Meningococcal Outbreak at UCSB

An Update from Public Health

Wednesday, December 25, 2013
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Greetings from the front lines of Disease Control. It’s been a little busy over here.

For the past month, I’ve been overseeing the Public Health Department’s coordinated response to the outbreak of meningococcal disease at UC Santa Barbara. I want to give our community a personal update on the latest developments, in an effort to stay transparent and direct with the public we serve.

Charity Thoman

For those of you playing catch-up on the details of this outbreak, let me give you a quick summary. Four cases of invasive meningococcal disease have been confirmed in UCSB undergraduate students between November 11 and November 21, 2013. All of these students were active in campus organizations and lived in different group-housing units. Three have fully recovered, and one sustained permanent disability and is still hospitalized. All four cases are serogroup B, which is not covered by the meningococcal vaccine routinely used in the United States. We know for sure that the UCSB outbreak is not related to the Princeton University outbreak, despite the fact that both are serogroup B. (A very specific “DNA fingerprint” test showed that the UCSB outbreak is serogroup B strain ST32, and the Princeton outbreak is serogroup B strain ST409.)

Since the moment the first case was confirmed, my goal in this outbreak has been to stay a few steps ahead of the bacteria. I asked myself, what stopgaps would we be trying to institute if there were a fifth case? Let’s do those now. What major decisions would we face? Let’s gather that critical information now, so it’s at our fingertips when the time comes. Our mantra has been to plan ahead, and then plan ahead some more.

Immediately after the first case, Public Health began working closely with UCSB to coordinate giving antibiotic pills to students who were close contacts to the ill student. This is called chemoprophylaxis. As the outbreak grew, the number of people receiving this prophylaxis grew. After the fourth case, we expanded the prophylaxis to include all members of five specific campus groups that we felt were at higher risk, due to overlapping exposures to the index cases. All told, over 1,200 UCSB students have received chemoprophylaxis. We don’t know for sure that this will stop the spread, but it will help.

A critical component of stopping this outbreak has been educating students on how to best protect themselves and to seek early medical care if they have symptoms. We know that attending social functions where there is smoking, alcohol, and close personal contact (kissing, sharing cups) is associated with a higher risk of contracting this disease. UCSB continues to educate and update students and parents via frequent emails and the UCSB student health website. I issued two Provider Alerts, asking our medical community to have a heightened awareness for meningococcal symptoms in college-aged students, and to have a low threshold to send suspected cases to the emergency room for blood cultures. Our department has conducted more than 30 media interviews with both local and national media, and even held our own press conference, in an effort to keep the public up to date on new developments and educate students. UCSB also cancelled fraternity/ sorority social events through December, at our request.

Since day one, we have worked closely with experts at the Centers for Disease Control and Prevention (CDC) and the California Department of Public Health (CDPH). At a very early stage we began discussing the possibility of obtaining the “investigational” vaccine targeted at serogroup B, which Princeton is now using after a long approval process. I want to be clear about the prospects of obtaining this non-FDA-approved vaccine for UCSB students. Yes, it’s a possibility. No, it isn’t available yet.

Immediately after the fourth case was confirmed, I invited CDC and CDPH investigators to come to Santa Barbara for an on-site visit at UCSB. We all agreed that we should work under the assumption that the vaccine would be needed at UCSB, and a site visit was the first step in moving the vaccine issue forward. Although we know that most outbreaks of serogroup B stop at three or four cases, staying a few steps ahead meant planning for the outbreak to grow. During their visit to campus, the CDC learned more about the four students who became ill, assessed the living arrangements and patterns of interactions among students, and discussed logistics of a potential vaccination campaign. Samples of the bacteria are also being tested against the vaccine, to ensure that it would protect against the very specific strain causing the current outbreak. We anticipate that the vaccine will be effective since it works against similar strains, but the specific bacteria associated with the UCSB outbreak have to be tested to be certain.

The CDC is continuing to work with UCSB on the multistep process involved in obtaining access to the vaccine, should it be necessary, under an Investigational New Drug (IND) application to the Food and Drug Administration (FDA). This process will take weeks and is not a guarantee that the vaccine will be recommended for use at UCSB, but it does keep all options on the table.

We are lucky to live in such a close-knit community that rallies together when our kids get sick. Although I think there is a greater than 50 percent chance the outbreak is over, we are planning as if it is not. The attitude of partnership I have witnessed over the past month between medical providers, hospitals, UCSB, and health officials has made me proud to live in this community.

For more information, please see the following websites:

Santa Barbara County Public Health Department:

UCSB Student Health:

Centers for Disease Control and Prevention:

Charity Thoman, MD, oversees the communicable disease, HIV, and tuberculosis functions at the Santa Barbara County Public Health Department.


Independent Discussion Guidelines

Dear Dr. Thoman,

I'd like to clarify a couple of conflicting and erroneous items in this report...

You state that you "think there is a greater than 50 percent chance the outbreak is over..."
To quote the CDC (all caps emphasis mine):
"CDC and state and local health officials have gathered and analyzed current and historical data and determined that ADDITIONAL CASES ARE LIKELY TO OCCUR AT UCSB. Based on that conclusion, the request will be made to FDA to gain access to the vaccine."

