Preparedness for and response to meningococcal outbreaks: preliminary results of a Canadian Immunization Research Network (CIRN) randomized controlled trial of two schedules of 4CMenB vaccine in adolescents and young adults.
https://www.meningitis.org/mrf-conference-2017
Current situation in the meningitis belt, impact of MenAfriVac, countries that have introduced or committed to introducing it into routine schedules, catch up campaigns, controlling outbreaks and the challenge of maintaining vaccine stockpiles, use of conjugate and polysaccharide vaccines
https://www.meningitis.org/mrf-conference-2017
Prospects for GBS prevention - current candidates & removing barriers to licensure of a GBS vaccine for pregnant women globally
https://www.meningitis.org/mrf-conference-2017
What next for prevention of pneumococcal disease in light of serotype replacement? Is there a pathway to licensure for novel pneumococcal vaccines?
https://www.meningitis.org/mrf-conference-2017
Preparedness for and response to meningococcal outbreaks: preliminary results of a Canadian Immunization Research Network (CIRN) randomized controlled trial of two schedules of 4CMenB vaccine in adolescents and young adults.
https://www.meningitis.org/mrf-conference-2017
Current situation in the meningitis belt, impact of MenAfriVac, countries that have introduced or committed to introducing it into routine schedules, catch up campaigns, controlling outbreaks and the challenge of maintaining vaccine stockpiles, use of conjugate and polysaccharide vaccines
https://www.meningitis.org/mrf-conference-2017
Prospects for GBS prevention - current candidates & removing barriers to licensure of a GBS vaccine for pregnant women globally
https://www.meningitis.org/mrf-conference-2017
What next for prevention of pneumococcal disease in light of serotype replacement? Is there a pathway to licensure for novel pneumococcal vaccines?
https://www.meningitis.org/mrf-conference-2017
Single-dose oral ciprofloxacin prophylaxis as a meningococcal meningitis outbreak response: results of a cluster-randomized trial
https://www.meningitis.org/mrf-conference-2017
Novartis satellite breakfast session at the Meningitis Research Foundation 2013 conference, Meningitis & Septicaemia in Children & Adults presented by Emeritus Professor Richard Moxon, Dr Jamie Findlow and Dr Simon Nadel
Single-dose oral ciprofloxacin prophylaxis as a meningococcal meningitis outbreak response: results of a cluster-randomized trial
https://www.meningitis.org/mrf-conference-2017
Novartis satellite breakfast session at the Meningitis Research Foundation 2013 conference, Meningitis & Septicaemia in Children & Adults presented by Emeritus Professor Richard Moxon, Dr Jamie Findlow and Dr Simon Nadel
Human Papillomavirus Immunization completion rates increased by the use of th...inventionjournals
Human Papillomavirus is the most common sexually transmitted infection in the United States and world wide. Vaccination is a critical public health measure for lowering the risk of cervical genital and anal cancers. Overall vaccination rates in the United States are low. This study highlights the need to change practices in primary care clinics to increase Human Papillomavirus vaccination rates. The study compares vaccination rates before and after the introduction of the American Academy of Pediatrics Tool Kit and a staff training session.
RESEARCH ARTICLE Open AccessThe impact of repeated vaccina.docxrgladys1
RESEARCH ARTICLE Open Access
The impact of repeated vaccination on
influenza vaccine effectiveness: a
systematic review and meta-analysis
Lauren C. Ramsay1, Sarah A. Buchan2, Robert G. Stirling2,3, Benjamin J. Cowling4, Shuo Feng4,
Jeffrey C. Kwong1,2,5,6,7 and Bryna F. Warshawsky1,8*
Abstract
Background: Conflicting results regarding the impact of repeated vaccination on influenza vaccine effectiveness
(VE) may cause confusion regarding the benefits of receiving the current season’s vaccine.
Methods: We systematically searched MEDLINE, Embase, PubMed, and Cumulative Index to Nursing and Allied Health
Literature from database inception to August 17, 2016, for observational studies published in English that reported VE
against laboratory-confirmed influenza for four vaccination groups, namely current season only, prior season only, both
seasons, and neither season. We pooled differences in VE (ΔVE) between vaccination groups by influenza season and
type/subtype using a random effects model. The study protocol is registered with PROSPERO (registration number:
CRD42016037241).
