Surveillance and Case Investigation

The New York City Health Code requires that IMD cases be reported immediately to DOHMH. Every reported IMD case is investigated to confirm the diagnosis, identify close contacts for antimicrobial drug prophylaxis, obtain risk factor information, characterize the isolate by serogroup and by pulsed-field gel electrophoresis (PFGE) at the New York City Public Health Laboratory. Case investigations include medical record review and interviews with health care providers, family members, close contacts, and the patient when possible. Antimicrobial drug prophylaxis is offered to persons who had prolonged close contact, both sexual and non-sexual, with the patient during the infectious period. For this outbreak, the case definition used was a clinically compatible illness for serogroup C meningococcal disease meeting the 2010 Council of State and Territorial Epidemiologists case definition for a confirmed or probable case in an MSM (9).

After DOHMH identified the serogroup C meningococcal disease outbreak and its association with MSM in September 2012, case investigators attempted to re-interview all male IMD case-patients in New York City since 2010 to explicitly inquire about sexual identity and behavioral risk factors and to identify any additional cases. Although sexual contacts are routinely elicited during all IMD case investigations, DOHMH staff did not previously record information about a patient’s sexual identity or sexual history beyond their period of infectiousness. During the outbreak period, 7 cases of serogroup C meningococcal disease were diagnosed in non-MSM; these cases were not considered to be part of the outbreak.

Vaccine Initiative and Tracking Vaccine Uptake

After the vaccine recommendation was made, DOHMH implemented an immunization initiative consisting of vaccine distribution and outreach events. DOHMH began tracking the aggregate number of doses administered at its clinics. In addition, public and private health care facilities with large MSM and HIV-infected patient populations were asked to make regular summary reports of meningococcal vaccine administration to MSM. The size of the population targeted for vaccination was estimated by using data from the New York City Community Health Survey and the HIV Surveillance Registry of DOHMH.

In the United States, quadrivalent meningococcal vaccine is used routinely and provides protection against N. meningitidis serogroups A, C, W, and Y. One dose is recommended for children 11–12 years of age, with a booster dose at age 16. This vaccine is also routinely recommended for first-year college students living in residential housing, travelers to disease-endemic areas, laboratory workers, and those at increased clinical risk (10).

Outbreak

Figure 1

Figure 1. Monthly invasive serogroup C incidence and cumulative vaccine uptake, New York City, New York, USA, 2009–2015. *Vaccine uptake among MSM only as part of outbreak response. MSM, men who have sex...

We identified 22 outbreak-related cases of serogroup C meningococcal disease during August 2010−February 2013 (Figure 1). The first case occurred in August 2010, and 8 additional cases occurred intermittently over the next 24 months. Transmission increased in September 2012; a cluster of 4 cases was diagnosed within 4 weeks. All 4 case-patients were HIV infected, and 2 reported sexual contact with each other. At that time, DOHMH formally recognized the outbreak, issued a vaccine recommendation (on October 4, 2012), and began implementing response efforts. The initial provider recommendation was to administer meningococcal vaccine to “HIV-infected men who are New York City residents and who had intimate contact with a man met either through an online website, digital application (app), or at a bar or party since September 1, 2012” (11). In accordance with the official Centers for Disease Control and Prevention (CDC) recommendation, those who were HIV infected and considered themselves at risk were encouraged to get a second dose of vaccine 8 weeks after the first dose (10).

Three additional cases of serogroup C meningococcal disease (1 in an HIV-infected person) were identified in MSM before mid-November 2012, shifting the epidemiology of the outbreak to indicate an association with certain neighborhoods in Brooklyn. This finding prompted revision of the vaccine recommendation to “men who have sex with men, regardless of HIV status, if they live in specific areas of Brooklyn and report intimate contact with a man met either through an online website, digital application (app), or at a bar or party since September 1, 2012” (12). Six additional cases were detected (3 in HIV-infected persons), including a cluster of 4 in early 2013, but the association with Brooklyn weakened. DOHMH further expanded the target population for vaccination in March 2013 to include all areas of the city and all HIV-infected MSM, regardless of risk behavior, in addition to MSM not infected with HIV who met the risk criteria (13). With no new cases identified 12 months after the final February 2013 case, DOHMH declared the outbreak over in March 2014.

Of the 22 outbreak-related cases identified, 7 (32%) were fatal. Co-infection with HIV was present in 12 (55%) case-patients, 5 (42%) of whom died. The age range of the case-patients was 21−59 years (median 31 years, mean 34 years). Case-patients lived throughout the city; the largest proportion (10 [45%]) lived in Brooklyn. Eleven (50%) case-patients were African American, and 4 (18%) were Hispanic or other. Eleven (50%) reported using recreational drugs; of the 15 case-patients for which a determination could be made, 9, including the index case-patient; reported using websites and mobile phone applications (apps) to connect with other men looking for sexual partners (Table 1).

