Meningococcal Disease Surveillance in Men Who Have Sex with Men — United States, 2015–2016

Meningococcal disease is a rare, but serious, bacterial infection that progresses rapidly and can be life-threatening, even with prompt antibiotic treatment. Men who have sex with men (MSM) have previously been reported to be at increased risk for meningococcal disease compared with other men, and recent outbreaks of serogroup C meningococcal disease among MSM have occurred (1). However, the epidemiology of meningococcal disease among MSM in the United States is not well described, in part, because information about MSM has not historically been collected as part of routine meningococcal disease surveillance. To better characterize and identify risk factors for meningococcal disease in general, supplementary data and isolates have been collected since 2015 through enhanced meningococcal disease surveillance activities. During 2015–2016, 271 cases of meningococcal disease in men aged ≥18 years were reported to the National Notifiable Diseases Surveillance System (NNDSS) in 45 states participating in this enhanced surveillance. Forty-eight (17.7%) cases were in men identified as MSM, including 17 (37.8%) with human immunodeficiency virus (HIV) infection. Among MSM, 39 (84.8%) cases were caused by Neisseria meningitidis serogroup C, whereas this serogroup was responsible for only 16.4% of cases among men who were not known to be MSM (non-MSM). Despite improvements in surveillance, MSM likely remain underascertained among men with meningococcal disease. Improved surveillance data are needed to understand the prevalence of and risk for meningococcal disease among MSM and inform policy and prevention strategies. Vaccination with quadrivalent meningococcal conjugate (MenACWY) vaccine is recommended for the control of meningococcal disease outbreaks caused by serogroups A, C, W, or Y, including during outbreaks among MSM; in addition, all persons aged ≥2 months with HIV infection should receive MenACWY vaccine because of the increased risk for meningococcal disease.

Since 2003, seven outbreaks (2) of serogroup C meningococcal disease have been reported among MSM in four metropolitan areas in the United States (Chicago, Los Angeles County/Southern California, Miami, and New York City) (1,3). An analysis of cases reported in NNDSS during January 2012–June 2015 demonstrated that the risk for meningococcal disease among MSM (0.56 cases per 100,000 population) was four times that among other men (0.14) (1). Whereas HIV infection appeared to be associated with the increased risk for sporadic illness observed in that study, additional risk factors for meningococcal disease, including in outbreak-associated cases, have not been well established. The prevalence and epidemiology of meningococcal disease in this population remain poorly described because information to identify MSM and HIV infection was not routinely collected before 2015.

In 2015, enhanced meningococcal disease surveillance activities were implemented in 45 U.S. states as part of the Epidemiology and Laboratory Capacity for Infectious Diseases Cooperative Agreement to routinely collect isolates and supplementary data (including information to identify MSM and HIV infection) on meningococcal disease cases reported to NNDSS. To assess completeness of this information and report updated findings on MSM with meningococcal disease, all confirmed and probable meningococcal disease cases among men aged ≥18 years reported to NNDSS by enhanced meningococcal disease surveillance–participating states during January 2015–December 2016 were reviewed. State or local health departments classified cases as occurring in either MSM or non-MSM; the latter group included men for whom information to identify MSM was missing. During this 2-year period, 39 state health departments identified MSM by asking adult male patients about either their sexual orientation or gender of their main sex partner or both or by obtaining this information from other sources (e.g., medical record); six states did not collect this information. States also classified cases as occurring in men with and without HIV infection, as well as being outbreak-associated or sporadic. A case report form to collect additional data on potential risk factors was completed for cases occurring in MSM. Serogroup was determined by polymerase chain reaction and slide agglutination. Sequence type (ST) was determined using whole genome sequencing. Incidence was calculated as the number of meningococcal disease cases per 100,000 men aged ≥18 years. Population denominators for non-MSM (4) and MSM (5) were derived from the 2016 American Community Survey. HIV prevalence among MSM was estimated from the 2014 National HIV Behavioral Surveillance Report (6).

