MENINGOCOCCAL MENINGITIS

MENINGOCOCCAL
MENINGITIS
Dr. Charmaine Gauci MD MSc, MSc,
PhD, FRSH
Director Health Promotion and
Disease Prevention

Meningitis
The meninges are the external
coverings of the brain and the spinal
cord. Inflammation of these covering
membranes, commonly due to
infection, is termed meningitis.
Meningitis is typically associated with
rapid onset headache, drowsiness,
aversion to light and neck stiffness

Types of Meningitis

Diagnosis
sample of spinal fluid collected by a
needle (lumbar puncture) is tested to
identify the type of meningitis and the
causative agent.

Meningococcal Disease
Severe bacterial infection of
bloodstream or meninges
Two common disease presentations
Meningococcal meningitis
Meningococcaemia

Meningococcal Disease
Medical Emergency
Urgent referral
Urgent treatment
Delay can be fatal
Often get deaths from meningococcal
disease

Aetiological agent
The causative agent is Neisseria Neisseria
meningitidis meningitidis which is a gram negative
diplococcus.
diplococcus.
There are three main serotypes A, B,
C.

Neisseria meningitidis
Neisseria meningitidis
3 serogroups - A, B, C

Neisseria meningitidis
3 serogroups - A, B, C
may invade to cause
• meningitis (85%)
• septicaemia (15%)

Transmission
Neisseria Neisseria meningitidis
meningitidis
bacteria
Only humans carry
Neisseria Neisseria meningitidis
meningitidis
Person to person
Inhalation of airborne
droplets when infected
person coughs/sneezes
or close contact
By carriers of Neisseria
meningitidis

Nasopharyngeal carriage
Neisseria Neisseria meningitidis meningitidis present mucosa
of nose and throat
Natural defence mechanisms contain
infection
Spread to other parts prevented
? humoral immunity
No symptoms seen

Who is at risk?
Healthy individuals
Increased risk in
Children 6 months – 4 years
Complement deficiencies
Splenectomy patients
Patients taking immunosuppressive drugs
Current viral infection

Incubation period and
Infectivity
Incubation period: 2-10 2 10 days
Infectivity period: as long as the
organism is present in the nasopharynx.
nasopharynx.
Reservoir: is man and the organism
dies quickly outside the host.

Signs and Symptoms
Meningococcal Meningitis
Children > 1 year and adults
Neck stiffness
Headache
Nausea and vomiting
Neck and/or back pain
Fever/chills
Increased sensitivity to light
Irritability, confusion
Children > 1 year and adults

Signs and Symptoms
Meningococcal Meningitis
Infants
Refusing feeds
Increased irritability
Sleeping all the time
Fever
Bulging fontanelle
Inconsolable crying
Epileptic fits
Usually respond well to antibiotics

Septicaemia
Occurs in 10-20% 10 20% of cases
Fever, pethechial rash, hypotension
Seizures, coma possible
CSF may be clear
Progresses rapidly
30% die: responds poorly to AB

Petechial rash

Rash

Necrotic rash

Signs and Symptoms
Meningococcaemia
Petechiae :
rash of small red or purple spots that do not
disappear when pressure is applied to skin
Occurs in 50-75% 50 75% of cases
Rash may progress to larger patches or purple
lesions
On trunk and extremities but any part
Severe cases lesions may burst and lead to
necrosis

Petechial rash

Petechial rash

Other signs and symptoms
Acute fever and chills
Headache
Neck stiffness
Low back and thigh pain
Nausea and vomiting
Confusion and unconsciousness
Epileptic fits
Collapse from septic shock

Meningococcal Disease
Distribution:world wide distribution.
Nasphargngeal carriage - about 10%
prevalence lies somewhere between 2-4% 2 4%
of the population rising to approximately
20% in epidemic situations and over 50%
in outbreaks in closed communities.
Severe problem in “meningitis meningitis belt” belt in
Africa

“Meningitis Meningitis belt” belt epidemics
Serogroups A and C
Neisseria Neisseria meningitidis
meningitidis
Begin in dry season;
end when rainy season
begins
Children and young
adults most affected
70% of cases die
without treatment
10% of cases die with
treatment

Meningococcal Disease
in Malta
Meningococcal disease has become a public
health concern since 1996 when we
experienced a steady increase in the
incidence of the disease. From an incidence
of 0.8 per 100,000 cases in 1994, the
incidence reached 8.1 per 100,00 in year
2000 and dropped to 4.4 per 100,000 in year
2003.

Meningococcal disease
Statuatory notifiable disease
Physicians legal obligation (Public health
Act)
Medical diagnostic labs (MKPO)

Purpose of surveillance
Detect outbreaks early
Estimate the number of cases and
deaths
Assess size and geographic extent of
outbreak
Plan vaccination campaign
Describe if control measures are
working

Collect Information
Record basic information
Date, name, age, gender, address
Record basic information
Diagnosis and method of confirmation
CLINICAL
Diagnosis and method of confirmation
LABORATORY
Treatment
LABORATORY
Treatment
Outcome
Consider separate epidemic register during an
epidemic (Attack rate substantially above the
usual rate)

Importance of Public health
management
Reduce risk of disease (carriage in
index and close contacts)
Early identification of other cases
Allay anxiety

Case ascertainment
EU Case Definition (Decision ( Decision 2119/98
EC)
Clinical Description:
Clinical picture compatible with
meningococcal disease, e.g. meningitis
and/or meningococcaemia/septicaemia
meningococcaemia/septicaemia
that may progress rapidly to purpura
fulminans, fulminans,
shock and death.
Other manifestations are possible.

