- Welcome, everyone, to <i>Wednesday Nite at the Lab</i>. I'm Tom Zinnen. I work here at the University of Wisconsin-Madison Biotechnology Center. I also work for UW Extension Cooperative Extension, and on behalf of those folks and our other co-organizers, Wisconsin Public Television, the Wisconsin Alumni Association, and the UW Madison Science Alliance. Thanks again for coming to <i>Wednesday Nite at the Lab</i>. We do this every Wednesday night, 50 times a year. Tonight, it's my pleasure to welcome back to <i>Wednesday Nite at the Lab</i> Meredith Leigh, who will be here talking about being on the lookout for bacterial meningitis. We have three presenters tonight. The third will be Sara Van Orman. She's a physician and the Director of the University Health Services. She was born in Salem, Oregon, went to school in Carleton in Minnesota, went to medical school at the Mayo Clinic, did a residency at the University of Chicago, and now she's the director here at the University Health Service. Craig Roberts was born here in Madison, got his undergraduate and graduate degrees at UW-Madison, got an undergraduate degree as a physician's assistant, back when you could still do that, 1895? (laughter) And he also has a Master's in Public Health degree. He's an epidemiologist with the University Health Service. And our first presenter will be Meredith Leigh. Meredith is from St. Paul. She was here last July to tell us about the journey of the heart. She's the mother of Henry Mackaman, who's a UW Madison student who died of bacterial meningitis in April of 2013, and many of his organs were donated in lifesaving methods to seven, eight different people, including Walt Goodman, who's here. Tonight, she's here in her role as a mother on meningitis. She's going to tell us about some of the programs that she's working with as a mom on meningitis. Please join me in welcoming Meredith Leigh back to <i>Wednesday</i> <i>Nite at the Lab</i>. (applause) - Hi, I'm Meredith, and, although I am from St. Paul, I did graduate from UW Madison, so I'm a Badger. (laughter) I got my degree in 1988 in the School of Pharmacy, so I'm a pharmacist. Tonight though, here I'm talking to you as a mom. I work for the National Meningitis Association because my son died from this horrible disease. I hate meningitis for the obvious reasons, but as a bereaved parent, I hate it because people remember Henry because of how he died, and what was really amazing about Henry was how he lived. So I'm going to spend a couple minutes talking about my wonderful, amazing son Henry. This picture was taken in high school, and he was just a happy kid, a happy person. He was always telling a funny story or a bad pun. Another feature of Henry that was pretty special was his ability to show his affection towards you. I think that's a unique quality for a young man to have. He would hold my hand when we were driving the car, and he would throw his arms around his grandpa or his brother when they'd be watching hockey or football. That was really special. He, of course, was brilliant. And he was 21 years old and a junior here at UW studying economics and creative writing. He loved writing stories his whole entire life. In fact, one of his creative writing instructors wanted him to turn one of his stories called The Deadly Ostrich into a screenplay. So Henry did that, and he entered it into a contest here and it won. So it was performed at the student union just a year before Henry died. I knew Henry was going to be famous, just not for meningitis. This is a huge part of Henry's life. Music. He sang songs starting at age two from show tunes and musicals. He was a gifted guitar player. He was double jointed, so he had a little advantage in his fingers. This was taken just two weeks before Henry died. So this is the last show that his band, Phantom Vibration, had in the Twin Cities. They had some local success. They played at a few venues, and they even had a song recorded on the radio. So it played locally at radio stations in the Twin Cities. He also was a deejay here at WSUM, and he worked for Murfie, a music sharing company. But then Henry got sick really fast. This is a timeline that I took from the NMA website, and it shows just how quickly a person can succumb to this really aggressive illness. Henry got sick on a Saturday night. It was about 8:30 or nine o'clock. His fever was 104 despite taking ibuprofen. His roommates dragged him to the ER. He was just really feeling just lousy. Just achy all over, and then this high fever that wasn't going down. The doctor examined him, gave him a chest X-ray to rule out pneumonia, and sent him home just saying we think you're getting the flu, keep taking your Tylenol and Advil, get lots of rest, come back if you're worse. Well, I talked to Henry the next day, Sunday morning, and I said how are you feeling? And he said, well, I'm getting better because my temperature is lower. What he didn't tell me was that he had thrown up and he was developing a little speckled rash on his arms. He told one of his friends that he thought he got bedbugs from going to the Dig & Save in Madison the week before. (laughter) Little did he know that these were really serious symptoms that he didn't know were significant in his diagnosis. So he went and visited his sick girlfriend, she was also running a very high fever, came back to his apartment, and it was probably about two o'clock on Monday morning when he started feeling really strange. He