Results: We identified 3435 unique articles, reviewed the full text of 634, and included 20 for meta-analysis. Compared to
prior season vaccination only, vaccination in both seasons was associated with greater protection against influenza H1N1
(ΔVE = 26%; 95% CI, 15% to 36%) and B (ΔVE = 24%; 95% CI, 7% to 42%), but not H3N2 (ΔVE = 10%; 95% CI, –6% to 25%).
Compared to no vaccination for either season, individuals who received the current season’s vaccine had greater
protection against H1N1 (ΔVE = 61%; 95% CI, 50% to 70%), H3N2 (ΔVE = 41%; 95% CI, 33% to 48%), and B (ΔVE = 62%;
95% CI, 54% to 68%). We observed no differences in VE between vaccination in both seasons and the current season only
for H1N1 (ΔVE = 4%; 95% CI, –7% to 15%), H3N2 (ΔVE = –12%; 95% CI, –27% to 4%), or B (ΔVE = –8%; 95% CI, –17% to 1%).
Conclusions: From the patient perspective, our results support current season vaccination regardless of prior season
vaccination. We found no overall evidence that prior season vaccination negatively impacts current season VE. It is
important that future VE studies include vaccination history over multiple seasons in order to evaluate repeated
vaccination in more detail.
Keywords: Influenza, Vaccine effectiveness, Repeated vaccination
Background
Seasonal influenza vaccination is the predominant strat-
egy for preventing influenza-related morbidity and mor-
tality. Annual vaccination is recommended because of
waning immunity and because influenza strains undergo
antigenic drift, necessitating reviewing and, in most sea-
sons, changing of the vaccine to better match the up-
coming season’s strains [1]. Because of the frequently
changing vaccine, influenza vaccine effectiveness (VE) is
assessed annually.
With increasing numbers of people being immunized
against influenza annually, the impact of repeated vac-
cination has gained significant interest. Of particul.
New Vaccines in the immediate pipeline - Slideset by Professor Susanna EspositoWAidid
Slideset by Professor Esposito on: Vaccines for adolescents/young adults/children; Maternal vaccines; Vaccines for the tropics.
It shows how several new vaccines will be available in the future with different targets and underlines the importance of better information and communication, that are keys to relevant use of vaccines.
Cancer Biomarkers Research, HPV and Cancer, HPV VaccineJames Lyons-Weiler
An overview of advances in cancer biomarker research strategies, the pathogenesis of HPV virus and a focus on the HPV vaccine with an analysis of evidence of type replacement.
Zika Virus: Medical Countermeasure Development Challenges by Robert W. MaloneJan-Cedric Hansen
Reports of high rates of primary microcephaly and Guillain–Barré syndrome associated with Zika virus infection in French Polynesia and Brazil have raised concerns that the virus circulating in these regions is a rapidly developing neuropathic, teratogenic, emerging infec- tious public health threat. There are no licensed medical countermeasures (vaccines, thera- pies or preventive drugs) available for Zika virus infection and disease. The Pan American Health Organization (PAHO) predicts that Zika virus will continue to spread and eventually reach all countries and territories in the Americas with endemic Aedes mosquitoes. This paper reviews the status of the Zika virus outbreak, including medical countermeasure options, with a focus on how the epidemiology, insect vectors, neuropathology, virology and immunology inform options and strategies available for medical countermeasure develop- ment and deployment.
Современное лечение ВИЧ.Объединенные данные с конференции IAS 2019 / Contemp...hivlifeinfo
Review key HIV data from IAS 2019 on the updated NTD risk in women receiving ART at conception, PrEP, first-line and switch options, and early-phase investigational strategies.
Population-based resistance of Mycobacterium tuberculosis
isolates to pyrazinamide and fl uoroquinolones: results from
a multicountry surveillance project
A brief overview of the process of vaccine production, clinical trials, and licensing, along with a summary of the different vaccines platforms and vaccine candidates.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Dr Sarah Meyer @ Meningitis & Septicaemia in Children & Adults
1. National Center for Immunization & Respiratory Diseases
Serogroup B Meningococcal Disease Outbreaks at
Universities and the Public Health Response – United States
Sarah Meyer, MD MPH
Centers for Disease Control and Prevention
November 15, 2017
2. 2
Incidence of meningococcal disease –
United States, 1996-2015
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Incidenceper100,000
Year
Abbreviations: MenACWY = quadrivalent conjugate meningococcal vaccine against serogroups A, C, W, Y; MenB vaccines = serogroup B meningococcal vaccines
Source: 1996-2015 NNDSS Data
0.12 cases/100,000 population
MenB vaccine
MenACWY vaccine
1.3 cases/100,000 population
3. 3
Current meningococcal vaccine recommendations for
adolescents and young adults in the United States
Quadrivalent conjugate meningococcal (MenACWY) vaccine: Routine vaccination of all
adolescents aged 11-12 years with a booster dose at age 16 years.
