MENINGOCOCCAL MENINGOCOCCAL MENINGITIS (MCM) AT MENINGITIS (MCM) AT

NEW DELHI & INDIANEW DELHI & INDIA

Dr. A. K. AVASARALA MBBS, M.D.PROFESSOR & HEADDEPT OF COMMUNITY MEDICINE & EPIDEMIOLOGYPRATHIMA INSTITUTE OF MEDICAL SCIENCES, KARIMNAGAR, A.P.INDIA: +91505417avasarala@yahoo.com

PART-IIPART-II

CLINICAL DISEASE, CLINICAL DISEASE, EPIDEMIOLOGY AND EPIDEMIOLOGY AND

CONTROLCONTROL

DEFINITIONDEFINITION

IT IS A PYOGENIC INFECTION OF IT IS A PYOGENIC INFECTION OF MEMBRANES COVERING THE BRAINMEMBRANES COVERING THE BRAIN AND SPINAL CORD ( DURA, PIA AND AND SPINAL CORD ( DURA, PIA AND ARACNOID MEMBRANES) BY ARACNOID MEMBRANES) BY MENIINGO-COCCI MENIINGO-COCCI

ALSO CALLED CEREBROSPINAL ALSO CALLED CEREBROSPINAL FEVERFEVER

CLINICAL PRESENTATIONSCLINICAL PRESENTATIONS

RESTRICTED TO NASOPHARYNX RESTRICTED TO NASOPHARYNX AS AS ASYMPTOMATICASYMPTOMATIC CASES OR CASES OR ONLY WITH LOCAL SYMPTOMSONLY WITH LOCAL SYMPTOMS

INVASIVE WITH ACUTELY ILL INVASIVE WITH ACUTELY ILL SEPTICEMIC AND TOXIC SEPTICEMIC AND TOXIC

MENINGEALMENINGEAL

CLINICAL PICTURE IN THE CLINICAL PICTURE IN THE NEWBORNNEWBORN

•MINIMAL AND VARIABLE, HENCE MINIMAL AND VARIABLE, HENCE DIAGNOSIS DIFFICULTDIAGNOSIS DIFFICULT•SLUGGISH, LETHARGIC WITH UNUSUAL SLUGGISH, LETHARGIC WITH UNUSUAL GAZEGAZE•DOES NOT TAKE FEED WELL , MAY VOMIT DOES NOT TAKE FEED WELL , MAY VOMIT •HIGH PITCHED CRY AND CONVULSIONSHIGH PITCHED CRY AND CONVULSIONS•HYPOTHERMIA SEEN USUALLYHYPOTHERMIA SEEN USUALLY, FEVER , FEVER MAY BE THEREMAY BE THERE•TENSE AND BULGING ANTERIOR TENSE AND BULGING ANTERIOR FONTANELLAE VERY USUALFONTANELLAE VERY USUAL

CLINICAL PICTURE IN CLINICAL PICTURE IN PRESCHOOL & SCHOOL CHILDPRESCHOOL & SCHOOL CHILD

WIDE SPECTRUM OF SIGNS WIDE SPECTRUM OF SIGNS & SYMPTOMS IN THIS AGE & SYMPTOMS IN THIS AGE GROUP AND GROUP AND MORE OBVIOUSMORE OBVIOUS

MODERATE TO HIGH FEVERMODERATE TO HIGH FEVER HEADACHE, VOMITING, HEADACHE, VOMITING,

PHOTOPHOBIA, PHOTOPHOBIA, CONVULSIONS,CONVULSIONS,

NECK STIFFNESS,NECK STIFFNESS, NEUROLOGICAL IRRITATION NEUROLOGICAL IRRITATION SKIN RASHESSKIN RASHES

CLINICAL PICTURE IN < 2 YEAR OLDCLINICAL PICTURE IN < 2 YEAR OLD CLASSICAL SIGNS MAY NOT BE PRESENT CLASSICAL SIGNS MAY NOT BE PRESENT