couldn't feel his right hand, which alarmed him as a guitar player, and his whole right side of his body, in fact, was going numb. And he couldn't speak clearly. So he put those two symptoms into Google, and it came up stroke. So that's the call that I got at 4:00 AM on a Monday morning that my son was having a stroke. It didn't make sense to me. I know it was the middle of the night, but I was like wasn't he just at your hospital last night with a 104 fever? Yes the doctor admitted, it was odd. So I made a few phone calls to my family to arrange to come to Madison. I called the hospital back about 20 minutes later, and at that point the doctor told me that Henry just had a cluster migraine. And I said, I don't care what you think he has, don't send him home again, and please let me talk to him. So at 4:30 in the morning I had my last conversation with Henry, and he told me that he was sorry for waking me up, that he had the worst headache of his life, and I said I loved him and that grandma and grandpa and I were coming and we'll come and get you from the hospital and take care of you. By the time I got to Madison, Henry had had a seizure. It was a little after noon by the time we got here, and he was comatose. He never regained consciousness, and two days later he was declared brain dead. A week or so later, I got a call from the Department of Health saying that it was the meningococcal B strain, which, at that time, there was no vaccine available to prevent that in the US. As time went on, I became more frustrated with Henry not knowing what he had, and the doctors didn't know what he had. I came with this idea for this magnet with all the symptoms of meningococcal disease. I would really like to think that if Henry had had this list, he might have gone to the hospital earlier on Sunday and he might still be here. I mean, maybe not, but that's my hope anyway is that someone will notice these symptoms as being significant and worse than the flu. So, I've made thousands of these, and Sarah Van Orman passes them out at the University Health Services here. Please grab one on your way out, if you haven't already. It's really good information. Through my work with the NMA, I met many families affected by this disease. And, in particular, I met, last October, a young lady named Amy Aiken. She had meningitis B, or meningococcal strain B, but she had meningococcemia, and that's when the bacteria goes into the bloodstream. So she swelled up and has had many complications from her having the disease. She wasn't able to be here tonight because she lives in Texas, but she very generously is allowing us to see her story by this little video that she made. - Before I got sick, I was a fun-loving and worked hard, played hard, loved to go to concerts and hang out with my friends, go swimming, loved fashion, and I'm still that girl. It was flu season so I thought I had the flu. I went to see my primary care doctor that day, and he agreed with me and he sent me home with pain meds and told me to sleep it off. So that's what I kind of tried to do, but when my symptoms worsened that day and through that night, I woke up to use the restroom and I just was seeing spots everywhere. I was really delirious and I felt like I had been hit by a truck and I just knew at that moment that something was wrong. It wasn't the flu because I had had the flu before, and that's when I picked up the phone and dialed 911. And I remember waking up and my legs were gone and my arms were bandaged and I did not know what was left of my arms, hands, and fingers. I didn't know what bacterial meningitis was. I had never heard of it. I did not know of a vaccine. It was hard to wrap my head around the fact that that's what I had contracted. The rehabilitation process was a struggle. I went through about two years of occupational and physical rehabilitation. I had to learn everything all over again. I had to learn to sit up again. I had to learn to walk again, but I feel fortunate that I have the ability to walk, and I'm really grateful for my prosthetic, actually. I want to tell as many people as possible about this disease because most people have never heard of it, as I had never heard of it. So I really just want to get the message out there. Get educated and please get vaccinated. - So, she's also and advocate and working for the NMA, and that's a great website. You can hear other people's stories and get more information about the disease and the vaccines that are available. A couple things that she doesn't mention on this little video is that she's had to have a kidney transplant. And I know she's really had problems with rejection. She also struggles with infections in what's left of her legs where her prosthetics attach. So some days it's just too painful, and she's wheelchair bound. But she's an amazing young woman, and she works and she paints and she kayaks. I'm so proud to know her and call her my friend. The last picture I'm going to show you might make you feel uncomfortable for a minute, a while, but this picture is ingrained in my head and my heart forever. And it's the last picture that I have of Henry and I together. And I'm saying goodbye to my son. Worst day of my life. But Henry was a hero. He was able to donate seven healthy organs into five people. There are five people across this country that have a second chance at life because of him. And that's another reason why I'm here tonight is because I want to be a hero