From the issue dated February 20, 2004
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The Meningitis DebateMore states are encouraging vaccines for students, despite objections from some campus health officials
One morning six years ago, Ryan N. Pike, a sophomore at Indiana University at Bloomington, woke up with a headache and slight nausea. After attending his morning class, he dragged himself back to bed and slept until 6 p.m. When he awoke, he realized that he had something much worse than the flu. He was dehydrated. When he tried to sit up in bed, he lost his vision. Purple pinpoint dots covered his arms and legs. After his parents took him to a hospital that night, doctors diagnosed Mr. Pike with meningococcal meningitis, a severe and rapidly advancing form of bacterial meningitis, which infects the lining of the brain and spinal cord. They gave him antibiotics but told his parents that he had only a 30-percent chance of survival. A priest from the family's parish church gave him last rites. Gangrene, caused by restricted blood flow, crept into Mr. Pike's limbs and hardened his toes, forcing doctors to amputate nine of them, along with most of his right foot. After more than six weeks in bed, Mr. Pike recovered. When he returned to Indiana to complete his degree, he began to study the disease that had hit him so suddenly, one that he had not even known existed. He learned that he was lucky to have lived after waiting so long to see a doctor. In cases of meningitis, a few hours can mean the difference between two legs and none, or between life and death. He learned that the disease is spread through saliva and can be transmitted through coughing, sneezing, shared drinks, or any other form of close contact. Most people who become infected, however, don't contract meningitis and aren't even aware that they are carriers. He also discovered that there is a vaccine that might have prevented him from catching the disease. After graduating, in December 2001, he accepted a job as development director for the Meningitis Foundation of America, a nonprofit advocacy group focused on increasing awareness of all types of meningitis. The foundation, formed in 1997, and the National Meningitis Association, founded in 2000, are run by volunteers and paid staff members, many of whom are meningitis survivors or family members of meningitis victims. In their short histories, both groups have proved effective at persuading states to establish laws requiring either vaccinations for college students or informational programs about the disease and the vaccine, Menomune. Since May 2000, 25 states have passed such laws, and similar bills are pending in six other states. Two members of Congress have proposed national legislation. New Jersey and Connecticut require the vaccination for students living in campus housing at both public and private colleges. But most of the state laws allow students to waive the vaccination by signing a form stating that they have read information about the disease provided by their college. On the surface, the meningitis laws are the swift product of grass-roots efforts to protect college students from a fatal disease. But many college health officials are questioning whether the laws are necessary. These officials argue that legislators have acted irrationally in response to lobbying efforts by pharmaceutical companies and emotional appeals from small groups of advocates. Some doctors and nurses who treat college students say that the laws place an unnecessary burden on campus medical facilities, and that their own time would be better spent dealing with the more widespread health needs of students. "We would have to spend time tracking and blocking enrollment [based on waiver signatures] instead of providing direct patient care" to comply with a waiver law, says Peter S. Dietrich, medical director of University Health Services at the University of California at Berkeley. In 2001, California passed a law that requires public colleges to provide information about meningitis and the vaccine to their students, but does not require families to sign waivers. "In lean times," Dr. Dietrich says, "we have to ask how much we want to chase paper for a relatively rare disease when you have to treat fractures every day and appendicitis at least once a week. It's a judgment call, because people can die from appendicitis if you don't have enough staff to recognize it right away." Emotional Appeal What do statistics say about the threat of meningitis? In the late 1990s, researchers began to track the incidence of the disease among college students. By 2000, the federal Centers for Disease Control and Prevention had analyzed the studies and concluded that freshmen living in dormitories, compared with the rest of the population their age, were at a "moderately increased risk" of contracting the disease. Yet the study also showed that the rate of meningitis among college students overall was less than the rate for 18-to-23-year-olds who were not in college. Various studies have found that the incidence of meningitis among 15-to-24-year-olds more than doubled from 1991 to 1997, from about 0.9 cases to 2.1 cases per 100,000. Yet the disease still affects only a small percentage of students relative to the overall college population: Roughly 125 college students contract meningitis each year, and 5 to 15 of them die. Another 12 to 20 suffer permanent hearing loss, brain damage, and loss of limbs. "There are just these awful stories that come before legislators, and they're always very moving stories about young, healthy people in the prime of their lives, and it's very sad," says James C. Turner, director of student health at the University of Virginia. Dr. Turner, who is chairman of the American College Health Association's vaccine committee, says that while 15 deaths per year "is not that many," the tragic nature of the disease overshadows the statistics. "Legislators probably become a little overzealous," he says. "They don't look at the scientific side as much." It is "hard to say to a parent, 'Oh, I'm sorry this happened to your child, but I don't support mandating [vaccination laws] across the country,'" says Reginald Fennel, president of the college-health association. Neither the college-health group nor the CDC has chosen to support waiver rules. Both organizations make only a general recommendation that college students and their parents be informed of the disease and the potential benefits of vaccination. But Lynn Bozof, founder of the National Meningitis Association, believes that many meningitis deaths could be prevented through vaccines and education on college campuses. She watched five years ago as her 20-year-old son, a pre-med honors student and star baseball player at Georgia Southwestern University, lost both his arms and legs during a 26-day battle with meningitis before succumbing to the disease. Only after her son's death did Ms. Bozof learn that there was a vaccine that might have kept him from getting sick. The