THIS IS A STATE LAW. YOU MUST COMPLETE THIS FORM.

MENINGITIS INFORMATION RESPONSE FORM

New York State Public Health Law requires that all college and university students enrolled for at least six (6) semester hours or the equivalent per semester, or at least four (4) semester hours per quarter, complete and return the following form. Please read the Meningitis Fact Sheet below.
*marked fields are required. Failure to complete all required fields will result in an invalid form.

First Name: * MI: * Last Name: *

* Banner ID:

* Email address: * Date of Birth: * (01/01/1999)

Phone #: * (716)555-5555

Address: * City: * State: * Zip: *

You must check one of the boxes below *:

had the meningococcal meningitis immunization within the past 5 years.
Date received: (01/01/2015)

read, or have had explained to me, the information regarding meningococcal meningitis disease. I understand the risks of not receiving the vaccine. I have decided that I (my child) will not obtain immunization against meningococcal meningitis disease.
Please read the information below first.

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MENINGOCOCCAL MENINGITIS FACT SHEET


What causes meningococcal disease? Meningococcal disease is caused by the bacterium Neisseria meningitidis. This bacterium has at least 13 different subtypes (serogroups). Five of these serogroups, A, B, C, Y, and W-135, cause almost all invasive disease. The relative importance of these five serogroups depends on geographic location and other factors.


How does meningococcal disease spread? The disease is spread person-to-person through the exchange of respiratory and throat secretions (e.g., by coughing, kissing, or sharing eating utensils). Me-ningococcal bacteria can't live for more than a few minutes outside the body, so the disease is not spread as easily as the common cold or influenza.


What are the symptoms of meningococcal disease? The most common symptoms are high fever, chills, lethargy, and a rash. If meningitis is present, the symptoms will also include headache and neck stiff¬ness (which may not be present in infants); seizures may also occur. In overwhelming meningococcal in¬fections, shock, coma, and death can follow within several hours, even with appropriate medical treat¬ment.


Is there a treatment for meningococcal disease? Meningococcal disease can be treated with antibiot¬ics. It is critical to start treatment early.


What people are at special risk for meningococcal disease?Studies have shown that college freshmen who live in a dormitory are at an increased risk of me¬ningococcal disease compared with others their age. In addition to certain age groups, people at increased risk include travelers to places where meningococcal disease is common (e.g., certain countries in Africa, and in Saudi Arabia), people with damaged or miss¬ing spleens, and people with persistent complement component deficiency (an immune system disorder). Other factors make it more likely an individual will develop meningococcal disease, including having a previous viral infection, living in a crowded house¬hold, having an underlying chronic illness, and be¬ing exposed to cigarette smoke (either directly or second-hand).


How safe is this vaccine? Both types of meningococcal vaccines are very safe. Polysaccharide (sugar) meningococcal vaccine has been used extensively since 1981, and millions of doses of meningococcal conjugate vaccine have been given since they were first licensed in 2005.


Should college students be vaccinated against meningococcal disease? College freshmen living in residence halls, are at an increased risk of meningococcal disease relative to other people their age. The MCV4 vaccine is recom¬mended for previously unvaccinated first-year col¬lege students, age younger than 22 years, who are or will be living in a residence hall. Some colleges and universities require incoming freshmen and oth¬ers to be vaccinated; some may also require that a meningococcal vaccination have been given since the age of 16 years. Although the risk for meningococcal disease among other college stu-dents (such as those 22 years or older, or not living in a residence hall) is similar to that of the general population of the same age, students who wish to decrease their risk of meningococcal disease can be vaccinated.


What kind of vaccines are they? The MPSV4 vaccine is made from the outer polysac-charide capsule (sugar coat) of the meningococcal bacteria. The meningococcal conjugate vaccines are made by chemically linking the capsular polysaccha¬ride antigens individually to a protein. The vaccines do not contain live bacteria.


How many doses of meningococcal vaccine are needed? The number of doses recommended depends on the age when the vaccine is given and the presence of certain medical conditions or risk factors. All ado¬lescents should be vaccinated at ages 11 through 12 years and need a booster dose at age 16 years. All teens who were vaccinated at ages 13 through 15 years need a booster dose at age 16 through 18 years (at least 8 weeks after the first dose). First-year college students younger than 22 years who are liv¬ing in a residential hall should get a booster dose if their previous dose was given before age 16 years. In addition, vaccinated people who remain at risk, such as people without a spleen, microbiologists who work with meningococcus, or those who travel repeatedly to parts of Africa, should receive a booster dose of MCV4 every 5 years.


How do I get more information about meningococcal disease and vaccination? Contact your physician or your student health services. Additional information is available on the websites of New York State Department of Health, www.health.ny.gov; Center for Disease Control and Prevention www.cdc.gov/vaccines; and American College Health Association, www.acha.org