too. I want to share my story and hopefully raise awareness so that people will talk to their doctors about getting all of the vaccines for meningococcal disease. I wanted Henry to be famous, you know, for something wonderful, his achievements and his accomplishments, and I hate to think him as a statistic. So please don't allow your loved ones to become statistics like my son. Thank you very much for coming out tonight and listening to me with my story. (applause) - Thank you, Meredith. That was really moving. I've never followed anyone with that kind of story before, but it is sort of a good segue. As an epidemiologist, one of my roles with the university is we track the data and statistics about diseases and what we see and what's happening nationwide and why we need to worry about this with our students. So I'm going to, epidemiologists tend to be full of statistics, but I'm going to try and keep those to a minimum for you. And then Dr. Van Orman will follow me, and she's going to talk some more specifically about the clinical aspects and the new vaccine, in particular, we're all really pretty excited about. So, just as an overview, as Meredith mentioned, meningococcal disease is really the proper term to use with this. A lot of times people just refer to meningitis, but it's really much more than meningitis per se. Meningitis is a specific symptom or outcome associated with meningococcal disease. In general, when we say meningococcal disease, we're talking about an invasive condition where the bacteria gets into the body in some way to cause symptoms and problems. Typically, and most famously, it causes meningitis, which is an inflammation of the lining of the brain. And that's why it causes neurological symptoms, including headache. Her description of the worst headache I've ever had in my life is a very classic presentation of meningitis. And there are many kinds of meningitis. There's viral meningitis. There are many kinds of bacterial meningitis. Meningococcal meningitis is probably just one of the most famous and what we're going to be talking about tonight. And then, also, she mentioned the other major form of meningococcal disease is meningococcemia where the bacteria gets into the bloodstream, and that actually causes quite different syndrome, different sort of clinical picture than meningitis per se. It is possible for people to have both of these things happening simultaneously. And, actually, probably in Henry's case that was what was going on. It's not an unusual situation. Meningococcemia typically is worse because it represents, essentially, blood poisoning with this bacteria and toxins are being released. It's a much, much more rapid onset, much more rapid progression of disease, and it has a much higher fatality rate than just simple sort of meningitis. The incidence of this disease is about one in 500,000 people in the United States. So it's actually a very, very rare condition. This is not something we see much. When I started in practice in the '80s, this was probably about one in 100,000 people. So we've really made a major reduction in the incidence in the United States of meningococcal disease overall, primarily because the vaccine we use now that covers four types but not group B. So that's really been a big change in my professional practice over the last couple of decades to see a big dramatic decrease. I don't have a slide about this, but it was typical at UW-Madison, we would probably see one or two students every year with meningococcal disease that needed to be hospitalized. Now we are typically seeing one case every two to three years. And so that kind of fits with the national statistics. But that's really about how common it is. One student on this campus develops this disease roughly every other year. Meningococcal disease in the worldwide perspective, though, is a much, much more common problem. In the United States, we have great healthcare, we have access, most of us have access to vaccination. People are routinely immunized in this country and especially in western and developed countries. And that's really what's made the difference in the epidemiology and the incidence of disease, but worldwide it's still a very, very big problem. And it can cause both what we call sporadic disease and endemic disease, epidemic disease. So, sporadic disease just refers to individual cases. This is how we see most meningococcal disease in the United States. A case here, a case there. A case in Madison, a case in Green Bay, a case in Minneapolis. They're not connected to each other. We now have the ability to do genetic testing of isolates and strains of meningococcal bacteria. And we can actually tell whether strains are related or not related. And then there's epidemic disease where people actually, multiple cases occur within a given population or community in a short period of time. Those are often all genetically related to each other. They're identical viruses, identical bacteria. We talked about clinical manifestations, and Dr. Van Orman will talk more about this in a few minutes. Actually, it's really varied. So, you've heard about some of the worst case scenarios, and that's always what makes the news and what gets the attention. I have talked to students who have walked into the ER and walked out within an hour with that same diagnosis. They didn't even need to be admitted. There really is tremendous variation in how sick people get with this. Probably a lot more