Invasive Meningococcal Disease Among People Experiencing Homelessness—United States, 2016–2019

Abstract

Background Recently, several invasive meningococcal disease (IMD) outbreaks caused by Neisseria meningitidis have occurred among people experiencing homelessness (PEH). However, overall IMD risk among PEH is not well described. We compared incidence and characteristics of IMD among PEH and persons not known to be experiencing homelessness (non-PEH) in the United States. Methods We analyzed 2016–2019 IMD data from the National Notifiable Diseases Surveillance System (NNDSS) and enhanced meningococcal disease surveillance. Incidence was calculated using U.S. census data and Point-in-Time counts from the U.S. Department of Housing and Urban Development. Results Of cases from states participating in enhanced surveillance during 2016–2019 (n = 1409), 45 (3.2%) cases occurred among PEH. Annual incidence was higher among PEH (2.12 cases/100,000) than non-PEH (0.11 cases/100,000; relative risk: 19.8, 95% CI: 14.8–26.7). Excluding outbreak-associated cases (PEH n = 18, 40%; non-PEH n = 98, 7.2%), incidence among PEH remained elevated compared to incidence in non-PEH (relative risk: 12.8, 95% CI: 8.8–18.8). Serogroup C was identified in 68.2% of PEH cases compared to 26.4% in non-PEH (p < 0.0001). Conclusions PEH are at increased risk for IMD. Further assessment is needed to determine the feasibility and potential impact of meningococcal vaccination for PEH in the United States.

Differences in meningococcal disease incidence by health insurance type and among persons experiencing homelessness—United States, 2016–2019

“…Our finding that meningococcal disease incidence among PEH enrolled in Medicaid was 27 times higher than among non-PEH is consistent with a recent analysis of enhanced meningococcal disease surveillance data from the same period, which found that incidence was 19.8 times higher among PEH than non-PEH nationally, or 24.6 times higher among persons aged 18 or more years [5]. Of note, this article also described outbreaks among PEH, including 10 meningococcal disease outbreak cases identified among PEH in Boston, Massachusetts, from 2016 through 2019.…”

“…Since our analysis suggests that the presence of certain underlying health conditions may contribute to, but does not fully explain, the increased risk of meningococcal disease among PEH, ensuring PEH have reliable access to the appropriate health care for managing underlying conditions is crucial for the overall health of this population and reduction of infectious disease risk. Additionally, exposure to crowded living conditions has been associated with increased risk of meningococcal disease [2], which is an important consideration for homeless shelters as some meningococcal disease outbreaks have included PEH who visited these facilities [5]. While PEH experience higher rates of vaccine-preventable diseases than the general population, it can be challenging to vaccinate PEH for several reasons, including lack of access to preventative health care, mistrust of providers, and lack of information about infectious disease risk or the importance of vaccination [16][17][18].…”

“…However, the prior claimsbased analysis included data from over 10 years ago (2006)(2007)(2008)(2009)(2010), from a subset of anonymous state Medicaid programs, excluded persons less than 19 years of age, and relied on a non-specific definition of meningococcal disease. Furthermore, a recent analysis of enhanced meningococcal disease surveillance data has demonstrated an increased risk among persons experiencing homelessness (PEH), with incidence observed to be 19.8 times higher than among persons not known to be experiencing homelessness (non-PEH) [5]. Neither of these prior analyses were able to ascertain whether the observed higher risk could be attributed to other factors known to impact meningococcal disease risk, such as concurrent underlying health conditions, crowded living conditions, or exposure to tobacco smoke.…”

Meningococcal B Immunisation in Adults and Potential Broader Immunisation Strategies: A Narrative Review

“…Mass gatherings and religious events such as the Hajj and Umrah pilgrimages are also well-recognized risk factors for meningococcal transmission and subsequent outbreaks [ 18 , 19 ]. Risk is also greater in people experiencing homelessness [ 20 ], and in immigrant and refugee populations [ 21 ]. Tobacco smoking and passive exposure may also increase IMD risk [ 22 ].…”

Invasive Meningococcal Disease and COVID-19 Co-Infection: A Case Report

“…Unstable living conditions have been identified as an extrinsic risk factor for increased exposure to infectious diseases, including meningococcal disease. Homelessness, for instance, is associated with higher meningococcal disease risk due to shelter overcrowding, lower vaccination rates, and increased exposure to other infectious diseases [ 4 , 12 ].…”