BUT HIGH DEGREE OF SUSPICION WHEN BUT HIGH DEGREE OF SUSPICION WHEN THE FOLLOWING PICTURE IS SEENTHE FOLLOWING PICTURE IS SEEN

FEVER COMMONFEVER COMMON MACULOPAPULAR PETECHIAL RASH IN MACULOPAPULAR PETECHIAL RASH IN HALF OF THE CASESHALF OF THE CASES REFUSAL OF FEEDSREFUSAL OF FEEDS VOMITINGS,VOMITINGS, ALTERED SENSORIUMALTERED SENSORIUM IRRITABILITYIRRITABILITY BULGING FONTANELLAEBULGING FONTANELLAE NEUROLOGICAL DEFICIT (EITHER MONOPLEGIA, NEUROLOGICAL DEFICIT (EITHER MONOPLEGIA,

HEMIPLEGIA AND SQUINTHEMIPLEGIA AND SQUINT

CLINICAL PICTURE IN THE ADULTCLINICAL PICTURE IN THE ADULT

CLEARCUT PICTURECLEARCUT PICTURE FEVER, INTENSE HEADACHEFEVER, INTENSE HEADACHE VOMITING, PHOTOPHOBIA,VOMITING, PHOTOPHOBIA, NECKPAIN AND STIFFNESSNECKPAIN AND STIFFNESS SIGNS OF MENINGEAL IRRITATIONSIGNS OF MENINGEAL IRRITATION

AND ALTERED SENSORIUMAND ALTERED SENSORIUM SKIN RASHESSKIN RASHES SIGNS AND SYMPTOMS OF SHOCKSIGNS AND SYMPTOMS OF SHOCK

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS IN NEONATE:IN NEONATE: SEPTICEMIA, GASTROENTERITIS, BIRTH HYPOXIA, SEPTICEMIA, GASTROENTERITIS, BIRTH HYPOXIA,

BIRTH TRAUMA, RESPIRATORY INFECTIONS, BIRTH TRAUMA, RESPIRATORY INFECTIONS, HYPOGLYCEMIA, METABOLIC DISORDERS HYPOGLYCEMIA, METABOLIC DISORDERS CAUSING CONVULSIONS AND KERNICTERUSCAUSING CONVULSIONS AND KERNICTERUS

IN OLDER CHILDREN AND ADULTS:IN OLDER CHILDREN AND ADULTS: ENCEPHALITIS, BRAIN ABSCESS, CEREBRAL ENCEPHALITIS, BRAIN ABSCESS, CEREBRAL

MALARIA, ASEPTIC MENINGITIS, MALARIA, ASEPTIC MENINGITIS, CARDIOVASCULAR ACCIDENTS, CRYPTOCOCCAL CARDIOVASCULAR ACCIDENTS, CRYPTOCOCCAL MENINGIT IS AND TUBERCULAR MENINGITISMENINGIT IS AND TUBERCULAR MENINGITIS

DIAGNOSISDIAGNOSIS

MENINGOCOCCI ARE DEMONSTRATED BY MENINGOCOCCI ARE DEMONSTRATED BY LUMBAR PUNCTURE AND EXAMINATION OF LUMBAR PUNCTURE AND EXAMINATION OF CEREBRO SPINAL FLUID (CSF) & CULTURE CEREBRO SPINAL FLUID (CSF) & CULTURE OF CSFOF CSF

BLOOD CULTUREBLOOD CULTURE CULTURE FROM NASOPHARYNXCULTURE FROM NASOPHARYNX EXAMINATION OF PETECHIAL SKIN LESIONSEXAMINATION OF PETECHIAL SKIN LESIONS IMMUNOLOGICAL METHODS FOR IMMUNOLOGICAL METHODS FOR

ANTIBODIES (IFP, ELISA, CIEP)ANTIBODIES (IFP, ELISA, CIEP)

