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) Recommendation regarding chemoprophylaxis in universities (or tertiary facilities) • When sporadic cases occur in a college setting, chemoprophylaxis is only recommended for contacts who fit the criteria of being close contacts. 7.3.5 Healthcare worker contacts of a case Healthcare workers in contact with cases of meningococcal disease are at increased relative risk of disease in the 10-day period after exposure, although absolute risks are very low; one study absolute risk was estimated at 0.8 per 100,000 healthcare workers at risk, which is 25 times that in the general population. 57 The data were consistent with a higher (but unquantifiable) risk in those heavily exposed to nasopharyngeal secretions of cases around the time of admission to hospital. After starting treatment with intravenous benzylpenicillin, carriage rates decrease rapidly so that meningococci are undetectable by nasopharyngeal swabbing after 24 hours of treatment. Recommendation regarding chemoprophylaxis among HCWs • Chemoprophylaxis is recommended only for those whose mouth or nose is directly exposed to large particle droplets/secretions from the respiratory tract of a probable or confirmed case of meningococcal disease during the acute illness until the case has completed 24 hours of systemic antibiotics. This type of exposure will only occur among staff who are working close to the face of the case without wearing a mask or other mechanical protection. In practice this implies a clear perception of facial contact with droplets/secretions and is unlikely to occur unless using suction during airway management, inserting an airway, intubating, or if the patient coughs in your face. General medical or nursing care of cases is not an indication for prophylaxis. • Pathologist and pathology technicians who may be exposed to aerosols during the performance of an autopsy should receive chemoprophylaxis when a face mask had not been worn and when the deceased patient did not receive antibiotics for a minimum of 24 hours antemortem. Exposure of the eyes to respiratory droplets is not considered an indication for prophylaxis. Such exposure may however, carry a low risk of meningococcal conjunctivitis and subsequent invasive disease. Staff should be counselled about the risk and advised to seek early treatment if conjunctivitis should develop with 10 days of exposure. 7.3.6. Index case The ECDC guidance document – Public Health Management of Sporadic Cases of Invasive Meningococcal Disease and their Contacts 2 reviewed the evidence and concluded that “the recommendation to give chemoprophylaxis should apply to all cases of IMD unless they have already been treated with an antibiotic (such as ceftriaxone or cefixime) that eradicates carriage. However, when other third generation cephalosporins are administered to inpatients, the recommendation may be considered weak.” There is also a comment that “for cephalosporins such as cefotaxime which are often used in case treatment, it would be useful to evaluate their effectiveness in carriage eradication.” Recommendation regarding chemoprophylaxis for index case • The index case should be given chemoprophylaxis when able to take oral medication and before discharge from hospital, unless the disease had already been treated with ceftriaxone (or cefixime). • When the disease has been treated with cefotaxime it may be prudent to give chemoprophylaxis until studies are available on its effectiveness in eradicating carriage. 7.3.7 Those who may have shared saliva with a case Saliva contains other bacteria that are able to inhibit the growth of meningococci, and consequently meningococci are not easily isolated from saliva. 44 The ECDC guidance document – Public Health Management of Sporadic Cases of Invasive Meningococcal Disease and their Contacts 2 reviewed the evidence regarding the risk to people who have -60-
Guidelines for the Early Clinical and Public Health Management of Bacterial Meningitis (including Meningococcal Disease) shared drinks with a case of IMD. They concluded that it is important to “distinguish between salivary contact and respiratory droplet contact. Neisseria meningitidis colonises the posterior pharyngeal wall and is transmitted through respiratory droplets. In practice, some contact activities may involve both. For example, activities such as intimate (mouth-to-mouth) kissing are likely to involve both an important exchange of saliva and also an important exchange of respiratory droplets and have been linked to increased risk of carriage and disease. However, activities such as sharing drinks and cigarettes may occur in the absence of close contact.” The expert group reviewed the available evidence and made a weak recommendation that “Sharing drinks or cigarettes or similar contact with a case of IMD is not in itself an indication for chemoprophylaxis”. 2 Recommendation regarding chemoprophylaxis in relation to salivary exposure: • Prophylaxis is not indicated for individuals who have had low risk salivary exposures unless already identified as close household type contact. • Prophylaxis is indicated for intimate mouth to mouth kissing contacts during the seven days before onset of illness. 7.3.8 People exposed to a case while traveling. Transient contact with the index case before acute illness is unlikely to be an important risk factor for disease, so that mere proximity to the case (e.g. during travel in a plane, bus or car) may not justify prophylaxis. The ECDC guidance document – Public Health Management of Sporadic Cases of Invasive Meningococcal Disease and their Contacts 2 reviewed the evidence and concluded that the quality of evidence for or against giving chemoprophylaxis to contacts who shared the same transport vehicle as a case of IMD is very low. The lack of clusters in the published literature suggests that the risk to contacts in these situations is very low. The expert group reviewed the available evidence and made a weak recommendation that “Sharing the same transport vehicle as a case of IMD is not in itself an indication for chemoprophylaxis”. 2 Recommendation regarding chemoprophylaxis for fellow travellers: • Prophylaxis is not indicated for those who shared the same transport vehicle (e.g. plane, boat, bus, car) as a case unless already identified as close household type contact. 7.3.9. Post mortem exposure to a case The national document, “Guidelines on Management of Deceased Individuals Harboring Infectious Diseases” for publication in 2012 by a sub-committee of the Scientific Advisory Committee of HPSC 58 states that for meningococcal disease “the risk of transmission from human remains in a funeral setting is extremely low”. Therefore, in the case of meningococcal disease there is no indication for precautions other than standard precautions in this setting. Recommendation regarding chemoprophylaxis following post mortem exposure • Post mortem contact with a case is not an indication for prophylaxis. • Kissing the body is not considered to be a risk. Body bags are not necessary unless otherwise indicated, e.g. as a practical measure to facilitate lifting or moving. Transport to other countries for burial or cremation does not pose a risk. There is no restriction on embalming. -61-
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