Meningitis - OU College of Nursing | Main Page

Meningitis

Ozair Naqvi, MS

Epidemiologist, Communicable Disease Division

Acute Disease Service

Oklahoma State Department of Health

Objectives

• Describe the occurrence of meningitis

• Describe the signs and symptoms of

meningitis

• Describe when these vaccinations should be

given

Meningitis and Public Health

• Two specific conditions that require

immediate response by public health

officials:

– Meningococcal Invasive Disease

• Neisseria meningitides

– Haemophilus influenzae Invasive Disease

• Haemophilus influenza type b (Hib)

Epidemiology of Meningococcal

Invasive Disease Globally

• Large epidemics of

meningococcal

disease occur in the

African “meningitis

belt”

• In each epidemic,

tens of thousands

of cases and

thousands of

deaths may occur

Epidemiology of Neisseria

meningitidis

0

10

20

30

40

50

60

CA

SE

S

YEAR

Incidence of Meningococcal Invasive

Disease in Oklahoma from 1990-2018

Epidemiology of Haemophilus

influenzae Invasive Disease

• In developing countries, where routine vaccination with Hib

vaccine is not widely available, Hib remains a major cause

of lower respiratory tract infections in infants and children

• In the United States, Hib disease is not common. In 2015,

the incidence of invasive Hib disease was 0.08 cases per

100,000 in children younger than 5 years of age

– Occurs primarily in underimmunized children and in infants too

young to have completed the primary immunization series

– Less than 10 cases in Oklahoma since 2000

Meningococcal Invasive

Disease Background

Organism: Neisseria meningitidis

Incubation Period: Varies 2 to 10 days (commonly 3 to 4 days)

Infectious Period: As long as the organism is present in the nasopharynx (may be weeks to months) Ends when the patient has been on appropriate

antibiotics for at least 24 hours

Asymptomatic carriage can be as high as 25% without cases of meningococcal invasive disease in the community; carriage may be higher with cases occurring in the community

Meningococcal Invasive Disease

Background

Mode of transmission: Direct exposure to respiratory droplets or direct contact with discharges from the nose or throat

Symptoms:

Meningitis: stiff neck, high fever, headache, nausea, vomiting, or mental confusion

Meningococcemia: fever, petechial or purpuric rash, hypotension, disseminated intravascular coagulation, and multiorgan failure

Case fatality rate of meningococcal disease: Lowered from 50% to 8-15% thanks to antibiotics, intensive care units, and improved supportive measures

Fatality rate of meningococcemia is up to 40%

Haemophilus influenzae Invasive

Disease Background

Haemophilus influenzae Invasive Disease: caused by bacteria Haemophilus influenzae. Type b (Hib) is the only type which control measures are necessary

Transmission:

direct exposure to respiratory droplets or direct contact with discharges from nose or throat

In neonates, infection is acquired intrapartum by aspiration of amniotic fluid or contact with genital tract secretions


Disease Background

Incubation Period: Incubation period is unknown, but

most likely 2 to 4 days

Communicability: As long as organism is present in the

nose and throat. Communicability ends when client has

been on appropriate antibiotics for at least 24 hours


Disease Background

Symptoms:

Meningitis: high fever, vomiting, lethargy,

meningeal irritation consisting of bulging

fontanelle in infants or stiff neck in older children

Clinical Illness: meningitis, septicemia,

pneumonia, cellulitis, arthritis, epiglottitis,

pericarditis, endocarditis, and osteomyelitis

Meningococcal: Confirm the diagnosis

To begin an investigation we need laboratory

confirmation:

Culture: Neisseria meningitidis from a

normally sterile site

OR

Gram negative diplococci on the gram stain

OR

Detection of N. meningitidis antigen from

CSF

Hib: Confirm the diagnosis

Culture Gold standard

Must be from sterile site (blood, CSF, aspirates from joints, pericardium, pleural fluid, etc.)

OSDH Public Health Lab confirms and serotypes all isolates received from Oklahoma labs

Antigen testing Clinicians may request antigen test on sterile site

fluid, esp when Type B (Hib) is suspected

Real-time Polymerase Chain Reaction (RT-PCR) Can be used for detection of Hib from sterile site in

which organism could not be detected by culture

Differentiating Bacterial vs. Viral

Meningitis LabsSpecimen Viral Bacterial

WBC CSF 6-100 Cells> 100 Cells

Elevated (50-1000)

Protein CSFSlightly Elevated Elevated

(45-150) (50-1000)

Glucose CSFNormal Below Normal

(> 40) (< 40)