TREATMENTTREATMENT

ISOLATION OR SEPARATIONISOLATION OR SEPARATION ALL PATIENTS NEED HOSPITALIZATION ALL PATIENTS NEED HOSPITALIZATION SPECIFIC TREATMENT SPECIFIC TREATMENT - FLUIDS - FLUIDS - CEFTRIAXONE/CEFOTOXIME- CEFTRIAXONE/CEFOTOXIME - AMPICILLIN ( NOT TO BE GIVEN IF - AMPICILLIN ( NOT TO BE GIVEN IF HYPERSENSITIVE TO PENICILLIN)HYPERSENSITIVE TO PENICILLIN) - CHLORAMPHENICOL- CHLORAMPHENICOL

SUPPORTIVE THERAPY: FOR SHOCK ANDSUPPORTIVE THERAPY: FOR SHOCK AND CONVULSIONSCONVULSIONS

EPIDEMIOLOGICAL INTERACTION EPIDEMIOLOGICAL INTERACTION

AGENT FACTORS

HOST FACTORS

ENVIRONMENT FACTORS

MCM

TIME DISRIBUTION

PLACE DISTRIBUTION

PERSONDISTRIBUTION

THE CAUSATIVE AGENTTHE CAUSATIVE AGENT

NEISSERIA MENINGITIDIS NEISSERIA MENINGITIDIS (MENINGO COCCUS)(MENINGO COCCUS) BISCUIT SHAPED GRAM + VE BISCUIT SHAPED GRAM + VE DIPLOCOCCUSDIPLOCOCCUS SIZE & SHAPE VARIATION IN OLDER SIZE & SHAPE VARIATION IN OLDER

CULTURES DUE TO AUTOLYSISCULTURES DUE TO AUTOLYSIS TRANSPARENT ,NON PIGMENTED, TRANSPARENT ,NON PIGMENTED,

NONHEMOLYTIC COLONIES 1-5 MM SIZE NONHEMOLYTIC COLONIES 1-5 MM SIZE

MENINGO COCCIMENINGO COCCI

SERO GROUP TYPINGSERO GROUP TYPING

DEPEND UPON THE POLYSACCHARIDE DEPEND UPON THE POLYSACCHARIDE CAPSULECAPSULE

NINE SEROLOGICAL GROUPS NINE SEROLOGICAL GROUPS IDENTIFIEDIDENTIFIED

A, B, C, D, X , Y, Z , W-135, 29EA, B, C, D, X , Y, Z , W-135, 29E ALL THE SEROGROUPS ARE ALL THE SEROGROUPS ARE

PATHOGENICPATHOGENIC BUT A, B, C, Y ARE MOST BUT A, B, C, Y ARE MOST

NEUROVIRULENTNEUROVIRULENT A AND C ARE MOST EPIDEMOGENIC A AND C ARE MOST EPIDEMOGENIC

MODE OF TRANSMISSIONMODE OF TRANSMISSION• HUMAN CASES AND THE CARRIERS ARE THE HUMAN CASES AND THE CARRIERS ARE THE

ONLY RESERVOIRSONLY RESERVOIRS

• TRANSMITTED BY TRANSMITTED BY DIRECT CONTACT DIRECT CONTACT (DROPLETS,DISCARGE FROM THE NOSE (DROPLETS,DISCARGE FROM THE NOSE

&THROAT OF THE PERSONS)&THROAT OF THE PERSONS)

INCUBATION PERIODINCUBATION PERIOD = 3-4 DAYS = 3-4 DAYS

PERIOD OF COMMUNICABILITYPERIOD OF COMMUNICABILITY IS AS LONG AS IS AS LONG AS THE MENINGOCOOCI ARE PRESENT IN THE MENINGOCOOCI ARE PRESENT IN DISCARGES FROM NOSE, THROAT AND DISCARGES FROM NOSE, THROAT AND NASOPHARYNXNASOPHARYNX