Isolates from 15 case-patients were available for PFGE; 14 (93%) isolates were >85% related to the unique outbreak strain, and 9 (64%) of these were indistinguishable from it. These 15 case-patients had culture-confirmed results. The remaining 7 case-patients had culture-negative results; these 7 case-patients were given a diagnosis by PCR. During the outbreak period, an additional 7 cases were diagnosed in non-MSM; isolates from 6 were available for PFGE and only 2, both in women, were found to be >85% related to the outbreak strain. None of the cases in non-MSM were considered to be part of the outbreak.

DOHMH estimated that in 2012, MSM in New York City were 52.5 times (95% CI 19.9−137.4) more likely to contract IMD than other male residents 18−64 years of age (12.6 cases/100,000 MSM compared with 0.24 cases/100,000 unknown or non-MSM). Furthermore, HIV-infected MSM (21.2/100,000) had 88.3 times (95% CI 30.5−252.9) the relative risk for infection than unknown or non-MSM residents of New York City in 2012 (Table 2).

Vaccination Initiative

After the initial recommendation was issued, vaccine was made available, free of charge, at DOHMH clinics in 9 locations throughout New York City. DOHMH staff also identified private health care facilities with large HIV-infected and MSM patient populations and encouraged them to administer vaccine to persons at risk and facilitated procurement and distribution of vaccine when necessary. It is estimated that >20,000 men were vaccinated with >1 dose during October 2012−August 2013 in New York City.

DOHMH also staged free vaccine events at bars and clubs geared toward MSM to provide convenient, stigma-free opportunities for men at risk to get vaccinated. A prominent MSM party promoter was hired to host and oversee marketing of these events, including the creation of a Facebook page and a promotional YouTube video (14). Vaccine uptake was much lower than expected; health officials administered only 85 doses at 4 DOHMH-sponsored events. Recognizing the value of supporting established patient–provider relationships, DOHMH also supplied vaccine for events hosted by clinicians with a history of treating HIV-infected and MSM patients. These events were staged on-site at their clinical facilities, as well as off-site at MSM bars, sex clubs, and 2013 NYC Pride parades and parties. Demand was much higher at these non-DOHMH events, which facilitated the administration of >2,800 doses of vaccine.

Outreach Campaign

To promote vaccination among the at-risk subset of the MSM population in New York City, DOHMH began a multifaceted outreach campaign in October 2012. The components of the campaign can be divided into 2 general categories.

Direct and Internet-Based Outreach

Figure 2

Figure 2. Meningococcal vaccination campaign outreach poster, New York City, New York, USA.

DOHMH provided updates to health care providers through the Health Alert Network, mailed and posted educational materials, and resources to facilitate vaccination (e.g., screening forms, consent forms, billing information) on its website and gave presentations at academic medical centers, large clinics, and community-based organizations. To reach MSM at risk, DOHMH distributed >1,200 posters (Figure 2) and >70,000 palm cards at locations geared toward MSM through established community-based partners participating in the DOHMH condom distribution program. Materials were printed in English, Spanish, Chinese, Japanese, Korean, and Thai.

Beginning in October 2012, DOHMH disseminated information through Twitter and >100 websites and blogs with high MSM viewership and paid for banner and pop-up advertisements on websites and apps targeting MSM, including the app Grindr. In addition, email messages were sent en masse to all registered members of Manhunt, DaddyHunt, and Adam4Adam. When possible, communications were targeted to reach only users in New York City and, before the expansion of the vaccine recommendation, only users who identified themselves as HIV infected.

Click-through proportions, defined as the number of persons who saw the advertisement/ message and clicked to get more information divided by the number of times the advertisement/message appeared, were used to evaluate the effect of these communications. In November 2012, a total of 40,116 (0.82%) of 488,000 pop-ups ads and 2,782 (0.06%) of 463,645 banner ads were clicked on, compared with 87 (14.5%) of 605 email blasts to users of a popular hook-up website. Of 266 users surveyed, 118 (44%) recalled receiving an email about the outbreak and 77 (29%) of users recalled seeing one of the banner ads run on the site.

Engagement of External Partners and Mainstream Media Coverage

To promote vaccination, DOHMH communicated with and distributed educational materials to community organizations and elected officials representing large numbers of MSM. To address challenges with provider reimbursement, New York state regulators notified health insurers that all insurance plans must cover the cost of meningococcal vaccination. DOHMH also worked with legislators to help design a bill authorizing New York pharmacists to administer vaccine; this bill was signed into law by the governor in July 2013.

Figure 3

Figure 3. Weekly invasive meningococcal disease incidence among men who have sex with men (MSM) and vaccine uptake, New York City, New York, USA, August 2012–2013, encompassing the last of 13 of 22...

Some small-scale print and electronic publications reported the story during the first few months of the vaccine campaign, but it was not until The New York Times ran a comprehensive article on March 21, 2013, more than a month after the last associated case was diagnosed, that the outbreak was featured in a variety of other more high-profile publications and engendered substantial coverage on social media sites (15). This pattern was repeated with 2 subsequent articles in The New York Times that provided updates on the outbreak; both articles also spurred additional reporting by other media outlets (16,17). These articles appeared to have a much more substantial effect on vaccine uptake than any of the other outreach initiatives (Figure 3).