people have had unrecognized meningococcal disease that they never sought care for or never got treated, and we don't even know about those cases in many situations. And then the most, probably one of the most striking things about this disease and why it scares everyone is the signs and symptoms of meningococcal disease, especially early on, mimic lots of other viral diseases, like influenza. It's a bacterial infection but it tends to cause a syndrome clinically that is very typical of your viral infection, like having a bad cold or early pneumonia or influenza, with fever, headache, you just don't feel well, there's tremendous fatigue, you're wiped out. Exactly what Meredith was describing about Henry. Very classic presentation in the early stages. Very difficult for providers, clinicians to recognize that and sort of do something about it before they're really even thinking about it being meningococcal disease. And then it has this tremendous capacity to progress from those sort of symptoms to very severe symptoms within a matter sometimes of just a few hours. The graphic that she showed you showed progression over a period of 24 hours, which is probably pretty typical, but there have also been people where this happens over a space of four, six, or eight hours where they wake up feeling like it's a normal morning for them and they're dead by four o'clock or six o'clock that evening. That is something that's absolutely striking. Many, especially college students, young adults, don't tend to seek healthcare until they've been sick for a couple of days, right? I mean, a lot of us would do that. But a 21-year-old who has class, who may have exams, they're not going to go in to come into UHS in those first few hours because they think it's a routine illness like everything else. And most of the time it is, right? But you just never know. So, a little bit about the bacteria itself. Neisseria meningitidis is the cause. It's part of a genus of other Neisseria species, most famously the bug that causes gonorrhea, which is a sexually transmitted infection. This is not. This is primarily a respiratory infection. The bacteria typically infects our nasal pharynx and sits in our throat, and that's typically what happens. There are 13 identified serogroups. We've talked a little bit about a few of them. There are four or five that really matter in terms of clinical presentation and disease in the US. This is an exclusively human pathogen. You can't spread it to your pets. The transmission is primarily by oral secretions. Either aerosolized, for example coughing and sneezing, you can spray somebody with your saliva and they can become infected or become colonized with the bacteria that way, and, of course, direct person to person transmission through what we call saliva exchange. About 10% of the population in the US at any given moment is thought to carry one of these bacteria in their throat. That's really how common it is out there. Probably everyone in this room has had this infection at some point as a carrier, and we don't really even think of that as an infection. You're just colonized with it on a transient basis, meaning days, weeks, or perhaps months. Most people, the bacteria sits in the back of your throat in your nasal pharynx, does nothing. It just sits there, right? It doesn't become invasive, doesn't get into your bloodstream, doesn't do anything, and you probably just get rid of it. Although, you would be at risk of transmitting that to someone sort of in the interim period. That's actually more the normal situation with this bacteria. We do not really understand very well why this becomes invasive in some people and becomes a serious disease. Again, if 10% of our population is colonized at some point but one in 500,000 get the disease, there's a huge gap between what happens in healthy people and why it's invasive. There probably are some underlying genetic reasons for that. Some people are probably just more susceptible to having invasion happen. And some of those things we know about, something called complement deficiency. Your immune system doesn't really have the ability to fight off the bacteria very well if it becomes invasive. So, in terms of the serogroups, I mentioned there are 13 identified serogroups. There are really only five that cause significant problems and disease. The first group, A, is almost never seen in the US. So this is something that's associated particularly in Asia, Africa, and Europe with epidemic disease, and particularly in Africa, and I'll show you that map in a moment. Group B, which caused Henry's illness and has now become the predominant type or subgroup of meningococcal bacteria that we see in young adults, the reason for that is that our current vaccine has largely eliminated the other causes. The current vaccine covers group A, which we don't really see, and it covers C, Y, and W. So everything on this slide except group B is covered by the current vaccine. Until that vaccine came into widespread use about 10 years ago in the US and Europe, we used to see a relatively even distribution between B, C, and Y. So we saw cases in all groups, and it didn't really matter, for the most part the disease is similar, it doesn't matter what group you have. The clinical presentation is fairly common. You can't really tell whether somebody has B or they have C based on their symptoms alone. And then W is a very rare cause of disease. And there are other serogroups out