Gram Stain CSF/Blood No Organisms

Gram + Cocci: Streptococcus pneumoniae

Gram - Rods: Haemophilus influenzae

Gram - Cocci: Neisseria meningitidis

WBC Differential CSFLymphocytes: 60-70% Mostly Neutrophils

Monocytes: 30-40% Few Lymphocytes & Monocytes

C-Reactive Protein Blood < 1 > 1

Bacterial Antigen/Latex

AgglutinationCSF No Antigen Detected Positive for Specific Bacteria

Bacterial Culture CSF/Blood No Growth Growth

Bacterial vs. Viral MeningitisViral

• It is often less severe than bacterial

meningitis, and most people get better

on their own in 7 to 10 days (no specific

treatment)

• Non-polio enteroviruses are the most

common cause of viral meningitis in the

United States, especially from late spring

to fall

• Initial symptoms of viral meningitis are

similar to those for bacterial meningitis,

not as severe

• Close contacts of someone with viral

meningitis can become infected with the

virus that made that person sick.

However, these close contacts are not

likely to develop meningitis

Bacterial

• Meningococcal meningitis is caused by

the bacteria Neisseria meningitidis, and

causes a more severe disease that

requires prompt treatment of the patient

with antibiotics

• Symptoms include stiff neck, high fever,

headache, nausea, vomiting, mental

confusion, petechial or purpuric rash,

hypotension, or multiorgan failure

• Can be caused by bacteria such as

Haemophilus, Streptococcus, or

Neisseria meningitidis, which are spread

by direct contact with saliva or

respiratory droplets from the nose and

throat of an infected person

The type of meningitis can only be confirmed through laboratory tests

Meningococcal Public Health

Investigation Steps

1. Confirm Diagnosis

2. Interview case/guardian/parent as soon as possible

• Complete disease report (obtain/verify following):

• Hospital dates

• Symptoms and specific onset dates

• Treatment

• High-risk setting

• Contacts

3. Contact Investigation

• Identify all close contacts in 7 days prior to illness onset to 24 hours after initiation of appropriate antibiotic

• Recommend post-exposure prophylaxis as necessary

Meningococcal Contact Identification

and Investigation

Contact = any members of the patient’s household and any individual who may have had close contact with the case during the infectious period

Exposure= Direct contact with the case’s saliva or oral/nasal secretions during the 7 days prior to symptom onset until 24 hours after initiation of appropriate antibiotic therapy

Contagious period = Begins 7 days prior to symptoms and ends 24 hours after treatment of appropriate antibiotics


and Investigation

Exposure Examples: Sharing food or eating/drinking utensils

Sharing lip gloss, lipstick, cigarettes, or similar items

Kissing

Explosive cough or sneeze to the face

Mouth-to-mouth resuscitation

Unprotected exposure, not wearing procedure mask or surgical mask, while performing a full medical examination of the nose and throat including medical/dental examination or procedure (suction, intubation, etc.)

Child care or pre-school contacts

Passengers seated directly next to the patient during airline flights lasting more than 8 hours

Meningococcal Contact Investigation

Household contacts

Recommended to ALL household contacts

regardless of vaccination status

Household-like and close, personal contacts

Recommended to anyone with intimate contact

or direct saliva contact


Community residential programs or facilities

Recommended to persons who had direct

contact with oral/nasal secretions of the case or

household-like contact

School setting

Not routinely recommended for all classmates

Identify close contacts (i.e. boyfriend/girlfriend)

as well as those with direct contact to nasal/oral

secretions


Group or residential homes

Recommend PEP to close contacts (i.e., roommates, those with direct contact to nasal/oral secretions)

Healthcare setting

Recommend PEP to healthcare workers performing full medical examination of the nose or throat without wearing PPE

Includes hospital staff and first responders.


and Investigation• PEP is recommended to all exposed contacts

regardless of vaccination historyDrug Age of

Contacts

Dosage Cautions

Rifampin ≤ 1 month 5 mg/kg, orally, every 12 hours x 2

days

Can interfere with efficacy of oral

contraceptives and some seizure and

anticoagulant medications> 1 month 10 mg/kg (max dose 600mg),

orally, every 12 hours x 2 days

Ceftriaxone ≤ 15 years 125 mg, IM (single dose) To decrease pain at injection site, dilute with

1% lidocaine> 15 years 250 mg, IM (single dose)