During 2015–2016, a total of 271 cases of meningococcal disease in men aged ≥18 years were reported. Among these, sufficient information to identify MSM was available for 124 (45.8%). Overall, 48 (17.7%) cases occurred in MSM (Table 1). Information on HIV status was available for 133 (49.1%) cases, although completeness of this information was higher among MSM (45 of 48; 93.8%) than among non-MSM (89 of 223; 39.5%). Among the 133 men with known HIV status, 17 (12.8%) had HIV infection, all of whom were MSM, accounting for 37.8% of 45 MSM with known HIV status. Among cases in MSM, the median age was 32 years, 66.7% of patients were white, and 77.8% were non-Hispanic. In contrast, among 223 cases in non-MSM, the median age was 41 years, 68.3% were white, and 81.7% were non-Hispanic. All cases in MSM were reported from 12 states. Thirty-two (66.7%) cases in MSM were associated with three outbreaks, which were reported through enhanced surveillance activities: 11 cases in the Chicago outbreak, 20 cases in the Southern California outbreak, and one case in Miami (four additional outbreak-associated cases were reported in 2017). Six (12.5%) additional cases were reported from jurisdictions that had previously reported an outbreak of meningococcal disease. In contrast, 18 (8.1%) cases in non-MSM were associated with an outbreak of meningococcal disease. N. meningitidis serogroup C accounted for 39 (84.8%) cases in MSM, compared with 16.4% of cases in non-MSM (Table 1). Among cases of serogroup C meningococcal disease in MSM with available molecular data, all were caused by ST-11 strains, although the meningococci had five different molecular profiles, as defined by the combination of ST, FetA, PorA, and PorB types. The outbreaks in Chicago and Southern California involved meningococci with different molecular profiles, and thus were distinct from each other. Among MSM, six of 48 (12.5%) cases were fatal, whereas 30 of the 203 (14.8%) cases in non-MSM were fatal. The case-fatality ratio was not statistically significantly different in MSM with and without HIV infection (11.8% and 14.3%, respectively). Among cases in MSM, HIV infection status and case-fatality ratios were not statistically significantly different among outbreak-associated cases (35.5% and 12.5%, respectively) and sporadic cases (42.9% and 12.5% respectively).

The incidence of meningococcal disease among MSM was 0.54 cases per 100,000 population (Table 2). The incidence of meningococcal disease among MSM in jurisdictions that reported an outbreak of meningococcal disease among MSM was 3.27 cases per 100,000 population, which was higher than the rate in jurisdictions that did not report an outbreak of meningococcal disease (0.19 cases per 100,000). The incidence of reported cases among non-MSM men was 0.10 per 100,000.

Acknowledgments

Sarah Kemble, Stephanie Black, Chicago Department of Public Health; Kathleen Harriman, Kathleen Winter, California Department of Public Health; Kyle Bernstein, Jeremy Grey, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC.

Corresponding author: Catherine H. Bozio, [email protected], 404-718-5697.

¹Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, CDC; ²Epidemic Intelligence Service, CDC; ³Los Angeles County Department of Public Health, California.

References

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Abbreviations: HIV = human immunodeficiency virus; MD = meningococcal disease; MSM = men who have sex with men.
* Includes 76 men known to be non-MSM and 147 men with missing MSM information.
^† Calculated among those with a known response.
^§ Number of known responses divided by the total number of responses.
^¶ Including Asian and other race.

Abbreviation: HIV = human immunodeficiency virus.
* Cases reported in jurisdictions that reported a cluster or outbreak of meningococcal disease among MSM; denominator was estimated from the population in the counties within these jurisdictions.
^† HIV status was available for 31 of 32 cases.
^§ Cases reported in jurisdictions that did not report a cluster or outbreak of meningococcal disease among MSM; denominator was estimated from the population in the counties within these jurisdictions.
^¶ HIV status was available for 13 of 15 cases.