there too, which don't even really make the list. So, again, globally, this is what we call the meningitis belt in Africa. This disease, it reaches epidemics where it affects hundreds or thousands of people at a time. Almost all of that is group A. So, in those countries, there is a dedicated single group, single valiant vaccine that's used to treat or prevent group A disease. And, again, group A is included in the vaccine we currently use in the United States. So this is important particularly for US citizens and college students who may be traveling to these countries. They would be at risk of getting A if they're in these countries. And this is particularly true during mass events, like the Hajj in Saudi Arabia in September. There have been outbreaks reported associated with that as well. And just some numbers here, again, in the US a very rare disease. But just remember, worldwide, meningococcal disease, and meningitis in particular, mostly due to group A, is actually a fairly common cause of serious illness and death in many other countries. The new vaccines, the men A vaccine that was introduced just a few years ago, now has been widely adopted thanks to efforts by the World Health Organization. So we're making some progress on that front as well. So, now I'm going to show you a few slides with some actual numbers and try not to bore you too much. But this is a classic age distribution of meningococcal disease. This is all groups, and this covers roughly a 10-year period. But the shape of this chart doesn't change. And I'm going to show you the Wisconsin data in a moment. And the important thing to know about this is, first of all, the group that's really at greatest risk of meningococcal disease is actually infants. This is where we see most of the disease in the United States is in children under a year of age. And then there's this other very prominent peak in one adolescents and young adults. And that's really what we're talking about here tonight. But it's not the only group, and you'll see this goes up with age. Some of this has to do with invasive disease and immunocompromised people. But, really, all of us are potentially at risk. Meningococcal disease does happen to people at any age. It's just that adolescents and young adults, adolescents and young adults tend to get most of the media attention. When they have a case, they tend to make the news. If I get meningococcal disease, well maybe because I work at the university it would make the news. (laughter) But I know of other cases in Wisconsin when they occur in other adults, they almost never make the news and you never hear about it unless you're in that person's social circle or family. But when a high school student or a college student gets this disease, and especially if they die, it's front page story. This shape of this curve, though, does not really change much from year to year. It's a very classic distribution for this disease. This is the Wisconsin data. Notice the shape of the curve is almost identical to the national data. Nothing's different in Wisconsin. This is a different time period. This is about 15 years of data, 452 total cases in Wisconsin over that period, showing the age distribution in the blue line and then the gray bars are the actual number of cases that we see every year. So, typically in Wisconsin in each of those five-year age groups, we're seeing one to two cases. But, again, large number of cases in infants and very young children, and again, in adolescents right here. This is the peak age group for this disease, very clearly is 15 to 19 and then really follow by college student age as well. This is the distribution of those cases in Wisconsin broken down by the serogroup. The navy blue bars at the bottom you can't see very well are the group B cases, the yellow bars are group C, the turquoise color is group Y, and then there's a few Ws thrown in there. And the gray are cases where they were unable to determine the serogroup that was involved. But especially if you notice back here 15 years ago or so, the distribution between B, C, and Y was not all that different from each other. Now we tend to see a lot more group B in the post-vaccine era. So, 2005 is when the vaccine was introduced. Menactra, that's the brand of the vaccine that covers A, C, W, and Y, and we've been using that routinely now for about 10 years. And we'll talk about what college bill means. And the last thing is just, again, the proportionate cases that are fatal versus nonfatal. Overall, this disease has about a 10% mortality rate. If you have actually meningococcemia, that form, mortality rate can be as high as 50%. This hasn't really changed over time. And then if we narrow that down and look just at this adolescent young adult age group, this is people aged 14 to 23 years in Wisconsin for the last 15 years, sort of showing just those individual cases, and in that group in Wisconsin overall now we're seeing probably two to three cases a year. And up until the last couple of years, actually, a lot of those students were not actually, those cases were not actually college students. So people often think of this as a college student disease, and Sarah's going to talk a little bit more about this, I think, but college students and high school students, when they get this disease, again tend to get in the media, but actually more of the cases have been in people of the same age group who are not in college. So there doesn't really