Guidelines for the Early Clinical and Public Health Management of ...

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Guidelines for the Early Clinical and Public Health Management of Bacterial Meningitis (including Meningococcal Disease) Chapter 4: Surveillance Key points Surveillance is required to: • Ensure prompt identification and appropriate management of cases and close contacts in order to implement appropriate control and communication measures to monitor changes in epidemiology and effectiveness of control measures to provide evidence for local and national guidelines Case definitions used in surveillance are available (see section 4.3 below and on HPSC website) Clinicians and laboratories are legally required to: • Notify all cases of suspected bacterial meningitis, invasive meningococcal or Hib disease to public health immediately without waiting for microbiological confirmation • Notify all cases of pneumococcal meningitis upon microbiological confirmation Departments of public health should: • Undertake enhanced surveillance on all cases • Implement prompt public health interventions as appropriate • Monitor disease incidence and trends • Evaluate public health interventions and policies • Review regularly surveillance data at local level (Health Protection Surveillance Centre reviews data at both national and regional level). 4.1 Surveillance of bacterial meningitis (including meningococcal, Hib, pneumococcal, streptococcal group B disease) Surveillance is based on notification of cases by clinicians and laboratories. Notification is a statutory requirement of both clinicians and laboratories. 4.2 Objectives of surveillance The objectives of disease surveillance are: • To ensure prompt identification and appropriate management of cases • To ensure prompt identification of close contacts in order to implement appropriate control and communication measures • Public health control measures are required for meningococcal disease and H. influenzae type b disease (and rarely invasive pneumococcal disease) to prevent ongoing transmission • To monitor changes in the epidemiology of the disease in relation to serogroup, serotype and antibiotic susceptibility • To monitor effectiveness of current control measures (vaccination programmes, chemoprophylaxis to contacts) • To provide an evidence base for local and national guidelines. All clinicians and laboratories should immediately notify cases of suspected meningococcal or H. influenzae infection by telephone, fax, or email. Laboratories using CIDR should also report all cases through CIDR. Notification of suspect meningococcal or Hib cases should not be delayed until microbiological confirmation is obtained. 4.3 Surveillance case definitions 33 Case definitions have been defined for all notifiable disease in Ireland since 2003 and updated cases definitions were produced in January 2012. A case definition means the set of clinical or microbiological characteristics by which a case of infectious disease is defined. This information is used to classify the notifications as possible, probable or confirmed. The classification according to the different levels might vary according to the epidemiology of the individual diseases. Prior to this case definitions for meningococcal disease had already been defined and were used for surveillance. The following case definitions are used to define the most commonly reported notifiable diseases associated with meningitis. -36-
Guidelines for the Early Clinical and Public Health Management of Bacterial Meningitis (including Meningococcal Disease) 4.3.1. Bacterial meningitis (not otherwise specified) (case definition 2012) Clinical criteria Any person with the following clinical picture: bacterial meningitis manifests most commonly with fever, headache, and a stiff neck; the disease may progress rapidly to shock and death. However, other manifestations may be observed. Laboratory criteria for a confirmed case At least one of the following two: • Isolation of a bacterial species from the cerebrospinal fluid (CSF) • Detection of a bacterial species nucleic acid from CSF Laboratory criteria for a probable case At least one of the following two: • Detection of bacteria in CSF by microscopy e.g. Gram stain • CSF white cell count (WCC) differential, protein and glucose levels consistent with bacterial meningitis Epidemiological criteria NA Case classification A. Possible case – Any person meeting the clinical criteria B. Probable case – Any person meeting the clinical criteria and the laboratory criteria for a probable case C. Confirmed case – Any person meeting the laboratory criteria for a confirmed case Note: 1. Exceptions: Nosocomial bacterial meningitis directly related to invasive procedures (e.g. craniotomy, placement of internal or external ventricular catheters, lumbar puncture, intrathecal infusions of medications, or spinal anesthesia), complicated head trauma, or in rare cases, metastatic infection in patients with hospital-acquired bacteremia is not notifiable. These cases of meningitis are caused by a different spectrum of microorganisms than cases acquired in the community setting and illness is the result of diverse pathogenic mechanisms. 2. Notification of specified diseases causing meningitis: If a diagnosis of meningitis due to Haemophilus influenzae, Neisseria meningitidis, Streptococcus pneumoniae, Streptococcus Group B infection (invasive) or another listed bacterial pathogen has been made (even if they are considered to be a nosocomial case), please see the case definition for the particular disease/pathogen and notify under the relevant disease. 4.3.2. Meningococcal case definition (amended case definition 2012) Neisseria meningitidis Clinical criteria Any person with symptoms compatible with meningococcal disease including: • Meningeal signs • Haemorrhagic rash • Septic shock • Other manifestations are possible Laboratory criteria for a confirmed case At least one of the following three: • Isolation of Neisseria meningitidis from a normally sterile site or from haemorrhagic skin lesions • Detection of Neisseria meningitidis nucleic acid from a normally sterile site or from haemorrhagic skin lesions (note: see laboratory section for further information) • Detection of Neisseria meningitidis antigen in CSF Laboratory criteria for a probable case At least one of the following two: • Detection of gram-negative stained intracellular diplococci in CSF or from haemorrhagic skin lesions • Isolation of Neisseria meningitidis from a nonsterile site (together with compatible purpuric rash or CSF findings compatible with bacterial meningitis) -37-
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