Serogroup B (MenB) vaccine: Not routinely recommended; based on clinical discretion may
be administered, with a preferred age of 16-18 years.
– Recommended for outbreak response:
• MenB-4C (Bexsero®): 2-dose series
• MenB-FHbp (Trumenba®): 3-dose series
4. 4
Incidence of meningococcal disease among persons aged
18-24 years by student status – United States, 2015-2016
Unpublished data redacted
5. 5
Serogroup B meningococcal disease outbreaks among
university populations – United States
Increased risk of meningococcal disease among university students is partly driven by
outbreaks.
– Although only ~5% of all U.S. cases are outbreak-associated, 40% of serogroup B
cases among university students in 2015-2016 are outbreak-associated.
Since 2013, 8 serogroup B outbreaks with a total of 32 cases and 2 deaths (6.3%) have
been reported at U.S. universities.
MenB vaccination implemented at all 8 universities:
– MenB-4C: 5 universities (including 2 prior to U.S. licensure)
– MenB-FHbp: 3 universities
6. 6
University Based Serogroup B Outbreaks† – United States,
2013–2017
†Where CDC consulted; *1 additional associated case identified after retrospective case review; **1 additional patient with inconclusive laboratory results
State of University Location Outbreak Period Cases (deaths) # Undergraduates
New Jersey Mar 2013 – Mar 2014 9 (1) 5,000
California Nov 2013 4* 18,000
Rhode Island Jan – Feb 2015 2 4,000
Oregon Jan – May 2015 7 (1) 20,000
California Jan – Feb 2016 2** 5,000
New Jersey Mar – Apr 2016 2 35,000
Wisconsin Oct 2016 3 30,000
Oregon Nov 2016 – Nov 2017 2 25,000
7. 7
Serogroup B meningococcal disease outbreaks and the
public health response
What is the outbreak threshold for vaccination?
Which MenB vaccine should be used?
Who should be vaccinated (all students or a subset)?
What strategies should be used to achieve high coverage, especially for the 2nd and 3rd
doses (when indicated)?
In 2017, based in part on the experiences in responding to serogroup B university
outbreaks, CDC revised its meningococcal disease outbreak guidance1.
1 Publication pending, will be published at https://www.cdc.gov/meningococcal/outbreaks.
8. 8
What is the outbreak threshold for vaccination?
Previous threshold: ≥3 cases of the same serogroup with an incidence of >10 cases per
100,000 during a 3 month period.
Is this definition still appropriate in the current epidemiologic context?
9. 9
Timeline of serogroup B meningococcal disease cases and
MenB vaccination at U.S. universities – 2013-2017
Unpublished data redacted
10. 10
Revised outbreak threshold for vaccination
Revised threshold (organization-based outbreaks): 2-3 outbreak-associated cases within a
3-month period.
– Outbreak-associated case: all cases of the same serogroup unless molecular typing
indicates that a strain is genetically different than the predominant outbreak strain.
11. 11
Which MenB vaccine (MenB-4C or MenB-FHbp) to use
during an outbreak?
As MenB vaccines are strain-specific, outbreak response could be optimized by
determining which vaccine affords the greatest protection against an outbreak strain.
Whole genome sequencing, performed on available isolates when an outbreak is
suspected, can assess presence, but not expression or expected coverage of a particular
vaccine.
– Logistical challenges to conducting additional testing in real-time during an
outbreak.
12. 12
Which MenB vaccine (MenB-4C or MenB-FHbp) to use
during an outbreak?
During the 2016 New Jersey serogroup B university outbreak, whole genome sequencing
results were used to make a preferential vaccine recommendation for MenB-FHbp1.
– FHbp A22/2.19
– Por A P1.5-1,10-1
– NHba p0020
– NadA negative
1Soeters. 2017. EID. 2 Data courtesy of Dan Granoff, University of California at San Fransisco.