seem to be anything specifically about college that puts people at risk. It's more the age group factor. And about two-thirds of people in this age group, between 18 and 23, are in college at some point during that five-year period. And I'm going just going to wrap up by saying a couple things about outbreaks. Again, sporadic cases where there's just random cases, those are far more common. Outbreaks have been in the news lately because there were several large college outbreaks at Princeton, at University of California Santa Barbara, and more recently at the University of Oregon this year, but most of the cases in the United States are not outbreak related. We have a very specific definition for this disease about what constitutes an outbreak, and we take different actions in an outbreak than we do with sporadic cases. So in those three colleges, for example, they have done mass vaccination campaigns of the entire campus, which is a big undertaking. And here, it would be a huge undertaking because we have almost 43,000 students that potentially would be susceptible. All of these outbreaks in the last two to three years have been group B outbreaks, which is part of the reason why the new vaccine is so important. So, I mentioned this is how the bacteria are transmitted. This is really the focus of our prevention efforts. When we have a case and we're trying to educate college students, it's really about saliva exchange in one way or another. You're either getting coughed on, sneezed on, or you're kissing somebody. This bacteria is in the saliva of people who are the carriers, and they transmit it to other people who either become carriers or potentially become infected and develop disease. So, kissing for certain, but water bottle sharing is probably one of the things that we're really trying to educate students about. If you have kids, if you have grandchildren, this is something to tell them you should not share water bottles with other people, or drinks. These four women are all sharing a diet cola. I'm sure that's what it is. (laughter) But so the message really is water bottles are for individual use and not for sharing. We talked a little bit about nasal carriage. Again, this bacteria colonizes in the back of our throat in our nasal mucosa. We transmit this through respiratory secretions. We think that when people come together at the beginning of the school year, that's a big factor that increases the risk of transmission. So there's some data out of England showing that the rate of colonization, the rate of carriage in the throat, spikes up during September and then sort of pops back down. And so you think about it, people from all over the world, all over the country coming together in one big social mixture at the beginning of the semester. That really is probably what counts for some of the spike in the disease in college and high school students. All right, I'm going to stop there and have Dr. Van Orman finish up with the clinical stuff, and then we'll open it up for questions. (applause) - Thanks, Craig. And I'll cover some of the things that Craig has also touched on a little bit but talk a little bit more about some of the clinical aspects of the disease and then a little bit more about what we can do in terms of prevention, treatment, and education. So, we've talked a lot about the spectrum of meningococcal disease, and that includes both meningococcemia as well as meningitis. Meningococcemia is when the bacteria is present in the bloodstream. As Craig mentioned, it's almost sort of a toxic type of phenomena that happens. And so, classically, that's when we see people presenting with a rash, which is one of the symptoms that we tell people to be aware of. It's a very fine rash that people notice on their hands. It's one of the things we want students to be aware of, that that's always something you'd want to seek care for. It also causes damage to the blood vessels or vascular changes in a condition called disseminated intravascular coagulation. Really what that is, is that there's an alteration in the normal blood clotting proteins, and there's sort of both bleeding as well as clotting that takes place. And we see some people, one of the things that we see and we saw highlighted in the young woman in the video where there's damage to the limbs, and that's really from the vascular changes and that disseminated intravascular coagulation where the blood supply is actually cut off to the distal extremities, to the fingers, the hands, the feet. So that's one of the very serious sequela that we see. There can be damage to all the organs of the body, such as kidneys, and meningococcemia typically, although it's variable, tends to progress much more rapidly over a course of several hours. It represents about five to 20% of cases, and the fatality of meningococcemia is about close to 50%. Meningitis, or when it's primarily an infection of the lining around the brain, sometimes has a little bit slower presentation, more over 24 to 48 hours. It has typical symptoms of many and it can mimic other viral illnesses. Flu-like symptoms, fever and headache, stiff neck, nausea. As it progresses, there can be a change in people's thinking, there can be a sense of confusion, and then seizures and sometimes what we talk about as a focal neurologic deficit, and that may be some of what Henry was experiencing with stroke symptoms where people can have sort of numbness, loss of feeling, and it may feel like a