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) Summary of key recommendations for chemoprophylaxis Risk assessment is needed For each notification of meningococcal disease, an individual event-specific risk assessment is needed to determine which individuals in contact with the case should be considered as “close contacts” and for whom chemoprophylaxis is therefore indicated. Prophylaxis generally indicated Chemoprophylaxis should be offered/considered for those who had close prolonged contact with a case in the seven days before onset of illness, irrespective of vaccination status, in the following categories: Household type contacts All household type contacts should be offered chemoprophylaxis. Examples of such contacts would be those living and/or sleeping in the same household (including recent visitors who have stayed overnight), pupils in the same dormitory, boy/girlfriend, or university students sharing a kitchen in a hall of residence. Babysitters may also be included depending on the level of contact. Intimate contacts Intimate mouth to mouth kissing contacts should be offered chemoprophylaxis. Attendance at house party - in certain circumstances Following risk assessment chemoprophylaxis should be considered if the index case (adult or child) attended a house party for four hours or more with children less than 5 years of age. If chemoprophylaxis is indicated it should be offered to all attendees, both adults and children, who attended for four hours or more. Other situations with possible close contact Special consideration should be given to situations in which there is greater than usual interactions between members of the extended family and an index case, particularly where overcrowded living conditions exist. Preschool child-care facilities contacts in certain circumstances Following risk assessment chemoprophylaxis should be considered in the following circumstances: • Family pre-school day care (where groups of children are cared for in a private home) • Preschool childcare -involving a group staying together in a single room for at least a four-hour session. -involving a group staying together in a single room for at least a three-hour session on more than one day. In this situation chemoprophylaxis may be considered if the setting is similar to a household, e.g. if the children share meals and nap together. Healthcare workers in certain circumstances 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 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. Index case Chemoprophylaxis is recommended when able to take oral medication and before discharge from hospital, unless the disease had already been treated with ceftriaxone. Note: Key recommendations are continued next page -62-
Guidelines for the Early Clinical and Public Health Management of Bacterial Meningitis (including Meningococcal Disease) Summary of key recommendations for chemoprophylaxis (continued) Prophylaxis generally not indicated Prophylaxis is generally not indicated for contacts of a sporadic case in the following categories unless already identified as close contacts: • Primary or secondary school contacts • General medical or nursing care of a case • Work colleagues • Friends • Residents of a nursing home/residential homes • Kissing on cheek or mouth (intimate mouth-to-mouth kissing contacts should be offered prophylaxis) • Food or drink sharing or similar low level of salivary contact • Travelling in next seat on same plane, train, bus or car • Post mortem contact with a case (other than performing an autopsy when may be indicated if exposed to aerosols and not wearing a mask). Timing of prophylaxis Ideally, chemoprophylaxis should be given to all contacts as soon as possible after diagnosis of a case. However, it is appropriate to administer chemoprophylaxis to close contacts who may not have come to notice initially, up to a month after the identification of the index case as carriage may persist for a long period. 7.4 Public health actions after a case Risk assessment is needed For each notification of meningococcal disease, an individual event-specific risk assessment is needed to determine which individuals in contact with the case should be considered as “close contacts” and for whom chemoprophylaxis is therefore indicated. 7.4.1 Cases requiring public health actions Public health actions should commence as soon as possible in all cases where the clinical diagnosis of meningococcal meningitis or septicaemia is considered the most likely diagnosis. (See section 7.5) Although not meeting the case definition of a confirmed, probable or possible case, meningococcal infection of the conjunctiva, without clinical evidence of sepsis, is considered an indication for public health action because it may precede invasive disease 59 or invasive meningococcal disease in a contact. 15 (See section 7.5) 7.4.2 Cases not requiring public health actions When the public health doctor, in consultation with the clinician managing the case considers that diagnoses other than meningococcal disease are at least as likely, then chemoprophylaxis is not indicated. This category includes cases treated with antibiotics whose probable diagnosis is viral meningitis. If further evidence emerges to change the diagnosis then appropriate actions should be taken. Isolation of meningococci from sputum or from swabs taken from nasopharynx or genital tract, in the absence of clinical evidence of sepsis, is not by itself an indication for public health action as asymptomatic carriage in the respiratory and genital tract is common. Meningococcal pneumonia is not an indication for public health action but may carry a low risk of transmission in healthcare settings especially to the immunocompromised. 3 -63-
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