Q: My granddaughter, who’s an excellent student, has applied for a number of top colleges on both coasts. I’m worried that it may be dangerous at some places like Princeton, which apparently now is suffering a meningitis outbreak.
A: You have heard correctly that there have been a large number of bacterial meningitis cases at Princeton University and recently at the University of California-Santa Barbara " eight over the course of the past year in New Jersey, three in California. Bacterial meningitis is a terrible illness with a large number of those affected dying and many more left with lifelong deficits, like epileptic seizures, deafness or loss of cognitive ability. Of course no one knows why the disease struck colleges near both coasts.
The bacterium that is causing the outbreak is a type B meningococcus. Like many colleges, Princeton requires that its entering students be vaccinated against meningococcal disease. But the two vaccines used in the United States protect against four other types of the germ, A, C, Y and W, but neither as yet protects against type B. It has been difficult developing a vaccine that protects against type B. You may also have heard that a type B vaccine has been brought in from abroad, where it has safely and effectively protected children in Europe and in Australia. Eventually, this vaccine will almost surely be approved by our Federal Drug Administration, either as a single vaccine or more likely as a five-part A-B-C-Y-W combination.
When I first came to New Mexico in 1970, meningitis was extremely common. Hardly a week would go by without my having to insert a long needle between the bones of the back to remove spinal fluid for analysis to see if meningitis had attacked yet another child. The procedure, called a spinal tap or a lumbar puncture, was something at which I and my fellow pediatricians became very adept " we had done many of them before we left our residencies in pediatrics.
We continue to keep meningitis in mind with patients who appear in our offices or emergency rooms, usually with high fever, lethargy and a stiff neck. But thanks to immunizations, we don’t see much meningitis anymore. Bacterial meningitis prior to 1990 was caused most commonly by three germs, Haemophilus influenzae (which we call H. flu and has nothing to do with influenza), the pneumococcus (better known as the cause of much pneumonia, thus the name), and the meningococcus, rare but extremely severe. There are immunizations against each of these, and the incidence of the diseases has plummeted.
H. flu was the first of these to be almost completely tamed. The first vaccine against our old nemesis was released in 1985, and an improved vaccine came out two years later. The results were spectacular " from about 20,000 cases per year before the vaccine to the low double digits shortly after. That remarkable and brain-protecting result was made easier by the fact that only one type of H. flu (type B) was responsible for a great majority of the cases, which can’t be said for either the meningococcus or the pneumococcus.
A recent medical journal article notes the frequency with which the pneumococcus has been found in cerebrospinal fluid, that liquid that runs around and cushions the brain and the spinal cord, a small amount of which we remove with those long needles I mentioned above. The report catalogs all 68 cases of pneumococcal meningitis in Utah for the years 1997 to 2010.
Even in this seemingly medically modern age, pneumococcal meningitis carries a tremendous price tag: 13 percent mortality, with more than half of the survivors having problems reflecting brain damage afterward. Why hasn’t the very successful pneumococcal vaccine avoided these cases? After all, it has been shown that giving the vaccine to babies decreases the incidence of disease due to this microbe in older adults. Have you heard of herd immunity " it works!
But there are 90 types of pneumococcus, and immunity to one does not mean you’re immune to another. There are now 13 types in the vaccine given to children, 23 in a different vaccine given to adults, but that leaves the remaining 77 or 67 unprotected against. Fortunately, the 13 are the most common, with the next 10 also in the adult vaccine. But now and then one of those other types causes meningitis, and then there are others whose parents, for whatever reason, have failed to get their children the vaccine.
The recent Princeton and Santa Barbara experiences show how much attention is given to a dreaded disease once an outbreak occurs. There seems to have been little agitation against use of a vaccine in such a situation, even one not previously used in the U.S. It is remarkable to me that people will, however, agitate against other well-proven vaccines, including the one that has reduced the incidence of H. flu meningitis from 20,000 annual U.S. cases before the vaccine to 30 last year. But then absence of a disease is never as newsworthy as an epidemic. It’s hard to count, and it’s hard to publicize epidemics averted.
Lance Chilton, M.D., is a pediatrician at the Young Children’s Health Center in Albuquerque, associated with the University of New Mexico. Send questions to lancekathy@gmail.com.