PERSON FACTORSPERSON FACTORS

POOR NUTRITIONAL STATUS & POOR NUTRITIONAL STATUS & IMMUNITYIMMUNITY

DRY NASAL MUCOSA DRY NASAL MUCOSA PHYSICAL EXERTIONPHYSICAL EXERTION FATIGUEFATIGUE CARRIER STATECARRIER STATE

AGE PREDILICTIONAGE PREDILICTION

PRIMARILY A CHILD PRIMARILY A CHILD DISEASE DISEASE BUT CAN AFFECT YOUNG BUT CAN AFFECT YOUNG ADULTS ALSOADULTS ALSO

SEX PREDILICTIONSEX PREDILICTION

MORE MALES ARE MORE MALES ARE AFFECTED THAN FEMALESAFFECTED THAN FEMALES

PLACE DISTRIBUTIONPLACE DISTRIBUTION

•MCM IS ENDEMIC IN LARGE MCM IS ENDEMIC IN LARGE TOWNSTOWNS•MORE COMMONLY IN PEOPLE MORE COMMONLY IN PEOPLE LIVING IN CROWDED LIVING IN CROWDED CONDITIONSCONDITIONS

TIME DISTRIBUTIONTIME DISTRIBUTION

GREATEST INCIDENCE IN GREATEST INCIDENCE IN WINTER AND SPRINGWINTER AND SPRING

CARRIER STATECARRIER STATE

TRANSMISSION OCCURS MORE TRANSMISSION OCCURS MORE OFTEN FROM CARRIERS RATHER OFTEN FROM CARRIERS RATHER THAN CASESTHAN CASES

BY AND LARGE HIGH CARRIER BY AND LARGE HIGH CARRIER RATE IS USUALLY ASSOCIATED RATE IS USUALLY ASSOCIATED WITH OUTBREAKSWITH OUTBREAKS

CONTROL MEASURESCONTROL MEASURES

VACCINATIONVACCINATION COMPOSITION: 50 MICRO GRAMS OF “A” COMPOSITION: 50 MICRO GRAMS OF “A”

POLYSACHARIDE, 50 MICRO GRAMS OF “C” POLYSACHARIDE, 50 MICRO GRAMS OF “C” POLY SACHARIDE, 1 MG OF LACTOSE.POLY SACHARIDE, 1 MG OF LACTOSE.

DOSE - 0.5 ML OF IRRESPECTIVE OF AGE GIVEN DOSE - 0.5 ML OF IRRESPECTIVE OF AGE GIVEN SUBCUTANEOUSLY.SUBCUTANEOUSLY.

EFFICACY– EFFICACY– SEROGROUP “A’SEROGROUP “A’ CLINICAL CLINICAL EFFICACY = 85-95%EFFICACY = 85-95%

SERO GROUP “A’ INDUCES ANTIBODY RESPONSE SERO GROUP “A’ INDUCES ANTIBODY RESPONSE IN CHILDREN AS YOUNG AS 3 MONTHS OLD.IN CHILDREN AS YOUNG AS 3 MONTHS OLD.

BUT BUT SEROGROUP “CSEROGROUP “C” DOES NOT INDUCE ” DOES NOT INDUCE ANTIBODIES BEFORE 2 YEARS OF AGE.ANTIBODIES BEFORE 2 YEARS OF AGE.

SEROGROUP “Y”SEROGROUP “Y” AND AND W-135 W-135 ARE SAFE AND ARE SAFE AND IMMUNOGENIC IN ADULTS AND CHILDREN IMMUNOGENIC IN ADULTS AND CHILDREN

ABOVE AGE OF 2 YEARS.ABOVE AGE OF 2 YEARS.