13. 13
Which MenB vaccine (MenB-4C or MenB-FHbp) to use
during an outbreak?
During the 2016 New Jersey serogroup B university outbreak, whole genome sequencing
results were used to make a preferential vaccine recommendation for MenB-FHbp1.
– FHbp A22/2.19
– Por A P1.5-1,10-1
– NHba p0020
– NadA negative
1Soeters. 2017. EID. 2 Data courtesy of Dan Granoff, University of California at San Fransisco.
Mismatch for MenB-4C
14. 14
Which MenB vaccine (MenB-4C or MenB-FHbp) to use
during an outbreak?
During the 2016 New Jersey serogroup B university outbreak, whole genome sequencing
results were used to make a preferential vaccine recommendation for MenB-FHbp1.
– FHbp A22/2.19
– Por A P1.5-1,10-1
– NHba p0020
– NadA negative
1Soeters. 2017. EID. 2 Data courtesy of Dan Granoff, University of California at San Fransisco.
MenB-FHbp expected to
provide cross-protection
15. 15
Which MenB vaccine (MenB-4C or MenB-FHbp) to use
during an outbreak?
During the 2016 New Jersey serogroup B university outbreak, whole genome sequencing
results were used to make a preferential vaccine recommendation for MenB-FHbp1.
– FHbp A22/2.19
– Por A P1.5-1,10-1
– NHba p0020
– NadA negative
However, later testing demonstrated low FHbp expression, with a similar immune response
by human serum bactericidal activity for either vaccine2.
Revised CDC outbreak guidance states that whole genome sequencing results should not
be used to drive MenB vaccine selection at this time.
1Soeters. 2017. EID. 2 Data courtesy of Dan Granoff, University of California at San Fransisco.
16. 16
Who is Affected in University Serogroup B Outbreaks?
Prior studies show increased risk of meningococcal disease cases in freshmen living in
dormitories, Greek society (fraternity/sorority) members, high social mixing.1-5
In the recent U.S. university outbreaks, many cases had no identifiable risk factors, and no
sub-groups of students at increased risk identified.
1Bruce et al. 2001, JAMA 286(6):688-93; 2Froeschle 1999, Clin Infect Dis 29(1):215-6; 3Harrison et al. 1999, JAMA 281(20):1906-10; 4Neal et al. 1999, Epidemiol Infect 122(3):351-7;5Mandal et al.
2013, Clin Infect Dis 57(3):344-8. Images from: http://www.scrippscollege.edu/life/residence, https://www.theodysseyonline.com/supoort-the-penn-state-greek-life-restrictions,
http://www.barsandnightclubs.com.au/perth/leederville/hipe-club/photos/2/
17. 17
MenB vaccination campaigns at U.S. universities
Based on the epidemiology, unable to
conduct targeted vaccination campaigns at
any of the universities.
University-wide vaccination of all
undergraduates and select other groups.
Vaccination coverage highly variable: 1st dose
coverage 8-95% of targeted students
18. 18
MenB vaccine 1st dose coverage at U.S. universities that
experienced serogroup B meningococcal disease outbreaks –
2013-2017
Unpublished data redacted
20. 20
Strategies to increase vaccination coverage
Evening hours
Schedule dorms/groups specific times to attend
Required attendance & opt-out forms
Keep wait times short
Clear cost information
Involve students in promoting vaccination campaigns
Get the word out: email, social media, posters, swag
– 2 surveys1,2 demonstrated that email was how the overwhelming
majority of students heard about vaccination campaigns and also
the preferred method of communication.
– Communicate with parents too
1Breakwell et al. 2016, J Adolesc Health 59(4):457-64; 2CDC/Oregon Health Authority unpublished data
21. 21
0
10
20
30
40
50
60
70
80
90
100
Meningitis is
serious
University says it's
important
Best way to
protect myself
My parents told
me to
I am unlikely to get
meningitis
I know signs/
symptoms and will
seek treatment
instead
Concerned about
side effects
Percent(%)
Reasons for vaccination (N=853) Reasons for non-vaccination (N=400)
What motivates students to get vaccinated during
serogoup B university outbreaks?
