Increase in Meningococcal Disease: Ongoing Statewide Outbreak and Local Detections of a Separate Antibiotic Resistant Strain
April 11, 2024
Dear Colleague:
The Virginia Department of Health (VDH) is reporting an increase in meningococcal disease activity. VDH continues to respond to the ongoing statewide outbreak caused by Neisseria meningitidis serogroup Y. Additionally, cases from a separate strain of ciprofloxacin and penicillin-resistant N. meningitidis serogroup Y continue to be detected in northern Virginia, impacting local post-exposure prophylaxis recommendations in this region. Healthcare providers should remain vigilant for additional cases.
Please consider the following actions:
- Maintain a heightened index of suspicion for meningococcal disease. Be aware that patients with invasive meningococcal disease may present with bloodstream infection or septic arthritis and without symptoms typical of meningitis (e.g., headache, stiff neck).
- Immediately notify your local health department (LHD) if meningococcal disease is suspected based on clinical findings or laboratory results of gram-negative diplococci or N. meningitidis from a normally sterile site. Please coordinate with your LHD to send specimens/isolates for newly identified cases to Virginia’s state public health laboratory, the Department of General Services Division of Consolidated Laboratory Services (DCLS), for serotyping.
- Because of the risks of severe morbidity and death, effective antibiotics should be administered promptly to patients suspected of having meningococcal disease. Empirical therapy for suspected meningococcal disease should include an extended-spectrum cephalosporin, such as cefotaxime or ceftriaxone. Ascertain susceptibility of N. meningitidis isolates to penicillin before using penicillin or ampicillin for treatment.
- Health care providers in northern Virginia should suspend use of ciprofloxacin as post-exposure prophylaxis (PEP) to prevent PEP failure in contacts. Alternative PEP options for northern Virginia include rifampin, ceftriaxone, or azithromycin.
- Ensure that all patients who are at increased risk for meningococcal disease are up to date on MenACWY vaccine. People at increased risk due to certain medical conditions include: people with HIV, those whose spleen is damaged or removed, people with sickle cell disease, anyone with a rare immune condition called complement deficiency, or people taking complement inhibitors. A MenACWY booster is recommended every five years for people with increased risk due to medical conditions.
- Continue to encourage routine administration of MenACWY vaccine in adolescents. As a reminder, a dose of MenACWY vaccine is required for students prior to 7th and 12th grade.
Situation Updates:
From June 2022 to March 2024, 36 outbreak-associated cases of N. meningitidis serogroup Y, including seven deaths, have been reported in Virginia. All isolates available for sequencing (34/36) were found to be the same strain and highly genetically related (specifically, sequence type 1466 within clonal complex 174). This strain is susceptible to ciprofloxacin and penicillin and is known to be contributing to a nationwide increase in meningococcal disease. Populations disproportionately affected by this outbreak include Black or African American adults 30-60 years of age and adults with HIV. The majority of case-patients (67%; 24/36) developed septicemia, with common symptoms including fever, nausea, vomiting, diarrhea, muscle aches, and altered mental status. Ninety-seven percent (35/36) of case-patients were unvaccinated for serogroup Y.
Additionally, cases of meningococcal disease caused by ciprofloxacin and penicillin-resistant N. meningitidis serogroup Y continue to be detected sporadically in northern Virginia. As such, VDH is advising local health departments and providers in northern Virginia to suspend the use of ciprofloxacin as PEP to prevent prophylaxis failure in known contacts. VDH will continue to monitor antibiotic resistance patterns of N. meningitidis isolates in Virginia through surveillance and healthcare provider reporting of prophylaxis failures; this information will be used to guide future updates to PEP recommendations for meningococcal disease.
VDH remains dedicated to increasing access to meningococcal conjugate vaccine (MenACWY), which provides protection against serogroup Y, and asks for your help in doing so. Contact your local health department if you have questions about accessing MenACWY vaccine for eligible patients.
Thank you for your attention and cooperation.
Sincerely,
Karen Shelton, MD
State Health Commissioner