Part III. Meningococcal and HPV Infections: Who’s at Risk?

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The college dormitory population is well-recognized for its risk for fatal meningococcal sepsis and as a target for inoculation, but other populations are also susceptible. Persons born with deficiencies in the complement pathway are at 10,000-times greater risk than the general population for a meningococcal infection. A newer medication that targets the terminal complement pathway-eculizumab (binds to C5), used to treat paroxysmal nocturnal hemoglobinuria-renders the recipient even more susceptible to meningococcal infections. People who have had the spleen removed, those with sickle cell disease, professionals (eg, microbiologists) who work with Neisseria meningitides and individuals inadvertently exposed to the bacterium are also at serious risk and should receive vaccine coverage.^1,2

Six of 12 meningococcal serotypes (A, B, C, W, X, and Y) are responsible for the majority of infections. The 2 major vaccine types target serotypes A, C, W, Y (quadrivalent [MenACWY]) and serotype B (MenB).²

Current US meningococcal vaccination recommendations are: A quadrivalent vaccine should be given at age 11-12 years with revaccination at age 16 years. Because of the “college dormitory” risk, if a first-year student has not received a quadrivalent dose at age 16 or after, it should be given before they begin school.^1,2

Since serogroup B is responsible for 40% of US cases, its use may be considered (not required) in the usual at-risk groups including college students living in close quarters.

A few questions will let you apply what you know about the vaccine and the N. meningitides infection.

ANSWER AND DISCUSSION »

[[{"type":"media","view_mode":"media_crop","fid":"53149","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_4163632253873","media_crop_h":"173","media_crop_image_style":"-1","media_crop_instance":"6630","media_crop_rotate":"0","media_crop_scale_h":"75","media_crop_scale_w":"127","media_crop_w":"292","media_crop_x":"36","media_crop_y":"23","style":"float: right;","title":"","typeof":"foaf:Image"}}]]Answer: D is false

As with persons with complement deficiencies, asplenic persons should be boosted every 5 years.^1,2

Close contacts of persons infected with meningococcus have a 100-times greater risk of developing an infection after exposure. The risk is immediate-infection may occur within 72 hours-and therefore antibiotic prophylaxis should begin immediately.

ANSWER AND DISCUSSION »

Answer: B. Ceftriaxone, 250 mg, IM, once

Antibiotic recommendations are: ciprofloxacin 500 mg, one dose; ceftriaxone 250 mg, intramuscular one dose; rifampin 600 mg PO twice a day for 2 days; azithromycin 500 mg one dose. Remember that it is critical to check your local resistance patterns. There are regions with increasing ciprofloxacin and rifampin resistance.²

NEXT QUESTION »

HPV: So many reasons to focus on adherence

[[{"type":"media","view_mode":"media_crop","fid":"53153","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_9313977982131","media_crop_h":"297","media_crop_image_style":"-1","media_crop_instance":"6631","media_crop_rotate":"0","media_crop_scale_h":"141","media_crop_scale_w":"150","media_crop_w":"315","media_crop_x":"5","media_crop_y":"39","style":"float: right;","title":"","typeof":"foaf:Image"}}]]The imperatives for administering the HPV vaccine series to eligible youth include more than prevention of invasive cervical cancer in women. The Centers for Disease Control recently reported some disturbing news about the oncogenic potential of HPV. From 2004 through 2008, there were 33,369 HPV cancers in the population.³ Unfortunately, from 2008 through 2012 there was a 17% increase in HPV cancers (n=38,793 annually).³  In addition to cervical cancer, the virus causes anal, oropharyngeal, and head and neck cancers in women and men and also penile cancer in men.³ Attention to appropriate vaccine administration could prevent 28,500 cases of cancer caused by HPV.³

ANSWER AND DISCUSSION »

Answer: C and D are false

[[{"type":"media","view_mode":"media_crop","fid":"53154","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_1307541484414","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"6622","media_crop_rotate":"0","media_crop_scale_h":"100","media_crop_scale_w":"100","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"","typeof":"foaf:Image"}}]]Vaccination against HPV is recommended by the CDC up to age 26 years for men who have sex with men. Anogenital warts are caused by HPV types 6 and 11, not types 16 and 18.³