Breakwell et al. 2016, J Adolesc Health 59(4):457-64
22. 22
Impact of MenB vaccination campaigns on serogroup
B meningococcal disease
Difficult to assess the impact of vaccination on the course of MenB outbreaks and what
would have happened in the absence of vaccination.
Of the 8 universities that implemented a campaign, 6 had no additional cases among
students at the affected university following completion of the 1st dose campaign.
23. 23
Timeline of serogroup B meningococcal disease cases and
MenB vaccination at U.S. colleges/universities – 2009-2017
Unpublished data redacted
24. 24
Impact of MenB-FHbp on serogroup B carriage during
a university outbreak
Observational, cross-sectional carriage evaluations conducted at two U.S. universities that
experienced a serogroup B outbreak and implemented mass vaccination campaigns
primarily using MenB-FHbp1,2.
Carriage assessed at baseline and 3 subsequent timepoints in 2015-2016.
– Round 1: Baseline/dose 1
– Round 2: Dose 2
– Round 3: Dose 3
– Round 4: 1 year post-outbreak/freshman dose 3
1 McNamara et al. JID. 2017; 2 Soeters et al. CID. 2017
25. 25
Impact of MenB-FHbp on serogroup B carriage during
a university outbreak
1 McNamara et al. JID. 2017; 2 Soeters et al. CID. 2017
0
5
10
15
20
25
30
Round 1 Round 2 Round 3 Round 4
Prevalence(%)
Overall Serogroup B
0
5
10
15
20
25
30
Round 1 Round 2 Round 3 Round 4
Prevalence(%)
Overall Serogroup B
Oregon 2015 (N=4,225)1 Rhode Island 2015 (N=2,843)2
26. 26
Impact of MenB-FHbp on serogroup B carriage during
a university outbreak
1 McNamara et al. JID. 2017; 2 Soeters et al. CID. 2017
0
5
10
15
20
25
30
Round 1 Round 2 Round 3 Round 4
Prevalence(%)
Overall Serogroup B
0
5
10
15
20
25
30
Round 1 Round 2 Round 3 Round 4
Prevalence(%)
Overall Serogroup B
Oregon 2015 (N=4,225)1 Rhode Island 2015 (N=2,843)2
• No association between MenB-FHbp vaccination and serogroup B carriage.
• No large or rapid reduction in serogroup B carriage or prevention of carriage acquisition; herd protection unlikely.
• Individual protection through vaccination is important
27. 27
When is an outbreak ‘over’?
Prolonged nature of some serogroup B university outbreaks make it difficult to know when
public health interventions can be stopped.
CDC revised guidance: for the purposes of public health decision-making, risk of
meningococcal disease likely returns to expected levels one year after the last reported
case.
Thus, in many situations, universities may consider vaccinating incoming freshman the
following academic year.
28. 28
Conclusions
Despite declines in the incidence of meningococcal disease in the United States,
college/university students are at increased risk for serogroup B disease and
outbreaks.
MenB vaccination is an important new tool for outbreak response.
– Additional evaluations to optimize its use for outbreak response and understand its
impact will be helpful to guide future interventions.
Outbreak preparedness planning and strong communication/social mobilization are
essential for the success of a MenB vaccination campaign.
30. For more information, contact CDC
1-800-CDC-INFO (232-4636)
TTY: 1-888-232-6348 www.cdc.gov
The findings and conclusions in this report are those of the authors and do not necessarily represent the
official position of the Centers for Disease Control and Prevention.
Thank you
smeyer@cdc.gov
Editor's Notes
Before starting, I just wanted to provide a little bit of context on the overall epidemiology of meningococcal disease in the U.S.
Since the late 1990s, a sustained decline incidence has been observed, decreasing from 1.3 to 0.12 cases per 100,000 population from 1996 to 2015.
This decline in incidence began prior to the introduction of a quadrivalent meningococcal conjugate, or MenACWY, vaccine in adolescents or the availability of serogroup B, or MenB, vaccines.
Just to review our current vaccine recommendations for adolecents and young adults:
MenACWY vaccine is routinely recommended for all adolescents, with the 1st dose at age 11 to 12 years and a booster dose at age 16 years.
MenB vaccine, on the other hand, is not routinely recommended. However, based on clinical discretion, it may be administered to person aged 16-23 years, with the preferred age of 16-18 years.
However, MenB vaccines are recommended for outbreak response:
MenB-4C, or Bexsero, as a two-dose series
And MenB-FHbp, or Trumenba, as a three-dose series.
