Sunday, April 10, 2016

Insights from Meningitis Outbreak at Princeton University and How it Was Managed

Last Thursday, after teaching my Humanitarian Logistics and Healthcare class and holding office hours, which went overtime  because of a great discussion with one of my students who has spent time in Haiti on multiple service trips post the earthquake, I grabbed a quick lunch and then ran in the rain to the UMass Amherst Campus Center.

I had been invited by Mr. Jeff Hescock, who is the Director of Emergency Management and Business Continuity  at UMass Amherst to view an emergency dispensing exercise and to also hear a presentation by Robin Izzo, who is the Director of Environmental Health and Safety at Princeton University.

Mr. Hescock has spoken in my Humanitarian Logistics and Healthcare class and I have, along with several students,  also had an opportunity to take part in a previous year at a mass sheltering exercise at the Mullins Center.

Ms. Izzo was speaking on the meningitis B outbreak that took place at Princeton University not that long ago and the challenges with vaccination, so this was a presentation that I did not want to miss. Plus, nursing students and others were to then take part in a training exercise and simulation associated with a mass vaccination at UMass. A co-organizer of this event was  nurse Ann Becker of the Medical Reserve Corps. posted a nice article and interview with Becker online.

Izzo is also the incident manager at Princeton and is responsible for communications and logistics in emergencies. The first case of meningitis B struck Princeton University in March 2013 and the student who had been on spring break in Florida went right home so he had not been on campus for 9 days. Princeton has about 5,200 undergraduates and 3,000 graduate students.  A few weeks after a 17 year old high school student who had spent time in one of the dorms contracted meningitis B, which is transmitted primarily through saliva.  Afterwards there was a case of  a Princeton student on campus who then attended a wedding in NYC.  Three cases signified that there was a cluster and there were more than three cases in three months.

The health department was notified as well as the Centers for Disease Control (CDC).  Given that almost all the Princeton students live on campus in dormitories and housing, this provided a perfect environment for contagion. Ultimately there were 9 cases, including a Drexel University student who had spent time at Princeton and who then died of this disease, which was quite terrifying. This death made national headlines.

Plus, at that time, there was no licensed vaccine for meningitis B, although Europe and Australia  had a vaccine that it was using.

Pursuing a mass vaccination campaign with an unlicensed vaccine, which was suggested by the CDC,  HAD NEVER BEFORE BEEN DONE IN THE UNITED STATES! Luckily, the FDA quickly approved this vaccine, known as Bexsero, and the first day of vaccinations took place on December 9, 2013. Two doses of this vaccine were needed per patient and, interestingly, it is only for those aged 10 to 25, so many faculty and staff were obviously very apprehensive.

Izzo stated that over the Thanksgiving of 2013 many parents were telling their children at Princeton not to come home since they were so worried about infection. According to Izzo, even if you do get vaccinated, you can still be a carrier for 6 months. Also, among the 8 cases at Princeton, there was no temporal connection.

She described Princeton as being a "really, really scary place" and I know of several faculty who teach there and also students from western Massachusetts who were there during the outbreak.

Information was disseminated to parents and many events during the 2013 - 2014 period were held but with extra care taken. Challenges included big events and reunions. Princeton students who were taking part in study abroad programs went with Cipro, a powerful antibiotic, and were told to look for tell-tale signs of meningitis B, including a rash.

Rizzo also began a mass communications campaign with student videos to emphasize that one should not be sharing drinking cups (although she shared with us that based on a survey 70% at Princeton said that it would be rude to not accept a drink from someone who has used the same cup or glass!).

The campaign included the bright cups below, which had "Mine Not Yours" on them.  She also emphasized the importance of peer pressure in getting the community vaccinated and protected.
She emphasized that it was important to manage the severity and fear but at the beginning the meningitis B was not feared enough.

She urged that the university, health department, and CDC should always speak "with one voice" in such emergencies.   After the first clinic was held,  96-100% of the students received a dose o fthe vaccine.

During the spring and summer of 2014 no overnight guests were allowed in Princeton dorms.  In October 2014, the FDA cleared a new vaccine, made by Pfizer, which requires 3 doses.

On March 13, 2015, Princeton University was considered no more likely than another college as a site for meningitis B.   Interestingly, she noted that there are areas of the US where this contagious bacterial disease is endemic, including parts of the Pacific Northwest and in the past several years there have been other cases at other universities.

During the Q&A I asked her whether Princeton ever considered closing and she said no. Clearly, there are students from around the world there and they may not be able to go home but there are several colleges this past year alone that closed due to norovirus outbreaks. This enabled the institutions to be thoroughly cleaned and sanitized but I suspect that meningitis B that can lurk in one's body for half a year may be another matter entirely.

I have done research on pharmaceutical supply chains with my students, and there is a lot of interest in the Operations Research community on the modeling of vaccine programs, so this was a very educational and timely event.

Many thanks to both Jeff Hescock and Ann Becker for their efforts! Special thanks to Ms. Izzo for her leadership and insights.