Case classification
Confirmed case:
A clinically compatible case diagnosed by one
or more of the following laboratory criteria.
Isolation of Neisseria Meningitidis from a normally
sterile site
Detection of N. meningitidis nucleic acid from a
normally sterile site
Detection of N. meningitidis antigen from a
normally sterile site
Demonstration of gram-negative
gram negative diplococci from a
normal sterile site by microscopy

Case classification
Probable case:
A clinical compatible case that is diagnosed
by one or more of the following laboratory
criteria:
High titre of meningococcal antibody in
convalescent serum
Or
Clinical picture compatible with
meningococcal disease (clinical definition
above) without any laboratory
confirmation.

Other cases
Clinical diagnosis of meningitis or septicaemia
or other invasive disease where the public
health physician, in consultation with the
clinician & microbiologist, considers that
diagnoses other than meningococcal disease
are at least as likely.
Cases here may be of viral origin but
antibiotics may be given to case until
diagnosis is confirmed.
Follow up by public health physician re
diagnosis and need for public health action

Family Slide

Cases in Contacts

Prophylactic treatment
Risk assessment
Index cases
Household contacts
Persons sleeping in the same household
Pupils in the same dormitory
Boy/girlfriends
Childminder in homes

Prophylactic treatment..
University students sharing a kitchen
Persons in contact with case > 4 hours
in a closed environment
History of intimate kissing
Passengers seated next to the index
symptomatic case
Health care workers

Prophylaxis NOT indicated
Staff and children attending same nursery or
crèche cr che
Students/pupils in same school/class/tutor group
Cheek kissing or mouth kissing
Health care workers
Pupils in other class rooms
Friends and work colleagues
Residents of nursing/residential homes
Attending the same social function
Food or drink sharing
Exposure of eyes

Chemoprophylaxis :
RIFAMPICIN
For those over 12 years, the dose is 600mg (150 mg or 300mg preparations)
twice daily for 2 days.
For those under 12 years:

Chemoprophylaxis :
CIPROFLOXACIN
500 mg single dose in adults and
children >12 yrs
250mg for children 5-12 5 12 yrs
125mg for children 2-4 2 4 yrs

Vaccines
A, C, W135 or Y vaccines available
close contacts who received
chemoprophylaxis should be offered
vaccination
early as possible up to 4 weeks after
the onset
Mencavax AC (bivalent)
Mencevax ACWY (quadrivalent
quadrivalent) )

Dissemination of
information
Household contacts
Group settings eg nurseries, schools
Response team:
Public health physician
Environmental health inspector
School health and safety officer
School/group management

Information
a case has occurred
describe & give information on the disease
(leaflet)
the chances of having another linked case is
very small
should the symptoms and signs of
meningitis occur, they should seek medical
attention rapidly
describe and give prophylaxis
Inform parents & those being prescribed
prophylaxis of possible side effects.

Managing clusters
Assess the information
Consider the options
Make a decision
Implement the decision
usually information and antibiotics +/-
vaccine to group at risk

Expected outcomes
Accurate and timely information
Alleviate fears
Early identification of cases in contacts
Compliance with control measures
Response team to initiate control measures
Reduce risk of disease
Accurate and timely information
Response team to initiate control measures
Communication with media
Information to general public : prevent panic and
rumors
Same key messages

Control Strategy
Communicable disease strategy
Meningococcal disease priority disease
Actions for control at all levels:
Management prior to referral to hospital
Management on arrival at hospital
Management prior to referral to hospital
Management on arrival at hospital
Laboratory Diagnosis
Discharge and post discharge planning
Surveillance
Management of sporadic cases and
outbreaks of meniningococcal disease

Meningococcal disease in
Malta in 2006
During the year 2006
38 sporadic cases of MD were reported in
Maltese residents.
26 cases septicaemia
12 cases meningitis

Case fatality rate
Proportion of cases that resulted in
death
If CFR is >25%: problems with case
management
If CFR is

LOCAL SEROGROUP
DISTRIBUTION
Cases
14
12
10
8
6
4
2
0
Meningococcal cases by serogroup (0-18 years)
1999 2000 2001 2002 2003 2004 2005 2006
Year
MenB MenC Other

AGE SPECIFIC INCIDENCE RATES
Incidence Rates of Laboratory Confirmed Invasive MenB
disease by Age
30
25
20
Incidence/100,000 15
10
5
0

Public Health Strategy
active surveillance of cases in hospitals for
the early detection of suspected cases
communication with the public and general
practitioners
early recognition and immediate treatment
can save lives.
Circulars were sent to doctors and patient
information leaflets were distributed.

Thank you
charmaine.gauci@gov.mt