Much of increased risk for serogroup B meningococcal disease among college students is driven by outbreaks.
Although only 5% of all U.S. cases are outbreak-associated, 40% of serogroup B cases among college students are outbreak-associated.
Since 2013, 8 serogroup B outbreaks, with a total of 32 cases and 2 deaths have been reported.
MenB vaccination has been implemented at all 8 colleges and universities.
Five conducted campaigns with MenB-4C, including 2 campaigns conducted prior to U.S. licensure of the vaccine.
And 3 conducted campaigns with MenB-FHbp
- These outbreaks have had a median of 4 cases, ranging from 2 to 9
The approximate duration, or the number of days between the date of onset of the first case and last case, is 16 days, though as you can see here there is quite a range, from 1 day to 347 days in between the first and last case.
The universities have had a median undergraduate student body size of 21,000, ranging from 4,000 to 35,000 students.
These outbreaks raised many questions.
What is the outbreak threshold for vaccination?
Which MenB vaccine should be used for outbreak response?
Who should be vaccinated – the entire university or a subset?
What strategies should be used to achieve high coverage
In 2017, based in part on the experiences in responding to serogroup B university outbreaks, CDC revised its meningococcal disease outbreak guidance.
Let’s start with the outbreak threshold for vaccination.
The previous threshold was 3 or more cases of the same serogroup with an incidence of >10 cases per 100,000 during a 3-month period.
However, we started to wonder if this was still an appropriate threshold given the current epidemiologic context.
Thus, taking into account the epidemiology of these outbreaks and other factors, the revised threshold for organization-based outbreaks, such as a university outbreak, is 2-3 outbreak-associated cases within a 3-month period.
- We define outbreak-associated cases as all cases of the same serogroup unless molecular typing indicates that the strain is from a case that is genetically different than the predominant outbreak strain.
Once it has been determined to implement a MenB Vaccination campaign, another frequent question is which MenB vaccine to use during an outbreak?
As MenB vaccines are strain-specific, outbreak response could be optimized by determining which vaccine affords the greatest protection against an outbreak strain.
Whole genome sequencing, which is performed on available isolates when an outbreak is suspected, can assess the presence but not the expression or expected coverage of a particular vaccine.
Additionally, there are logistical challenges to conducting additional testing in real-time during an outbreak.
During a 2016 serogroup B university outbreak, whole genome sequencing results were used to make a preferential vaccine recommendation for MenB-FHbp.
This was based off the FHbp A22, which is not a complete match with MenB-FHBp, but MenB-FHbp was thought to confer cross-protection.
On the contrary, the PorA, FHbp, Nbha, and NadA were a complete mismatch for MenB-4C.
However, later desting demonstrated low FHbp expression, and serum bactericidal activity showed a similar immune response for either vaccine.
Thus, although whole genome sequencing results indicated that Men-FHbp would likely be a more appropriate vaccine to use, this was not the case on further testing.
Thus, the revised CDC outbreak guidance states that whole genome sequencing results should not be used to drive MenB vaccine selection at this time.
During a 2016 serogroup B university outbreak, whole genome sequencing results were used to make a preferential vaccine recommendation for MenB-FHbp.
This was based off the FHbp A22, which is not a complete match with MenB-FHBp, but MenB-FHbp was thought to confer cross-protection.
On the contrary, the PorA, FHbp, Nbha, and NadA were a complete mismatch for MenB-4C.
However, later desting demonstrated low FHbp expression, and serum bactericidal activity showed a similar immune response for either vaccine.
Thus, although whole genome sequencing results indicated that Men-FHbp would likely be a more appropriate vaccine to use, this was not the case on further testing.
Thus, the revised CDC outbreak guidance states that whole genome sequencing results should not be used to drive MenB vaccine selection at this time.
During a 2016 serogroup B university outbreak, whole genome sequencing results were used to make a preferential vaccine recommendation for MenB-FHbp.
This was based off the FHbp A22, which is not a complete match with MenB-FHBp, but MenB-FHbp was thought to confer cross-protection.
On the contrary, the PorA, FHbp, Nbha, and NadA were a complete mismatch for MenB-4C.
However, later desting demonstrated low FHbp expression, and serum bactericidal activity showed a similar immune response for either vaccine.
