Update on Meningococcal Meningitis Health Protection Team April 2014

Overview Bacterial Meningitis Overview Symptoms of Meningococcal Disease, Diagnosis and Treatment Epidemiology of Meningococcal Diseases Public Health Response Prevention

Meningitis is caused when the protective membranes covering the brain and spinal cord (Meninges) become inflamed, usually the result of infection.

Viral Meningitis Generally less severe, rarely fatal Enterovirus: around 80% of cases Other Viruses: mumps, Epstein- Barr. Rare but serious forms – Herpes group viruses Resolves 3- 8 days No specific preventative or curative treatment (excluding Herpes viruses )

Bacterial Meningitis Severe illness with potential for extensive complications Brain damage Loss of limbs Hearing Loss

Causative Agents Most common – S pneumoniae Meningitidis - M H. influenzae type b Listeria Group B Strep TB Staplococcus

Neisseria meningitidis Gram negative aerobic diplococcus with polysaccharide capsule 13 serogroups classified by their capsule 5 account for almost all disease.

Other Causes Head/ spinal Injury Cancer Fungal

Meningococcal Disease Important Public Health problem The most common cause of death due to infectious disease in children in the UK Most common cause of bacterial meningitis May cause meningitis or septicaemia (blood poisoning) Highest incidence in infants and teenagers Rapid and often dramatic onset Approx 10% die despite antibiotic treatment Can occasionally cause outbreaks (ie 2 or more linked cases), e.g. in schools, universities and colleges 3 common types A,B,C

Epidemiology Can affect any age group –but the young are most vulnerable Highest age specific attack rates seen in infancy Rates decline with age during childhood but secondary peak observed at years Occurs in all months but incidence highest in winter

age season contact with a case (close, household) overcrowding / new mixing (military recruits, students) socio-economic status influenza A passive smoking immunological conditions / genetic susceptibility Risk factors for meningococcal disease

Symptoms of meningococcal disease

Presentation of Meningitis Flu like symptoms A head ache Stiff neck Dislike of bright light Difficulty weight bearing Fever Vomiting+ diarrhoea Confusion and drowsiness

Presentations of meningococcal Septicaemia Cold hands and feet Limb pain (legs) Abnormal colour (pallor or mottling) Classic textbook symptoms of rash, neck stiffness and impaired consciousness typically occur later

Babies and Toddlers In addition to symptoms mentioned, other symptoms include: Blotchy skin, pale turning blue Tense or bulging soft spot Poor feeding High pitched cry/ irritable

Do the tumbler test Someone who becomes rapidly unwell should be examined particularly for the meningococcal septcaemic rash. Over 50% of people will develop a rash of tiny pin pricks which can rapidly turn into purple bruising. To identify the rash, press a glass tumbler against it. If it does not fade it could be meningococcal septicaemia. On dark skin check on lighter parts of the body i.e. finger tips

Meningococcal septicaemia

Raised Intracranial Pressure

Diagnosis Classical symptoms with  Blood for culture + PCR  Serum (on admission and 2-6 weeks later)  CSF for microscopy, culture and PCR (when stable and RICP rule out)  Aspirate from other suspected sterile sites for microscopy, culture and PCR  Pharyngeal swab  Any other specimen to check for alternate diagnosis e.g. stool, viral throat swab.

Treatment Administer intramuscular or intravenous benzyl penicillin whist arranging urgent treatment at hospital. Adults and over 10 years-1.2g 1-9 years 600mg Under 1year -300mg Clear history of penicillin related anaphylactic shock- Administer 2 grams cefotaxime or cefriaxone (children under 12years - 80mg/kg) All GPs should carry benzyl penicillin and alternate cephalosporin in bag as pre admission administration halves mortality from meningococcal septicaemia. Details of antibiotic treatment given to case should be passed to admitting doctor. Clinician suspects a case of invasive meningococcal disease

Case definitions Confirmed case- diagnosis of meningitis and/or septicaemia confirmed microbiologically as caused by Neisseria meningitidis including meningococcal infection of joint, heart or eye. Probable Case- diagnosis of meningicoccal meningitis and/or septicaemia, without microbiological confirmation that managing Clinician and CPHM or deputy consider meningococcal disease to be the most likely diagnosis Public Health Response Required

Possible Case As per probable case but CPHM and managing clinician considers that other diagnosis other than meningococcal disease are at least as likely Includes those cases treated by antibiotics whose probable diagnosis is viral meningitis In the absence of an alternative diagnosis, a feverish, ill patient with a petchial/purpuric rash Possible cases do not routinely require Public Health response unless level of suspicion increases. Awareness raising may be useful

Reducing risk of Linked Cases People living in same household or have slept in or attended house for prolonged periods 7 days prior to onset have higher risk of developing disease than others in community If prophylaxis not given, attack rate in 1 st month increases by times, representing risk of around 1% per household Highest risk in first 7 days after index case – risk reduces rapidly during following weeks Increased risk to household members may be due to combination of genetic susceptibility and increased rate of exposure to disease

Key to successful control Early notification Good communication between Clinicians, Microbiology Labs and Health Protection Team Formal notification is a legal requirement. If a diagnosis of meningitis is suspected an alert call to CPHM enables prompt appropriate response and distribution of prophylaxis to risk contacts within recommended 24hr period Early measures minimise public anxiety

Chemoprophylaxis – Public Health Response Chemoprophylaxis (short course of antibiotic) given in an attempt to reduce risk. Aim to eliminate carriage from network of close contacts, reducing risk of invasive disease in susceptible family members Offered to at risk/ close contacts i.e. living in the same household as the case during 7 days prior to onset

Examples of such contacts include: Those living/sleeping in the same household (including extended household and sleepovers) Students in the same dormitory/ room/kitchen or flat as index case Childminder or relative looking after a case for many hours a day

Additionally: Mouth kissing contacts, boyfriend/girlfriend/partner or those involved in mouth to mouth resuscitation Unprotected HCW exposed to large droplets before 24 hours of systemic AB treatment *Schools/nurseries –after 1 case, prophylaxis not advised for children or staff –important to give out information

Meningitis Immunisation Group B and Group C are the most common forms of meningococcal meningitis in young adults Men B Vaccine has been licensed and recommended for use in routine immunisation by the JCVI. UK governments are still considering its implementation. To date HPA have made recommendations about Men B vaccine when dealing with Public Health aspects of a case of Invasive Meningococcal B Disease. Scottish recommendations remain in consultation

Immunisation cont. There is a vaccine available for Men C In the UK primary immunisation exists with 3 separate doses are given as a baby as well as a booster dose as a teenager Men C vaccine is given to contacts of a confirmed case of Men C Vaccines are also available for meningitis caused by HIB and pneumococcus

Prevention methods Students should be advised to check if they have been vaccinated before starting university/college. Universities/colleges are advised to issue meningitis information about and its available vaccination to international students who may not have been vaccinated as a routine.

Prevention Methods Encourage enrolment with a local GP and request MenC vaccine if no history of vaccination Raising awareness among students i.e signs & symptoms leaflets, posters, through student newspaper, local media, internet/intranet, student union etc. Encourage students to look out for each other’s welfare and inform someone if symptoms occur eg warden or friend if not well and to seek medical attention

Further Information University UK Management Guidance. Managing meningococcal disease (septicaemia or meningitis) in higher education institutions National Meningitis Trust MengitisReaserchFoundation