meningococcal meningitis (mcm) at new delhi & india dr. a. k. avasarala mbbs, m.d. professor...
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MENINGOCOCCAL MENINGOCOCCAL MENINGITIS (MCM) AT MENINGITIS (MCM) AT
NEW DELHI & INDIANEW DELHI & INDIADr. A. K. AVASARALA MBBS, M.D.PROFESSOR & HEADDEPT OF COMMUNITY MEDICINE & EPIDEMIOLOGYPRATHIMA INSTITUTE OF MEDICAL SCIENCES, KARIMNAGAR, A.P.INDIA: [email protected]
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PART-IIPART-IICLINICAL DISEASE, CLINICAL DISEASE,
EPIDEMIOLOGY AND EPIDEMIOLOGY AND CONTROLCONTROL
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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
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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
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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
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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
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CLINICAL PICTURE IN < 2 YEAR OLDCLINICAL PICTURE IN < 2 YEAR OLD CLASSICAL SIGNS MAY NOT BE PRESENT BUT CLASSICAL SIGNS MAY NOT BE PRESENT BUT
HIGH DEGREE OF SUSPICION WHEN THE HIGH DEGREE OF SUSPICION WHEN THE FOLLOWING PICTURE IS SEENFOLLOWING 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
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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
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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
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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)
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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
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EPIDEMIOLOGICAL INTERACTION EPIDEMIOLOGICAL INTERACTION
AGENT FACTORS
HOST FACTORS
ENVIRONMENT FACTORS
MCM
TIME DISRIBUTION
PLACE DISTRIBUTION
PERSONDISTRIBUTION
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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
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MENINGO COCCIMENINGO COCCI
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SERO GROUP TYPINGSERO GROUP TYPING DEPEND UPON THE POLYSACCHARIDE DEPEND UPON THE POLYSACCHARIDE
CAPSULECAPSULE NINE SEROLOGICAL GROUPS IDENTIFIEDNINE SEROLOGICAL GROUPS IDENTIFIED 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
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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
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PERSON FACTORSPERSON FACTORS POOR NUTRITIONAL STATUS & POOR NUTRITIONAL STATUS &
IMMUNITYIMMUNITY DRY NASAL MUCOSA DRY NASAL MUCOSA PHYSICAL EXERTIONPHYSICAL EXERTION FATIGUEFATIGUE CARRIER STATECARRIER STATE
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AGE PREDILICTIONAGE PREDILICTION
PRIMARILY A CHILD PRIMARILY A CHILD DISEASE DISEASE BUT CAN AFFECT YOUNG BUT CAN AFFECT YOUNG ADULTS ALSOADULTS ALSO
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SEX PREDILICTIONSEX PREDILICTION
MORE MALES ARE MORE MALES ARE AFFECTED THAN FEMALESAFFECTED THAN FEMALES
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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
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TIME DISTRIBUTIONTIME DISTRIBUTION
GREATEST INCIDENCE IN GREATEST INCIDENCE IN WINTER AND SPRINGWINTER AND SPRING
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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
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CONTROL MEASURESCONTROL MEASURES
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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.
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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
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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.
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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
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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.
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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
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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
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PUBLIC EDUCATION PUBLIC EDUCATION AVOID OVERCROWDING. AVOID OVERCROWDING. DO NOT SHARE DRINKING BOTTLES, DO NOT SHARE DRINKING BOTTLES,
GLASSES, CIGARETTES, LIPSTICKS GLASSES, CIGARETTES, LIPSTICKS OR OTHER ITEMS THAT MAY BE OR OTHER ITEMS THAT MAY BE COVERED IN SALIVA. 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 SPORTS CUPS, SOFT DRINK CANS OR SPORTS WATER BOTTLES. WATER BOTTLES.