Thus, although whole genome sequencing results indicated that Men-FHbp would likely be a more appropriate vaccine to use, this was not the case on further testing.
Thus, the revised CDC outbreak guidance states that whole genome sequencing results should not be used to drive MenB vaccine selection at this time.
During a 2016 serogroup B university outbreak, whole genome sequencing results were used to make a preferential vaccine recommendation for MenB-FHbp.
This was based off the FHbp A22, which is not a complete match with MenB-FHBp, but MenB-FHbp was thought to confer cross-protection.
On the contrary, the PorA, FHbp, Nbha, and NadA were a complete mismatch for MenB-4C.
However, later desting demonstrated low FHbp expression, and serum bactericidal activity showed a similar immune response for either vaccine.
Thus, although whole genome sequencing results indicated that Men-FHbp would likely be a more appropriate vaccine to use, this was not the case on further testing.
Thus, the revised CDC outbreak guidance states that whole genome sequencing results should not be used to drive MenB vaccine selection at this time.
So within each university, which students are most likely to be affected in an outbreak? Several older studies have shown an increased risk of meningococcal disease in freshmen living in dormitories, Greek society members, and other students engaging in a lot of what we call “social mixing” – attendance at parties, bars, etc..
However, in the recent U.S. university outbreaks, many of the cases have had no identifiable risk factors, and no sub-groups at increased risk identifie.d
Thus, in our outbreaks, university-wide vaccination of all undergraduates, along with select other groups, such as graduate students living in dormitories, was implemented. Because of the lack of identified subgroups, we were unable to use the epidemiology of the outbreaks to conduct more targeted vaccination campaigns.
The vaccination coverage at these 8 universities was highly variable, ranging from 1st dose vaccination coverage of 8 to 95% of targeted students.
Some strategies that we’ve anecdotally heard to be helpful are evening clinic hours, scheduling dorms and specific groups (such as athletic teams) to attend, requiring students to attend the clinic and then opt-out, keep wait times short, clearly explain if there is a cost to the student, involving students in promoting the vaccination campaigns, and
Getting the word out through a variety of communications methods.
We always here that kids these days don’t use email anymore.
But in 2 surveys, email was not only how the overwhelming majority of students heard about vaccination campaigns, but was also the preferred method of communication.
We also found that it’s important to communicate with the parents too.
When we asked what the main motivators for vaccination were, we were not surprised that students reported getting vaccinated because meningitis is a serious disease, the university says it’s important, and it’s the best way to protect myself. We were surprised that about 70% of students also stated they got vaccinated because their parents told them too.
On the other hand, the main reasons for non-vaccination were: I am unlikely to get meningitis, I know the signs/symptoms and will seek treatment instead, and concern about side effects. So this shows that we still have some work to do in educating students.
It is also important to assess the impact of MenB vaccination campagins on serogroup B meningococcal disease.
Howeve,r it is difficult to assess what would have happened in the absence of vaccination.
Of the 8 universities that implemented vaccination campaigns, 6had no additional cases among students of the affected university following completion of the 1st dose campaign.
However, as mentioned earlier, 2 universities had additional cases following vaccination.
Both were large universities, with >20,000 undergraduates.
And both had vaccination coverage of approximately 50% or less, which suggests that there were still large numbers of susceptible persons in the population, allowing continued transmission of the outbreak strain.
So we conducted cross-sectional carriage evaluations at 2 U.S. universities that experienced serogroup B outbreak and implemented mass vaccination campaigns primarily using MenB-FHbp.
Carriage was assessed at baseline and 3 subsequent timepoints, co-inciding with a baseline assessment, and then folllwing the 3 vaccine doses.
At both universities, while there were some minor fluctuations in overall carriage prevalence, serogroup B prevalence remained the same.
Thus, this suggests that MenB-FHbp does not rapidly reduce meningococcal carriage or prevent serogroup B carriage acquisition. Thus, this vaccine is unlikely to provide herd immunity during outbreaks.
In conclusion, despite declines in the incidence of meningococcal disease in the United States, college and university students are at risk for serogroup B disease and outbreaks.
MenB vaccination is a relatively new tool for outbreak response. Howevere, there is still much to be learned in order to optimize it’s use for outbreak response and understand the impact of vaccination in order to guide future interventions.
Outbreak preparedness planning and strong communication/social mobilization are essential for the success of a MenB vaccination campaign.