The full content of Annals is available to subscribers

Subscribe/Learn More  >
Original Research |

Elevated Risk for Invasive Meningococcal Disease Among Persons With HIV

Laura Miller, MPH; Lola Arakaki, MPH; Arianne Ramautar, MPH; Sara Bodach, MPH; Sarah L. Braunstein, PhD, MPH; Joseph Kennedy, MPH; Linda Steiner-Sichel, RN, MPH; Stephanie Ngai, BA; Colin Shepard, MD; and Don Weiss, MD, MPH
[+] Article, Author, and Disclosure Information

From the New York City Department of Health and Mental Hygiene, Queens, New York.

Acknowledgment: The authors thank Mike Antwi, Beth Begier, Blayne Cutler, Paula Del Rosso, Marie Dorsinville, James Hadler, Marcelle Layton, and Jay Varma.

Grant Support: By the New York City Tax Levy, the Epidemiology and Laboratory Capacity for Infectious Diseases grant of the CDC (ELC ARRA 317-MCV and 3U50C1223667-05S2), and CDC HIV Epidemiology and Field Services Program cooperative agreements (PS08-80202, no. U62/CCU223595, and PS13-1302, no. 1U62PS003993-01).

Potential Conflicts of Interest: None disclosed. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-1593.

Reproducible Research Statement: Study protocol and statistical code: Available from Dr. Weiss (e-mail, dweiss@health.nyc.gov). Data set: Not available.

Requests for Single Reprints: Don Weiss, MD, MPH, New York City Department of Health and Mental Hygiene, Gotham Center, CN#22a, 42-09 28th Street, 6th Floor, Queens, NY 11101-4132; e-mail, dweiss@health.nyc.gov.

This article was published online first at www.annals.org on 29 October 2013.

Current Author Addresses: Ms. Miller; Ms. Arakaki; Ms. Ramautar; Ms. Bodach; Mr. Kennedy; Ms. Steiner-Sichel; Ms. Ngai; and Drs. Braunstein, Shepard, and Weiss: New York City Department of Health and Mental Hygiene, 42-09 28th Street, Queens, NY 11101-4132.

Author Contributions: Conception and design: L. Miller, S. Bodach, S.L. Braunstein, J. Kennedy, L. Steiner-Sichel, C. Shepard, D. Weiss.

Analysis and interpretation of the data: L. Miller, L. Arakaki, S. Bodach, S.L. Braunstein, S. Ngai, D. Weiss.

Drafting of the article: L. Miller, L. Arakaki, A. Ramautar, D. Weiss.

Critical revision of the article for important intellectual content: L. Miller, L. Arakaki, A. Ramautar, S. Bodach, S.L. Braunstein, J. Kennedy, L. Steiner-Sichel, S. Ngai, C. Shepard, D. Weiss.

Final approval of the article: L. Miller, L. Arakaki, A. Ramautar, S. Bodach, S.L. Braunstein, J. Kennedy, L. Steiner-Sichel, S. Ngai, C. Shepard, D. Weiss.

Statistical expertise: L. Arakaki, S. Bodach, S.L. Braunstein, S, Ngai, C. Shepard, D. Weiss.

Obtaining of funding: C. Shepard, D. Weiss.

Administrative, technical, or logistic support: L. Arakaki, A. Ramautar, S. Bodach, J. Kennedy, L. Steiner-Sichel, D. Weiss.

Collection and assembly of data: L. Miller, L. Arakaki, A. Ramautar, S. Bodach, S.L. Braunstein, J. Kennedy, L. Steiner-Sichel, D. Weiss.

Ann Intern Med. 2014;160(1):30-37. doi:10.7326/0003-4819-160-1-201401070-00731
Text Size: A A A

Background: An association between HIV and invasive meningococcal disease (IMD) has been suggested by several previous studies but has not been fully described in the era of highly active antiretroviral therapy in the United States.

Objective: To estimate the risk for IMD and death in people living with HIV/AIDS (PLWHA) in New York City (NYC) and the contribution of CD4+ cell count and viral load (VL) to IMD risk.

Design: Comparison of the incidence rate of IMD among PLWHA with that among HIV-uninfected persons. Surveillance data on IMD for patients aged 15 to 64 years from 2000 to 2011 were matched to death and HIV registries to calculate IMD risk and case-fatality ratios. A subset of PLWHA who had a CD4+ cell count and VL measurement near the time of their IMD infection was included in age-matched case–control analyses to assess HIV markers and IMD risk.

Setting: Retrospective cohort from communicable disease surveillance.

Patients: 265 persons aged 15 to 64 years with IMD during 2000 to 2011.

Measurements: Meningococcal and HIV data abstracted from surveillance and registry databases, including CD4+ cell counts and VL.

Results: The average annual incidence rate of IMD was 0.39 cases per 100 000 persons. The relative risk for IMD among PLWHA in NYC during 2000 to 2011 was 10.0 (95% CI, 7.2 to 14.1). Among PLWHA, patients with IMD were 5.3 times (CI, 1.4 to 20.4 times) as likely as age-matched control patients to have CD4+ counts less than 0.200 × 109 cells/L.