Between June 2006 and March 2016, there were nearly 90 million doses of HPV vaccines distributed in the United States. Among adverse events reported, most have not been serious, eg, syncope, headache, injection site reactions. No deaths have been attributed to the vaccines.⁴

There are 3 vaccines available³:

• Quadrivalent (HPV 6, 11, 16, and 18)
• 9-valent (6, 11, 16, 18 as well as types 31, 33, 45, 52, and 58)
• Bivalent vaccines (16 and 18)

All 3 prevent cervical disease in women. Rates of cervical, vaginal, and vulvar disease in women were the same after quadrivalent and 9-valent vaccines.⁵

ANSWER AND DISCUSSION »

Answer: B and D are true

[[{"type":"media","view_mode":"media_crop","fid":"53155","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_3289362335760","media_crop_h":"191","media_crop_image_style":"-1","media_crop_instance":"6632","media_crop_rotate":"0","media_crop_scale_h":"100","media_crop_scale_w":"162","media_crop_w":"309","media_crop_x":"25","media_crop_y":"16","style":"float: right;","title":"","typeof":"foaf:Image"}}]]HPV is not a live vaccine, so it can be given to patients with HIV and have lower CD4 counts, at the discretion of the treating physician.⁶ The CDC recommends that the HPV vaccine not be given to pregnant women. If a woman is found to be pregnant after the HPV series has been initiated, the remainder of the 3-dose series should be delayed until the post-partum period. Pregnancy testing is not needed before vaccine initiation.⁵

It is recommended on the vaccination information sheet (VIS) for Cervarix that the administering physician should be alerted if the person getting vaccinated has any severe allergies, including an allergy to latex. Latex may be a component of vaccine packaging.⁷

For Part IV: Adult Vaccination: Special Populations »

For Part I: Adult Vaccination: Patients with Diabetes Mellitus

For Part II: Older Adults

References:

1. CDC Advisory Committee on Immunization Practices. Recommended Adult Immunization Schedule United States - 2016 Adult Schedule. http://www.cdc.gov/vaccines/schedules/hcp/adult.html

Recommended Adult Immunization Schedule United States – 2016 PDF

https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&ved=0ahUKEwi139aRk6PPAhUq6oMKHaDiDSUQFgglMAE&url=http%3A%2F%2Fwww.cdc.gov%2Fvaccines%2Fschedules%2Fdownloads%2Fadult%2Fadult-combined-schedule.pdf&usg=AFQjCNGK0j42zhXLFlRxOz2-GSggbvPZ_Q&cad=rja

2. Crum-Cianflone N, Sullivan E. Meningococcal vaccinations. Infect. Dis. Ther. 2016; 5:89-112. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4929086/

3.  Viens L J, Henley SJ, Watson M, et al. Human papilloma-associated cancers-United States, 2008-2012. Morbidity and Mortality Weekly Report (MMWR) 2016;65;661–666. http://www.cdc.gov/mmwr/volumes/65/wr/mm6526a1.htm

4. CDC Vaccine Safety. Specific Vaccines Human Papillomavirus (HPV) Vaccine Safety Frequently Asked Questions about HPV Vaccine Safety. http://www.cdc.gov/vaccinesafety/vaccines/hpv/hpv-safety-faqs.html

5. Petrosky E, Bocchini JA, Hariri S. Use of 9-valent human papillomavirus (HPV) vaccine: Updated HPV vaccination recommendations of the Advisory Committee on Immunization Practices. Morbidity and Mortality Weekly Report (MMWR) 2015; 64: 300-304. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6411a3.htm

6. CDC. Vaccine information for adults. HIV Infection and Adult Vaccination.  http://www.cdc.gov/vaccines/adults/rec-vac/health-conditions/hiv.html

7. CDC. VIS Home. HPV (Human Papillomavirus) Cervarix® VIS. http://www.cdc.gov/vaccines/hcp/vis/vis-statements/hpv-cervarix.html