a (benign and gentle) autocracy where “no” is not an option. Though that too overnight can become someone’s worst nightmare.