Ciprofloxacin ≥ 1 month 20 mg/kg; (max 500 mg), orally

single dose

Not recommended routinely for people

younger than 15 years of age

Azithromycin 10 mg/kg (max 500 mg), single

dose

Not recommended routinely

Hib Public Health Investigation Steps

1. Confirm Diagnosis

2. Interview case/guardian/parent as soon as possible

• Complete disease report (obtain/verify following):• Hospital dates

• Symptoms and specific onset dates

• Treatment

• High-risk setting

• Contacts

3. Contact Investigation

• Identify all close contacts in 7 days prior to illness onset to 48 hours after initiation of appropriate antibiotic

• Recommend post-exposure prophylaxis as necessary

4. If household contacts <4 years

• Gather Hib vaccination hx to determine susceptibles

• Determine if any of these children have immunocompromising condition

Hib Post-Exposure Prophylaxis (PEP)

Recommend appropriate antibiotic prophylaxis to: 1) Case

2) HH contacts

3) CCS contacts

Only recommend PEP to contacts considered exposed to case 7 days prior to hospital admission and until 48 hours after initiation of appropriate antibiotics If last date of exposure has been more than 14 days

or if a pregnant women, PEP is not recommended.

Hib Post-Exposure Prophylaxis (PEP) 1. Case

If treated with ampicillin or chloramphenicol needs rifampin prior to discharge

If treated with cefotaxime or ceftriaxone no rifampin needed

2. Household Contacts Rifampin recommended for all household contacts if at

least one child <4 years of age in home (other than the case) and if: i. Infants <12 months who not received primary 2- or 3-series

ii. Child 1-3 years who is inadequately vaccinated

iii. Child has immunological impairment, regardless of child’s Hib vaccine status

Recommended Dosage for Rifampin

Prophylaxis of Contacts to a Case of H.

influenzae type b

1 Not to be taken during pregnancy.

2 Side effects of Rifampin include orange discoloration of urine, discoloration of soft contact lenses (removal

recommended for duration of chemotherapy), discoloration of teeth, nausea, vomiting, and diarrhea. May interfere

with efficacy of oral contraceptives and some seizure prevention and anticoagulant medications.

Source: American Academy of Pediatrics. Haemophilus influenzae Infections. In: Pickering LK, Baker CJ, Kimberlin

DW, Long SS, eds. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL:

American Academy of Pediatrics; 2009: 316-317.

Contacts Dosage

Infants < 1 month age Not established, some experts

recommend lowering dose to 10

mg/kg once daily for 4 days

Children >1 month age and adults 20 mg/kg (maximum dose 600 mg)

once daily for 4 days

Meningitis Rumors

Meningitis in Schools

Meningococcal Immunization

Recommendations

• MenACWY is

given as part of

7th grade

vaccinations

• MenB is given

prior to starting

college

Hib Immunization

Recommendations

• ActHIB, Hiberix, or Pentacel: 4-dose series at 2, 4,

6, 12–15 months

• PedvaxHIB: 3-dose series at 2, 4, 12–15 months

Neisseria meningitidis Outbreak in an

Elementary School — Oklahoma, 2010

Timeline

10March

March 10

• Preliminary CSF culture N. meningitidis from

7 year-old boy: Case A

• Household members and close contacts identified

• Chemoprophylaxis recommended for contacts

Timeline

Index

Case

Reported

10March 11

March 11

• 6:20–8:20 AM: Cases B, C, D reported (1 death)

• All attended same school

• Rural northeast Oklahoma

• School district population 1,850 students

• 9:45 AM: Investigation team departs OSDH

School District A

Lower Elementary

School

High School

Upper Elementary

School

Middle School

Investigation

• Active surveillance to identify additional cases – Contacted hospital IPs daily to identify new cases

– Contacted laboratories daily for any preliminary results

– Contacted local pediatricians to identify in possible new cases

• N. meningitidis serogrouping at state public health laboratory – Requested all isolates be sent to OSDH PHL

• Pulsed-field gel electrophoresis (PFGE), polymerase chain reaction (PCR), and multilocus sequence typing (MLST) at CDC

Case Definitions

• Epidemiologically linked to School District A

• Disease onset no earlier than March 1, 2010

• Samples taken from normally sterile body site

• Confirmed: Neisseria meningitidis isolated by culture

• Probable: N. meningitidis-specific nucleic acid detected by polymerase chain reaction (PCR)

• Suspect: fever and rash in hospitalized person

Timeline

Index

Case

Reported

10March

March 11 continued

• 11:45 AM: OSDH team arrives

• 12:00 PM: Postexposure chemoprophylaxis (PEP)

clinic in school gym by County Health Dept

– Ceftriaxone (rifampin as

alternative)

