MENINGOCOCCAL MENINGITIS (MCM) AT NEW DELHI & INDIA

1. MENINGOCOCCAL MENINGITIS (MCM) AT NEW DELHI & INDIA Dr. A. K. AVASARALA MBBS, M.D. PROFESSOR & HEAD DEPT OF COMMUNITY MEDICINE & EPIDEMIOLOGY PRATHIMA INSTITUTE OF MEDICAL SCIENCES, KARIMNAGAR, A.P. INDIA: +91505417 avasarala@yahoo.com

2. PART-II CLINICAL DISEASE, EPIDEMIOLOGY AND CONTROL

4. DEFINITION • IT IS A PYOGENIC INFECTION OF MEMBRANES COVERING THE BRAIN AND SPINAL CORD ( DURA, PIA AND ARACNOID MEMBRANES) BY MENIINGO-COCCI • ALSO CALLED CEREBROSPINAL FEVER

5. CLINICAL PRESENTATIONS • RESTRICTED TO NASOPHARYNX AS ASYMPTOMATIC CASES OR ONLY WITH LOCAL SYMPTOMS • INVASIVE WITH ACUTELY ILL SEPTICEMIC AND TOXIC • MENINGEAL

6. CLINICAL PICTURE IN THE NEWBORN • MINIMAL AND VARIABLE, HENCE DIAGNOSIS DIFFICULT • SLUGGISH, LETHARGIC WITH UNUSUAL GAZE • DOES NOT TAKE FEED WELL , MAY VOMIT • HIGH PITCHED CRY AND CONVULSIONS • HYPOTHERMIA SEEN USUALLY, FEVER MAY BE THERE • TENSE AND BULGING ANTERIOR FONTANELLAE VERY USUAL

7. CLINICAL PICTURE IN PRESCHOOL & SCHOOL CHILD • WIDE SPECTRUM OF SIGNS & SYMPTOMS IN THIS AGE GROUP AND MORE OBVIOUS • MODERATE TO HIGH FEVER • HEADACHE, VOMITING, PHOTOPHOBIA, CONVULSIONS, • NECK STIFFNESS, • NEUROLOGICAL IRRITATION • SKIN RASHES

8. CLINICAL PICTURE IN < 2 YEAR OLD CLASSICAL SIGNS MAY NOT BE PRESENT BUT HIGH DEGREE OF SUSPICION WHEN THE FOLLOWING PICTURE IS SEEN • FEVER COMMON • MACULOPAPULAR PETECHIAL RASH IN HALF OF THE CASES • REFUSAL OF FEEDS • VOMITINGS, • ALTERED SENSORIUM • IRRITABILITY • BULGING FONTANELLAE • NEUROLOGICAL DEFICIT (EITHER MONOPLEGIA, HEMIPLEGIA AND SQUINT

9. CLINICAL PICTURE IN THE ADULT • CLEARCUT PICTURE • FEVER, INTENSE HEADACHE • VOMITING, PHOTOPHOBIA, • NECKPAIN AND STIFFNESS • SIGNS OF MENINGEAL IRRITATION AND ALTERED SENSORIUM • SKIN RASHES • SIGNS AND SYMPTOMS OF SHOCK

10. DIFFERENTIAL DIAGNOSIS IN NEONATE: SEPTICEMIA, GASTROENTERITIS, BIRTH HYPOXIA, BIRTH TRAUMA, RESPIRATORY INFECTIONS, HYPOGLYCEMIA, METABOLIC DISORDERS CAUSING CONVULSIONS AND KERNICTERUS IN OLDER CHILDREN AND ADULTS: ENCEPHALITIS, BRAIN ABSCESS, CEREBRAL MALARIA, ASEPTIC MENINGITIS, CARDIOVASCULAR ACCIDENTS, CRYPTOCOCCAL MENINGIT IS AND TUBERCULAR MENINGITIS

11. DIAGNOSIS • MENINGOCOCCI ARE DEMONSTRATED BY LUMBAR PUNCTURE AND EXAMINATION OF CEREBRO SPINAL FLUID (CSF) & CULTURE OF CSF • BLOOD CULTURE • CULTURE FROM NASOPHARYNX • EXAMINATION OF PETECHIAL SKIN LESIONS • IMMUNOLOGICAL METHODS FOR ANTIBODIES (IFP, ELISA, CIEP)

12. TREATMENT • ISOLATION OR SEPARATION • ALL PATIENTS NEED HOSPITALIZATION • SPECIFIC TREATMENT - FLUIDS - CEFTRIAXONE/CEFOTOXIME - AMPICILLIN ( NOT TO BE GIVEN IF HYPERSENSITIVE TO PENICILLIN) - CHLORAMPHENICOL • SUPPORTIVE THERAPY: FOR SHOCK AND CONVULSIONS

13. EPIDEMIOLOGICAL INTERACTION • AGENT FACTORS TIME DISRIBUTION MCM HOST FACTORS ENVIRONMENT FACTORS PERSON DISTRIBUTION PLACE DISTRIBUTION

14. THE CAUSATIVE AGENT • NEISSERIA MENINGITIDIS (MENINGO COCCUS) • BISCUIT SHAPED GRAM + VE DIPLOCOCCUS • SIZE & SHAPE VARIATION IN OLDER CULTURES DUE TO AUTOLYSIS • TRANSPARENT ,NON PIGMENTED, NONHEMOLYTIC COLONIES 1-5 MM SIZE