So, to repeat: the official stance from the CDC is that additional cases at UCSB are LIKELY to occur.

Your statement that "We anticipate that the vaccine will be effective since it works against similar strains, but the specific bacteria associated with the UCSB outbreak have to be tested to be certain." is misleading. The strain is known to be 100% susceptible to Bexsero. The ST32 strain at UCSB is a fHbp 1.1 variant. The fHbp 1.1 is an exact match to one of the 4 component antigens in the vaccine. This specific information has been known at least since December 11, when I talked to Dr. Amanda Cohn of the CDC.

cplete (anonymous profile)
December 26, 2013 at 12:13 a.m. (Suggest removal)

As a community, we need to be proactive about this situation, given the high stakes involved. Remember, this is a disease with a 10% fatality rate, and a 20% permanent disability rate. Dr. Tom Clark of the CDC said in his public statements that “If you look back at the meningitis [strain B] outbreaks we’ve seen, out of the 13 we looked at, 11 were four cases or fewer.” In my private conversation with Dr. Cohn, also of the CDC, she tailored this risk specifically to college campuses, and told me that in 2 out of 4 menB outbreaks on college campuses the outbreak was prolonged. So how do we feel about this risk, ranging from 2/13 (15%) to 2/4 (50%) that more of our students could contract an often fatal disease?

The email sent out on December 23rd from Chancellor Yang and Dr. Ferris at UCSB to parents and students seemed to convey that the vaccine was actively being advocated for: "While we are reassured that no additional cases of meningococcal disease have occurred in community members since November 21, 2013, the nature of the disease and the cases at Princeton University this fall support moving forward with vaccination."

We actually should not be reassured at all that the last reported UCSB case was November 21st. Remember also that at Princeton University, the initial cases were a month apart, and then there was a 3 month lull between the 5th and 6th cases...and they went on to have 2 more cases after that. This is the nature of prolonged meningitis B outbreaks.

Your statement that "The CDC is continuing to work with UCSB on the multistep process involved in obtaining access to the vaccine, should it be necessary..." is a stock phrase I keep encountering from officials in form letters, and it's just inappropriate. The vaccine is undoubtedly necessary.

Yesterday there was an opinion piece published in the Annals of Internal medicine by 2 experts on the field, Drs. Feemster and Offit from the Children's Hospital of Philadelphia, in which they discuss the menB outbreaks at Princeton and UCSB. They explicitly state that Bexsero is of proven safety and efficacy. In their conclusion, they state:
"Although the efforts implemented by Princeton and public health authorities will probably mitigate this outbreak, the tool that would most likely have prevented it [Bexsero] was not accessible. Our ability to mobilize resources in response to this situation should compel us to take measures to ensure access to this prevention tool with proven safety and efficacy to all who are at risk." Ann Intern Med. Published online 24 December 2013 doi:10.7326/M13-2927

I agree with Drs. Feemster and Offit wholeheartedly. Bexsero is of proven safety and efficacy. Our students are at risk. Let's not be complacent and let bureaucracy get in the way of what our students need, which is a meningitis B vaccination program, as soon as possible.

Cristina Lete, MD

cplete (anonymous profile)
December 26, 2013 at 12:13 a.m. (Suggest removal)

To respond to the opinions expressed in the above comment:

Most Serogroup B meningococcal outbreaks stop after 3 or 4 cases. Since the Public Health Department and UCSB implemented a number of proactive, forward-thinking measures after the fourth case (expanded chemoprophylaxis and cancelling Greek social events to name a few), there have not been further cases. It is very reasonable for me to hold the opinion that we probably won't have more cases as part of this particular acute outbreak. To say that does not mean that UCSB will never have another case; to the contrary, I expect they will have cases in the future as they have a large population of students living in congregate settings, and this is a known risk factor for contracting this disease.

One should also keep in mind that there is much more going on behind the scenes to respond to outbreaks than is readily visible to an outside observer. Health officials, UCSB, and the CDC are working tirelessly- around the clock and through holidays- to implement preventive measures, not all of which I am able to discuss at this point. We, too, are parents and community members whose only motivation is to protect students and do the right thing. We wouldn't have entered public service otherwise.

More updates on the status of the investigational vaccine will be provided as they become available. UCSB should be commended for their commitment to pursue this vaccine, as it is requiring an enormous amount of effort and resources on their part.

Thank you for your interest in this topic.

Charity Thoman

cthoman (anonymous profile)
December 26, 2013 at 5:14 p.m. (Suggest removal)

Yes, you're an insider and I'm an outsider. Thanks for clearing that up.

Neither you nor I nor any of the brilliant and dedicated public servants involved know whether another case of menB will or will not occur on the UCSB campus. Given a 15 to 50% chance (based on public and private statements from CDC officials) that another student may contract an often-fatal disease, and also given that a safe and effective vaccine exists, it would be immoral to withhold this vaccine until a fifth case develops...and yet, the public statements from the CDC up until the 12/23 announcement (that they were finally filing the IND application with the FDA) all reflected that strategy. It was as though the teachable moments from the Princeton outbreak had become lessons unlearned. In the 8 weeks it took from the IND filing until the vaccination program was initiated at Princeton, 2 more of their students fell ill.