– Lower elementary school students

– Older students in close contact

with cases

– Riders on same buses as cases

Cases B-D

Reported

1st Fatality

11

Timeline

12:30–

8:00

PM

Index

Case

Reported

10March

6:20

–

9:45

AM

Cases B-D

Reported

1st Fatality

1112:00

PM

OSDH

Team

Arrives

PEP

Clinic

#1

March 11 continued

• Active surveillance begins in 6 counties

• 12:30 PM: School closes for Spring Break

• 1:30–4:00 PM: Cases E and F reported

Case D death

• 8:00 PM: PEP clinic closes for 1st day

PEP Clinic Summary

• ~975 people as contacts warranted

prophylaxis

• 1,063 (109%) received prophylaxis

Timeline

12:30–

8:00 PM

Cases E &

F Reported

2nd Fatality

Index

Case

Reported

10March

6:20–

9:45

AM

Cases B-D

Reported

1st Fatality

11 12

12:00

PM

OSDH

Team

Arrives

PEP

Clinic

#1

March 12

• 8:22 AM: Case G, high school student

• 9:00 AM: 2nd PEP clinic opens

• 10:55 AM: Serogroup C multilocus

sequence type (MLST) ST-11/CC-11

• 12:15 and 2:00 PM: Additional

chemoprophylaxis arrives

• Decision made to hold

vaccination clinics

Index case

Case Links

Classroom A

5yo case

Classroom B Choir A and B

Asymptomatic

5yo sibling

Asymptomatic

17yo sibling

Index Case

2 additional cases

(2 deaths)

18yo case

Timeline

12:30–

8:00 PM

Cases E

& F

Reported

2nd

Fatality

Index

Case

Reported

10March

6:20–

9:45

AM

Cases B-D

Reported

1st Fatality

11

Case G

Report

ed PEP

Clinic

#2

12

12:00

PM

OSDH

Team

Arrives

PEP

Clinic

#1

March

16

• 3rd

PEP

clinic

191613 21

Scheduled

Spring

Break

Timeline

12:30–

8:00 PM

Cases E & F

Reported

2nd Fatality

Index

Case

Reported

10March

6:20–

9:45

AM

Cases B-D

Reported

1st Fatality

11

Case G

Reported

PEP

Clinic #2

12 19

PEP

Clinic #3

1613 21

12:00

PM

OSDH

Team

Arrives

PEP

Clinic

#1

March 19

• Vaccinati

on clinic

#1

Scheduled

Spring Break

Timeline

12:30–

8:00

PM

Cases E &

F Reported

2nd Fatality

Index

Case

Reported

10March

6:20–

9:45

AM

Cases B-D

Reported

1st Fatality

11

Case G

Reported

PEP

Clinic #2

12

Vaccination

Clinic #1

19

PEP

Clinic #3

1613 21

12:00

PM

OSDH

Team

Arrives

PEP

Clinic

#1

Additional

Vaccination

Clinics

22-26

Scheduled

Spring Break

Vaccination Clinic Summary

Persons vaccinated

Total 1,459

Children 1,250

Dose funding

VFC 1,092 (77%)

State 367 (23%)

Clinical and Laboratory

CharacteristicsDetection of

N. meningitidis

CaseAge

(Years)Classification Onset Death Blood CSF

A 8 Confirmed 3/08 No Culture, PCR Culture, PCR

B 7 Probable 3/10 Yes PCR PCR*

C 6 Confirmed 3/10 No Culture, PCR Not Done

D 8 Confirmed 3/10 Yes Culture, PCR Culture, PCR

E 5 Suspect 3/10 No No No

F 8 Suspect 3/11 No No Not Done

G 18 Confirmed 3/10 No Culture No

*Cerebral Tissue

Timeline

12:30–

8:00

PM

Cases E &

F Reported

2nd Fatality

Index

Case

Reported

10March

6:20–

9:45

AM

Cases B-D

Reported

1st Fatality

11

Case G

Reporte

d PEP

Clinic #2

12

Active

Surveillance

Ends

31

Vaccination

Clinic #1

19

PEP

Clinic #3

1613 21

12:00

PM

OSDH

Team

Arrives

PEP

Clinic

#1

Additional

Vaccination

Clinics

22-

26

Scheduled

Spring Break

Conclusions

• Chemoprophylaxis and vaccination well

accepted

• Rapid, two-pronged intervention interrupted

outbreak

• Use of VFC funds for outbreak-control-related

vaccine purchase another avenue to obtain and

provide vaccine in outbreak setting

Questions?

Call Acute Disease Service

24/7/365

405-271-4060

http://ads.health.ok.gov

http://ads.health.ok.gov/

Meningitis - OU College of Nursing | Main Page

Documents

Transcript of Meningitis - OU College of Nursing | Main Page