15. MENINGO COCCI

16. SERO GROUP TYPING • DEPEND UPON THE POLYSACCHARIDE CAPSULE • NINE SEROLOGICAL GROUPS IDENTIFIED • A, B, C, D, X , Y, Z , W-135, 29E • ALL THE SEROGROUPS ARE PATHOGENIC BUT A, B, C, Y ARE MOST NEUROVIRULENT • A AND C ARE MOST EPIDEMOGENIC

17. MODE OF TRANSMISSION • HUMAN CASES AND THE CARRIERS ARE THE ONLY RESERVOIRS • TRANSMITTED BY DIRECT CONTACT (DROPLETS,DISCARGE FROM THE NOSE &THROAT OF THE PERSONS) • INCUBATION PERIOD = 3-4 DAYS • PERIOD OF COMMUNICABILITY IS AS LONG AS THE MENINGOCOOCI ARE PRESENT IN DISCARGES FROM NOSE, THROAT AND NASOPHARYNX

18. PERSON FACTORS • POOR NUTRITIONAL STATUS & IMMUNITY • DRY NASAL MUCOSA • PHYSICAL EXERTION • FATIGUE • CARRIER STATE

19. AGE PREDILICTION PRIMARILY A CHILD DISEASE BUT CAN AFFECT YOUNG ADULTS ALSO

20. SEX PREDILICTION • MORE MALES ARE AFFECTED THAN FEMALES

21. PLACE DISTRIBUTION • MCM IS ENDEMIC IN LARGE TOWNS • MORE COMMONLY IN PEOPLE LIVING IN CROWDED CONDITIONS

22. TIME DISTRIBUTION • GREATEST INCIDENCE IN WINTER AND SPRING

23. CARRIER STATE • TRANSMISSION OCCURS MORE OFTEN FROM CARRIERS RATHER THAN CASES • BY AND LARGE HIGH CARRIER RATE IS USUALLY ASSOCIATED WITH OUTBREAKS

24. CONTROL MEASURES

25. VACCINATION • COMPOSITION: 50 MICRO GRAMS OF “A” POLYSACHARIDE, 50 MICRO GRAMS OF “C” POLY SACHARIDE, 1 MG OF LACTOSE. • DOSE - 0.5 ML OF IRRESPECTIVE OF AGE GIVEN SUBCUTANEOUSLY. • EFFICACY– SEROGROUP “A’ CLINICAL EFFICACY = 85-95% SERO GROUP “A’ INDUCES ANTIBODY RESPONSE IN CHILDREN AS YOUNG AS 3 MONTHS OLD. • BUT SEROGROUP “C” DOES NOT INDUCE ANTIBODIES BEFORE 2 YEARS OF AGE. • SEROGROUP “Y” AND W-135 ARE SAFE AND IMMUNOGENIC IN ADULTS AND CHILDREN ABOVE AGE OF 2 YEARS.

26. VACCINATION LIMITATIONS • LIMITED SHELF LIFE AFTER REVACCINATION • NO VACCINE IS AVAILABLE AGAINST GROUP B • SHORT INCUBATION PERIOD vis-à-vis MORE TIME TAKEN FOR THE DEVELOPMENT OF IMMUNITY • 4.UNSATISFACTORY RESPONSE VACCINATION UNDER 2 YEARS OF AGE WHICH IS THE HIGHEST SUSCEPTIBLE AGE-GROUP

27. PRESENT STRATEGY FOR VACCINATION • ONLY HIGH RISK PEOPLE (HEATH CARE WORKERS, TRAVELLERS, PEOPLE LIVING IN OVERCROWDED PLACES) AND CLOSE CONTACTS HAVE TO BE VACCINATED.

28. VACCINATION FOR CONTACTS • FORTUNATELY, WE HAVE QUADRIVALENT VACCINES AT PRESENT • PROTECTION OCCURS ONLY AFTER 14 DAYS OF VACCINATION • HENCE CHEMOPROPHYLAXIS IS PROVIDED WITH ANTIBIOTICS IN THE MEANTIME

29. VACCINATION FOLLOWED BY +CHEMOPROPHYLAXIS FOR CLOSE CONTACTS • HOUSEHOLD MEMBERS • DAY-CARE CENTRE CONTACTS • ANYONE DIRECTLY EXPOSED TO THE PATIENT'S ORAL SECRETIONS OR RESPIRATORY DROPLETS.

30. CHEMOPROPHYLAXISFOR CLOSE CONTACTS CIPROFLOXACIN, RIFAMPICIN, MINOCYCLINE, SPIRAMYCN, CEFTRIAXIONE • WITHIN 24 HOURSFOR • HOUSEHOLD • CONTACTS • CLOSE CONTACTS • HIGH RISK PERSONS WITH

31. RISK COMMUNICATION THROUGH PUBLIC EDUCATION REGARDING • RISK FACTORS AND POSSIBLE CONTROL STRATEGIES • NOTIFICATION OF CASES AT THE EARLIEST • SURVEILLANCE FOR ACTIVE AND SUSTAINED COMMUNITY PARTICIPATION TO CONTROL THE EPIDEMIC

32. PUBLIC EDUCATION • AVOID OVERCROWDING. • DO NOT SHARE DRINKING BOTTLES, GLASSES, CIGARETTES, LIPSTICKS OR OTHER ITEMS THAT MAY BE COVERED IN SALIVA. • AVOID SMOKY AND DUSTY PLACES. • TEACH CHILDREN NOT TO SHARE CUPS, SOFT DRINK CANS OR SPORTS WATER BOTTLES.