I was full of optimism about getting Bexsero to the UCSB student body after the announcement of the IND application was made, until I read your piece above. With your use of the phrase, "The CDC is continuing to work with UCSB on the multistep process involved in obtaining access to the vaccine, should it be necessary..." I wasn't sure if you wrote the piece prior to the 12/23 turnabout by the CDC, or if the involved agencies were backing off on their commitment.

As an "outside observer" who happens to be a parent of a UCSB freshman, I'm not ready to start awarding commendations to anyone just yet. I reserve judgment until these students have access to the vaccine.

You say you want to "stay transparent and direct with the public," but yet you still insist on perpetuating this idea that "the specific bacteria associated with the UCSB outbreak have to be tested [for effectiveness against the UCSB strain]..." Not true. The strain is susceptible to the vaccine. The students are at risk. The time is now to implement a menB vaccination program at UCSB. The ball, it would seem, is now in the FDA's court.

Don't placate. Don't obfuscate. Advocate! And vaccinate.

cplete (anonymous profile)
December 26, 2013 at 9:20 p.m. (Suggest removal)

My husband talked with Dr. Tom Clark of the CDC today.

He assured us that there is no scenario in which the FDA will not approve the CDC's IND application...good news!

Also, the goal of the University and the CDC is absolutely to get Bexsero to the campus...nothing wishy-washy. Also good news!

He explicitly stated that the goal is to offer the vaccine to all undergraduates at UCSB.

He could NOT give us a timeline for the vaccine's appearance on our campus. He wants to see the vaccine doses offered about 2 months apart, and everyone fully vaccinated before the school's summer break.

Interesting insights:
He told my husband that the UCSB strain is known as "the Oregon strain" which caused a smoldering outbreak in the Pacific northwest for a decade in the 1990's.

He told us that the UCSB strain is without question susceptible to Bexsero.

He expressed concern that student apathy and/or misguided concern about an "investigational" vaccine may cause the campaign to fall short. He was very pleased with the >90% vaccination rate achieved at Princeton University.

So Dr. Thoman, I have some requests:

1. Stop telling the UCSB students that they probably don't have anything to be concerned about. The threat of an ongoing outbreak is very very real.

2. Stop using the term "investigational" when referring to Bexsero.
This term is only technically correct in a bureaucratic jargon sort of sense. It leaves people with the mistaken impression that they are being experimented on, and undermines your public health goal, which is to protect these vulnerable students by vaccinating as many as possible. From the CDC website: "FDA has concluded that the benefits of using the vaccine to prevent meningococcal disease outweigh the risks of possible adverse events in certain outbreak situations."

3. Use your bully pulpit to advocate for the public good. Make people aware of the importance of this vaccine, and do whatever is in your power to help these students get access.

cplete (anonymous profile)
January 3, 2014 at 4:22 p.m. (Suggest removal)

The_Flu_Guru (anonymous) says...
The media completely missed th e shift in CDC tone.

Dr.Lete is the Erin Brockovitch of this story and she is right on many points. The term "investigational" should be scrapped, along with "herd immunity" and other bad nomenclature.
The petition linked at the causes website seeks theCDC IND via FDA (!) but also inclusion in the IND of UCSB staff and IV's legions of dumpster diving houseless who handle thousands of beer cans daily.

Geof Bard
The Cough Hygiene Initiative

The_Flu_Guru (anonymous profile)
January 6, 2014 at 9:04 p.m. (Suggest removal)

Another piece of bad terminology or nomenclature is the way public health uses the tern "surveillance" as in "disease surveillance" or "CDC Weekly Surveillance Report".

That kind of jargon is very alienating to people in the community/ For instance, there was a meningitis outbreak in Brazil during a time when the military government was allegedly responsible for disappearances of trade unionists, students, members of the press who were presumably subjected to extrajudicial execution imprisonment or exile. The junta ordered everyone vaccinated and used the military to line people up to enforce the edict.

That sort of approach is not likely to go over well in the US. We need to build trust and understanding,In fact, an angry mob recently besieged Santa Barbara City Council to denounce the gang injunction, and one might expect that many of those same people would bristle at the notion that they are subject to "surveillance" by the CDC or anyone else,

There is growing concern with surveillance by the NSA, and stickers can be seen around town somewhat sarcastically advising people :you are under surveillance".

No one wants to be "surveilled", CDC should lead the way and review nomenclature and substitute new terms which are not so heavility loaded,

As Dr, Lete has pointed out, the terms of art can be misleading, They may do more harm than good, This is only part of what she has brought to light, but an important part,

Reference: The Coming Plague by Laurie Garrett, p 64 "Disapearnance was a euphemism for death..."

Note also at p 65: "The [meningitis] bacteria [in Brazil]...could be passed...via shared towels, clothing cleaning rags or kerchiefs."

The_Flu_Guru (anonymous profile)
January 10, 2014 at 1:15 p.m. (Suggest removal)

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