stroke but really it's from damage to those parts of the brain, and that can be a common symptom. It's about half of cases are meningitis, and meningitis itself has about a 10% fatality rate. People can have both. So, many times people with meningitis can also have the presence of the bacteria in the bloodstream or the meningococcemia. Meningitis itself really is a term that just refers to an infection of the lining of the brain or the meninges, and there can be a lot of overlap. So, for example, some of the headache, low grade fever, stiff neck, vomiting, rash can overlap with both bacterial as well as viral meningitis. But some of the other more serious things, the loss of consciousness, the seizures, the sort of confusion, are much more common with bacterial meningitis. So, a little bit now about prevention of meningococcal disease, and I'll talk a great bit more about vaccination. Vaccination has been a tremendous tool. As Craig talked about already, the incidence of this disease has been reduced by almost five fold, and that's really powerful. This is a great success story when it comes to vaccine preventable diseases. But as we'll talk more and as we hear tonight, the work is absolutely not over yet. There is a state law in Wisconsin, as there are in many other states, requiring some level of meningitis vaccine for college students. In Wisconsin, this is our states meningitis statute. We can't, we do not require students to have the vaccine, but we require them to tell us whether they've had it, and we track that very carefully and it gives us the opportunity to reach out to all students and their families as they're coming to the university to educate them about the signs and symptoms of the disease as well as if they haven't been vaccinated to really encourage them and make sure they have good information about that. I'll show you in a minute what our vaccine rates here are on campus. They're very high, but we still have students who are not vaccinated, and that's a gap we want to close. We also know that when there has been a case, we do have the ability and we do a lot of surveillance after a case, reaching out to people who may have contact with that individual, to give what's called post-exposure antibiotics. So, anyone who may have had that exchange of saliva with someone who has meningitis or meningococcal disease, particularly housemates, roommates, partners, we can give them a dose of antibiotics. We try to give that just as close to the time as we can identify them as possible, and those people are at increased risk of developing invasive meningococcal disease, somewhere between a 10 and a hundredfold increased risk, but by delivering that dose of antibiotics, we can really reduce that risk. So that's something we do here on campus if there's ever a case, or a community do, in collaboration with our public health department. And finally, this is why we're here tonight, is we want to educate people about meningitis and meningococcal disease signs and symptoms and do what we can to spread the word to help people reduce their risk and help families protect their youth. A few words on vaccines. The first generation meningococcal vaccine was what we call a polysaccharide vaccine. It didn't have a long duration of protection, so it's not really used much anymore. We've had the current meningococcal, what we call conjugate vaccine that protects against A, C, Y, and W. There's a couple brands available for about 10 years now, and it really has made a huge difference in terms of the impact of this disease. We give the first dose at age 11 or 12. We recently realized that we had to give a booster at age 16, so we're doing that. And then it can also be given to other people at increased risk. It can't be given to infants and children, very small infants, and we'll talk about why that's important, but it can be given to younger children who might have an immune system dysfunction. It can also be given to adults and older people that have immune system dysfunction or might be traveling to one of those endemic areas of the world. The vaccine rates nationally for 17-year-olds are about 77%. Here at UW Madison, we track this pretty closely. Our overall rate for all students is about 87.7%, and for entering first-year students it's 90.2%. We're always working to increase those numbers, but we do have much higher rates, and Wisconsin as a state actually has very good overall immunization rates for its youth and child and adolescent populations. But, clearly, we want every student to have it. The largest group of students that we see that don't have the vaccine are actually incoming international students. And that's one of the groups that we've been working on trying to get them information about that, get them educated, make sure that they're all vaccinated. One of the things about the current meningococcal A, C, Y, W vaccine is it both protects the individual who gets the vaccine as well as it protects the rest of the community. And it does that because it likely reduces that nasal carriage that we've been talking about that's so important and can create something that we call herd immunity. So, many people have heard of this concept. People were talking a lot about this when there was a lot of conversations about the measles outbreaks that have happened nationally. The concept of community or herd immunity. Community is probably a better term for it. And the idea is that if no one is immunized a