VACCINATION LIMITATIONSVACCINATION LIMITATIONS

1.LIMITED SHELF LIFE AFTER

REVACCINATION

2.NO VACCINE IS AVAILABLE AGAINST GROUP B

3.SHORT INCUBATION PERIOD vis-à-vis MORE TIME TAKEN FOR THE DEVELOPMENT OF IMMUNITY

4.4.UNSATISFACTORY RESPONSE VACCINATION UNDER 2 YEARS OF AGE WHICH IS THE HIGHEST SUSCEPTIBLE AGE-GROUP

PRESENT STRATEGY FOR PRESENT STRATEGY FOR VACCINATIONVACCINATION

ONLY HIGH RISK PEOPLE ONLY HIGH RISK PEOPLE (HEATH CARE WORKERS, (HEATH CARE WORKERS, TRAVELLERS, PEOPLE TRAVELLERS, PEOPLE LIVING IN OVERCROWDED LIVING IN OVERCROWDED PLACES) AND CLOSE PLACES) AND CLOSE CONTACTS HAVE TO BE CONTACTS HAVE TO BE VACCINATED.VACCINATED.

VACCINATION FOR CONTACTSVACCINATION FOR CONTACTS

1. FORTUNATELY, WE HAVE QUADRIVALENT VACCINES AT PRESENT

2. PROTECTION OCCURS ONLY AFTER 14 DAYS OF VACCINATION

3. HENCE CHEMOPROPHYLAXIS IS PROVIDED WITH ANTIBIOTICS IN THE MEANTIME

VACCINATION FOLLOWED BY +VACCINATION FOLLOWED BY +CHEMOPROPHYLAXIS FOR CHEMOPROPHYLAXIS FOR

CLOSE CONTACTSCLOSE CONTACTS

HOUSEHOLD MEMBERS HOUSEHOLD MEMBERS DAY-CARE CENTRE CONTACTSDAY-CARE CENTRE CONTACTS ANYONE DIRECTLY ANYONE DIRECTLY

EXPOSED TO THE PATIENT'S EXPOSED TO THE PATIENT'S ORAL SECRETIONS OR ORAL SECRETIONS OR RESPIRATORY DROPLETS.RESPIRATORY DROPLETS.

CHEMOPROPHYLAXISCHEMOPROPHYLAXISFOR CLOSE CONTACTSFOR CLOSE CONTACTS

CIPROFLOXACIN,CIPROFLOXACIN, RIFAMPICIN,RIFAMPICIN, MINOCYCLINE,MINOCYCLINE, SPIRAMYCN, SPIRAMYCN, CEFTRIAXIONECEFTRIAXIONE

WITHIN 24 HOURSWITHIN 24 HOURS FORFOR• HOUSEHOLD HOUSEHOLD CONTACTS CONTACTS •CLOSE CONTACTS CLOSE CONTACTS •HIGH RISK HIGH RISK PERSONSPERSONS

WITH

RISK COMMUNICATIONRISK COMMUNICATION

THROUGH PUBLIC THROUGH PUBLIC EDUCATION EDUCATION REGARDING REGARDING

RISK FACTORS AND RISK FACTORS AND POSSIBLE CONTROL POSSIBLE CONTROL STRATEGIESSTRATEGIES

NOTIFICATION OF NOTIFICATION OF CASES AT THE CASES AT THE EARLIESTEARLIEST

SURVEILLANCE SURVEILLANCE

FOR ACTIVE AND SUSTAINED COMMUNITY PARTICIPATION TO CONTROL THE EPIDEMIC

PUBLIC EDUCATION PUBLIC EDUCATION AVOID OVERCROWDING. AVOID OVERCROWDING. DO NOT SHARE DRINKING DO NOT SHARE DRINKING

BOTTLES, GLASSES, CIGARETTES, BOTTLES, GLASSES, CIGARETTES, LIPSTICKS OR OTHER ITEMS THAT LIPSTICKS OR OTHER ITEMS THAT MAY BE COVERED IN SALIVA. MAY BE COVERED IN SALIVA.

AVOID SMOKY AND DUSTY PLACES. AVOID SMOKY AND DUSTY PLACES. TEACH CHILDREN NOT TO SHARE TEACH CHILDREN NOT TO SHARE

CUPS, SOFT DRINK CANS OR CUPS, SOFT DRINK CANS OR SPORTS WATER BOTTLES. SPORTS WATER BOTTLES.