VDH Clinician Letter: Meningococcal Disease Outbreak Update, Invasive Group A Strep Infections

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Via vdh.gov

Dear Colleague:

I am writing to provide you with important updates on several emerging conditions of public health significance.

Meningococcal Disease Outbreak in Eastern Virginia

The Virginia Department of Health continues to respond to a community outbreak of meningococcal disease in the eastern region of Virginia.  Twelve cases of invasive meningococcal disease (IMD) serogroup Y have been reported since June 2022 in eastern Virginia,  a doubling of cases since VDH notified eastern region providers in September 2022.  Most case-patients have presented with symptoms of IMD meningococcemia, including fever, chills, nausea, and vomiting.  All isolates available for sequencing (9 out of 12) were genetically related and susceptible to ciprofloxacin and penicillin.  VDH has not identified a common risk factor; we suspect the cases are connected by asymptomatic community transmission.  Case-patients are all residents of Hampton Roads and most are Black or African American adults between 30-60 years of age.  Eleven case-patients are unvaccinated for serogroup Y, and one is partially vaccinated.  Three case-patients have died from complications associated with the disease, indicating this outbreak strain may have a higher case fatality rate (25% CFR) than is commonly observed in serogroup Y cases.  This strain is believed to be circulating more widely, both in Virginia and other states.

VDH responds to reports of suspect meningococcal disease by rapidly identifying close contacts for whom short-term antibiotics are recommended for prophylaxis and recommending one dose of the meningococcal conjugate vaccine (MenACWY) to all outbreak-associated close contacts who are identified as high-risk for meningococcal disease.

Healthcare Providers should maintain a high index of suspicion for IMD.  Immediately notify your local health department (LHD) of clinical findings or laboratory results of gram-negative diplococci or Neisseria meningitidis from a normally sterile site. Your LHD can coordinate sending specimens/isolates from newly identified cases to the Division of Consolidated Laboratory Services (DCLS) for serotyping.  Ensure that all individuals who are high-risk for meningococcal disease are up-to-date on the MenACWY vaccine.  Continue to encourage routine administration of the MenACWY vaccine in younger children and adolescents, as required for students enrolled in the 7th and 12th grades.

Increase in Invasive Group A Strep Infections

The Centers for Disease Control and Prevention (CDC) have noted an increase in invasive group A Streptococcus (iGAS) infections in children in the United States.  Although the number of iGAS cases reported in children in Virginia is not above average for this time of year, we are observing increased activity in general.  Group A Streptococcus bacteria can cause a range of illnesses; severe iGAS infections include necrotizing fasciitis and streptococcal toxic shock syndrome and require immediate treatment, including appropriate antibiotic therapy.

VDH responds to reports of suspect iGAS infections by rapidly identifying close contacts for whom short-term antibiotics are recommended for prophylaxis, and urgently investigating clusters of GAS infections, especially in high-risk settings such as among residents of long-term care facilities and school aged children.

Please consider the following actions:

  • Consider iGAS as a possible cause of severe illness, including in children and adults with concomitant viral respiratory infections. Be mindful of potential alternative agents for treating confirmed GAS pharyngitis in children due to the shortage of amoxicillin suspension.
  • Offer prompt vaccination against influenza and varicella to eligible persons. Educate patients, especially those at increased risk, on signs and symptoms of iGAS requiring urgent medical attention, especially necrotizing fasciitis, cellulitis and toxic shock syndrome.
  • Notify your local health department (LHD) as soon as possible about severe iGAS cases affecting minors or clusters of any iGAS infections. All cases of Streptococcal disease, Group A, invasive or toxic shock should be reported within 3 days to VDH.  Laboratories in Virginia are required to submit GAS isolates to DCLS when cultured from a normally sterile site.

Thank you for your attention and partnership.

Sincerely,

Laurie Forlano, DO, MPH
Acting State Epidemiologist and Director
Office of Epidemiology