couple people get sick, they're going to spread it to everybody. If more people are immunized, they can still spread it to everybody. But if you get enough people in your population that are immunized, if someone gets it, you can't spread it to other people. And so the meningococcal vaccine does cause herd immunity, and that's really important, and probably the most important group it protects is that we have seen with the introduction of the vaccine, we've actually seen the incidence of disease in those infants who are not able to be immunized go down. And so we think that the adolescents and young adults were really the reservoir of the bacteria in our community. And so immunization is really important, again, for the individuals getting the vaccine but also for the whole community. B, so as of this fall we have now two serogroup B vaccines that have been licensed, Bexsero and Trumenba. I never say that right. We recently, in February, the ACIP, the American Committee on Immunization Practices, put out the first set of recommendations for use of this vaccine. And it recommended that it could be used during outbreaks, such as the outbreaks of B that we've seen at campuses just this past year, and as well as in high risk individuals. We think that the recommendations for individual use are going to be coming out later this summer. And so we're very excited to have this tool. There are challenges with the B vaccine, and I'll talk about why. But there's concerns that it may not provide long-lasting protection. It does not, may not reduce carriage, and it may not lead to herd immunity. And it's also multiple doses. So Bexsero is two doses and Trumenba is three doses. And so it's going to be a challenge. So it's absolutely great that we have the B vaccine available, but these current B vaccines as they are, the work is not done on an effective vaccine for serogroup B. We need a better vaccine than either of those two, and I'm glad we have them. But there are some challenges with them that may not make them quite as effective as the A, C, Y, W was for those serogroups. B is a very different bacteria. I'll just do a little microbiology. In most vaccines, they're sort of reacting to the outside or the capsule around the bacteria, that's kind of the proteins that the vaccine is targeted at. The B capsule is structurally similar. It's different than the other serogroups, and it looks like a human nerve cell. So our body doesn't really have a good response to it. And then the other challenge is there's lots and lots of genetic diversity of the B serogroup. There's hundreds of subtypes. So creating a single vaccine that's going to provide long-lasting protection against serogroup B is really challenging. And if someone says you're fine, you have the flu, they know to say no, I'm not fine, and they feel empowered to do that. That's really important. Healthcare providers need that education, have that high index of suspicion to initiate rapid diagnosis and treatment. Keep it on your list of things. And that includes antibiotics and something called the glucocorticoid. Steroids are anti-inflammatory and can kind of help turn down the immune system, which is what causes a lot of the consequences of this. As I mentioned, about 10% to 15% of cases are fatal. And then, even people who survive the disease, somewhere around 10% to 20% have serious long-term health effects such as loss of limb, hearing loss, organ damage, cognitive problems. So it's a very serious disease even among people who recover from it. I'll close with a few notes about college students. And Craig alluded to the fact that there's lots of reasons why we focus on this disease on college and university campuses. Certainly, part of it is we know it happens in other students, other young adults, but there is some evidence that they may be at slightly increased risk, but not much, first-year college students who live in residence halls. That's probably because of the all coming together and the colonization that happens. There's one very good study out of, I think it was out of Great Britain, that showed that the incidence of carriage among first-year college students increased almost 33% at one point during their first year on campus, and then it goes back down. So it really is about that period of transient colonization. We know that most of the population is in higher incidence age groups. We are a perfect setting for outbreaks, although certainly other situations like military, prisons, are a setting for outbreaks. And, really, and I think that's, again, why we're here today, we have an opportunity because we can reach our students and we can reach their families and we can reach their loved ones and we're their healthcare providers, we really have an opportunity to do prevention in this population through promotion of vaccine, mandates for vaccines, and education about the disease so that we can reduce those numbers any more. So, I know that we're happy, Craig and I are happy to take questions. I just want to take a moment to, again, thank Meredith for her advocacy on this issue. As someone who views myself as charged with taking care of the 43,000 precious lives that are on our campus, there's nothing that is more terrifying for me and horrifying to me than to lose one of our students to this disease. So we've made a lot of good progress so far, but there's a lot more work to do so we don't have to be doing this talk again in 10 years. (applause)