discovery inspired her to found the group, which she says was "instrumental" in persuading lawmakers in her state to adopt a law requiring college students to receive the vaccination or sign a waiver. "Our mission is to educate parents, students, and even the medical community that this disease is out there," says Ms. Bozof. "I wasn't given any information to make a decision, and I want other parents to have that choice." No Protection From Type B Many college health officials question the laws, however, because Menomune, the only meningitis vaccine approved in the United States, does not protect against all strains of the disease. In studies conducted by Aventis Pasteur Limited, which produces the drug, Menomune was at least 90 percent effective in protecting against four of the five main types of bacteria that lead to meningitis. The vaccine does not, however, provide any protection against the fifth strain, known as Type B, which is responsible for 30- to 40-percent of the cases of bacterial meningitis in the United States, according to Berkeley's Dr. Dietrich. The CDC has found that 24 percent of the college students who contracted meningitis in 1998 had Type B. The strain also caused the most recent case of meningococcal meningitis among students: Alisa Lewis, a 20-year-old junior at the University of California at Berkeley, died a few hours after being admitted to a hospital with a fever and flu-like symptoms in January, says Dr. Dietrich. "This is not a great vaccine, because it doesn't cover all types" of meningitis, Dr. Dietrich says. "If there was a better one out there, we might revisit the decision to encourage it, and probably be more proactive about it." What's more, he said, if students are encouraged to get the vaccine, there is the added risk that some of them will ignore symptoms of meningitis because they assume they are immune to it. Drug Company's Role College students' deaths related to alcohol abuse can be as wrenching and sudden as meningitis fatalities, but a big difference between the organizations devoted to discouraging alcohol use and those encouraging meningitis vaccination is financial support from drug companies. Aventis Pasteur donates about $1.9-million to the National Meningitis Association annually, about 95 percent of the group's operating budget. The company also makes donations to the Meningitis Foundation of America and finances the meningitis-education efforts of the American College Health Association. In many of the states with meningitis laws, Aventis hired lobbyists to make a case for greater education efforts about the disease and the vaccine. Len Lavenda, a spokesman for Aventis, says the company's position is consistent with the federal CDC's recommendation that parents and students be informed about meningitis and the availability of a vaccination. The requirement that students sign a statement indicating that they have read information provided by their college about meningitis has led to more of them getting the vaccine, according to a study published in the Journal of American College Health. Although there are no nationwide numbers available on the total increase in vaccines administered on campuses over the past few years, statistics from Brown University are telling: Since the university began mailing brochures to freshmen before their arrival on campus, the proportion of those being vaccinated rose from 13 percent in 1999 to 60 percent in 2001. The cost of vaccination, $50 to $85 per student, is usually covered by college or independent health-insurance plans. Mr. Lavenda declines to provide sales information on Menomune, saying only that "the meningitis vaccine is one of our smaller-selling vaccines. We're not talking about a huge market or level of sales for us." Ms. Bozof and Mr. Pike, of the anti-meningitis associations, insist that laws requiring signatures for vaccines are necessary because students will not read the information if doing so isn't mandatory. "It ends up in the garbage can, because there's just too much other paperwork" sent by colleges, she says. Many college health officials, however, say waiver laws are too labor-intensive to enforce. Large universities like Berkeley, with 30,000 students, have too many students to keep track of immunizations, says Dr. Dietrich. New York's law, which requires all students to either get the vaccine or sign a waiver, even if they don't live on campus, has made for "quite a workload," says Linda MacKenzie, administrative director of health services at the State University of New York at Binghamton. "There's a lot of programming time spent so we can enter codes and tie [the waiver form] into the registration system," she says. "It's another piece of paperwork that has to be reviewed by a nurse and sent back to the student if it isn't complete." Recently, the governor of Washington, Gary Locke, a Democrat, reached the same conclusion. When a law on vaccination education and waivers was approved by the Legislature last April, he approved the general-education mandate but vetoed the waiver section, on the grounds that it placed an "unnecessary administrative burden on our higher-education institutions." 'It's Fairly Simple' Conclusive data on the long-term effect of meningitis-vaccination laws is unlikely to be available for some time. Over the past few years, the number of cases of meningitis at colleges has decreased slightly, but Mr. Lavenda, at Aventis, says that dip could be a function of the natural cycle of the disease's incidence. In the meantime, some college health providers say campus prevention efforts should focus on what they see as more-pressing health issues, like sexually transmitted diseases and alcohol-related deaths and injuries. Advocates for anti-meningitis efforts, however, see those problems in a different light. "In my mind, it's a pretty simple difference" between the disease, on the one hand, and alcohol abuse or unprotected sex, on the other, says Mr. Pike, at the Meningitis Foundation of America. "In college, I was able to make choices about that stuff. But I didn't choose to get meningitis." That distinction reveals one of the main reasons that meningitis laws have won approval in so many states. Unlike other health problems that plague college campuses, meningitis can be contracted regardless of a student's personal habits or moral choices. Instead of getting involved in debates about handing out condoms or controlling access to alcohol, colleges can act to lower the threat of meningitis on their campuses with one seemingly simple requirement. "When parents are sending their kids off to school, they are looking at ways to reduce risk," says Dr. Turner, at Virginia. "So much of morbidity in college is self-induced, like drinking and driving -- and as parents, they can't prevent that. But with this, it's fairly simple. They give them a shot and the risk is reduced." http://chronicle.com Section: Students Volume 50, Issue 24, Page A33 | |||||||||||||||
Copyright © 2004 by The Chronicle of Higher Education