Limitation: Missing data on smoking status and comorbidity.

Conclusion: People living with HIV/AIDS in NYC are at increased risk for IMD. Cost-effectiveness and vaccine efficacy studies are needed to evaluate the value of a national recommendation for routine meningococcal vaccination of PLWHA.

Primary Funding Source: New York City Tax Levy.


Grahic Jump Location

Study flow diagram.

IMD = invasive meningococcal disease; NYC = New York City.

Grahic Jump Location




Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).


Submit a Comment/Letter
Do behavioral risk factors confound association between HIV and invasive meningococcal disease?
Posted on February 8, 2014
Jason D. Goldman MD, H. Nina Kim MD MSc, Robert D. Harrington MD
Division of Allergy and Infectious Diseases, Harborview Medical Center, University of Washington Seattle, WA
Conflict of Interest: None Declared
To the Editor-

Miller and colleagues (1) demonstrate an increased risk of invasive meningococcal disease (IMD) in HIV-infected persons in New York City. Utilizing public health surveillance databases, the authors reported that HIV infected persons had higher rates of IMD than HIV uninfected persons regardless of age, gender and time period. Furthermore, HIV infected individuals with CD4 T-cell counts below 200 cells/µL were at higher risk for IMD than were those with higher CD4 T-cell counts, suggesting that the elevated risk of IMD in HIV-infected persons could be related to immune suppression.

A limitation of the current study is the lack of attention to behavioral risk factors which could increase the risk of IMD in the HIV infected population. While outbreaks cause only 2% of IMD cases (2), recent outbreaks in men who have sex with men (MSM) in Toronto, Chicago, New York City, Los Angeles, Berlin and Paris (3-5) have highlighted specific risk factors for IMD including congregate living, mass gatherings, nightclubs, male bath houses, intimate kissing and intravenous drug use (2,3,6).

Neisseria meningitides is transmitted by droplet aerosol or exchange of nasopharyngeal secretions from colonized or infected persons to susceptible individuals. In a minority of exposed persons, the bacterium evades mucosal defenses leading to pneumonia, bacteremia and /or meningitis. Sexual and behavioral risk factors besides smoking could therefore facilitate the spread of this infection.

Meningococcal vaccination is currently recommended for HIV-infected adolescents, but not adults (7), and Miller et al. recommend extending this vaccine recommendation to HIV-infected adults. We believe it is premature to recommend more widespread vaccination without first addressing behavioral risk factors that could confound the relationship between HIV status and IMD. While the elevated rates of IMD in HIV positive individuals with lower CD4 T-cell counts suggests that immune suppression may play a role in disease, further data are needed to understand the impact of behavioral risk factors on IMD in HIV infected individuals. This paper would have been strengthened by an analysis of all cases of IMD (both HIV positive and negative) for risk factors associated with possible exposure such as visiting male bath houses, nightclubs, mass gatherings and other risk factors that bring individuals in close contact with others.


1) Miller L, Arakaki L, Ramautar A, Bodach S, Braunstein SL, Kennedy J, Steiner-Sichel L, Ngai S, Shepard C, Weiss D. Elevated Risk for Invasive Meningococcal Disease Among Persons With HIV. Ann Intern Med. 2014; 160(1):30-37. [PMID: 24166695]
2) Simon MS, Weiss D, Gulick RM. Invasive meningococcal disease in men who have sex with men. Ann Intern Med. 2013;159:300-1. [PMID: 23778867]
3) Tsang RS, Kiefer L, Law DK, Stoltz J, Shahin R, Brown S, Jamieson F. Outbreak of serogroup C meningococcal disease caused by a variant of Neisseria meningitidis serotype 2a ET-15 in a community of men who have sex with men. J Clin Microbiol. 2003;41(9):4411-4. [PMID: 12958279]
4) Centers for Disease Control and Prevention (CDC). Notes from the field: serogroup C invasive meningococcal disease among men who have sex with men - New York City, 2010-2012. MMWR Morb Mortal Wkly Rep. 2013;61(51-52):1048. [PMID: 23282863]
5) Kupferschmidt K. Bacterial meningitis finds new niche in gay communities. Science. 2013; 341(6144):328. [PMID: 23888010]
6) Weiss D, Stern EJ, Zimmerman C, Bregman B, Yeung A, Das D, et al.; New York City Meningococcal Investigation Team. Epidemiologic investigation and targeted vaccination initiative in response to an outbreak of meningococcal disease among illicit drug users in Brooklyn, New York. Clin Infect Dis. 2009;48(7):894-901. [PMID: 19231975]
7) Bridges CB, Coyne-Beasley T. Advisory committee on immunization practices recommended immunization schedule for adults aged 19 years or older - United States, 2014. Ann Intern Med. 2014; 160(3):190-197. [PMID: 24500291]
Submit a Comment/Letter

Summary for Patients

Clinical Slide Sets

Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.


Buy Now for $32.00

to gain full access to the content and tools.

Want to Subscribe?

Learn more about subscription options

Related Articles
Related Point of Care
Topic Collections
Forgot your password?
Enter your username and email address. We'll send you a reminder to the email address on record.