An attempt at an epidemiological explanation - Epib.nl

Secondary cases and chemoprophylaxisINTRODUCTIONThe household contacts of a patient with meningococcal disease (meningitis and/orsepticemia) have an increased risk of contracting the disease,I -) To protect thesehousehold contacts against secondary disease, chemoprophylaxis is recommended inthe United States and Great Britain.ofS The objective of this measure is to eliminatemeningococci from the nasopbarynx of carriers, by which the further transmission ofthe meningococcus within the household is interrupted. It is assumed that this willprevent secondary cases of meningococcal disease (MD). The most preferred drug forchemopropbylaxis is rifampicin. Alternative drugs are minocycline. ceftriaxone andciprofloxacin. 111cse antibiotics are capable of eliminating meningococci from thenasopharynx (efficacy as compared to placebo: 79-100%).6-' Because most secondarycases occur within 5 days after hospital admission of the primary patient,! tbe usualrecommendation is to prescribe the prophylaxis to the household contacts as 50011 aspossible after diagnosis." 5 Because most antibiotics which are used for treatment ofgeneralized MD do 110t reach sufficient salivary concentrations, it is recommended togive prophylaxis to the primary patient as well, prior to the patient's discharge fromhospital, to ensure that carrier strains are not reintroduced into the household by theprimary patient.' so Medical personnel that has been in close contact with a patientwith MD (mouth-to-mouth resuscitation), should also be prophylactically treated."In the Netherlands the prescription of chemoprophylaxis is not accepted practice.In 1980 the National Health Council preferred close monitoring of the health-statusof contacts of a primary patient, and left the prescription of chemoprophylaxis to theopinion of the attending physician." Apart from the advocation of rifampicin, nofurther instructions were provided with regard to chemoprophylaxis. In 1988 theprescription of chemoprophylaxis with rifampicin to the household contacts of aprimary patient with MD was recommended in the Du tch journal "NederlandsTijdschrift voor Geneeskunde", but in a subsequent paper in this journal no unifiedpolicy could be established with regard to chemoprophylaxis." 12 In 1990 it wasconcluded, again in this journal, that there was too little evidence of the beneficialeffect of chemoprophylaxis with rifampicin to justify its prescription." In the protocol"Infectieziekten" issued by the Department of the Chief Medical Officer of Health(CM OH), to which the Dutch Public Health Services refer, chemoprophylaxis withrifampicin is suggested, but not officially recommended. J4During the period from 1st April 1989 to 30th April 1990, a nation-wide survey onMD was conducted in the Netherlands. Secondary study-objectives were the assessmentof the secondary attack rate (SAR) of MD among the household contacts ofprimary patients with rvrn, and the inventarization of the application of chemoprophylaxisill the Netherlands. In this article we present the results of tbis part ofthe survey, and advocate a reappraisal of the recommendation of chemoprophylaxis inthe Netherlands.77