1. Meningococcal Disease

2. What is Meningococcal Disease
Meningococcal disease is a potentially life-threatening bacterial infection.
Expressed as either
Meningococcal meningitis, or
Meningococcemia
Meningococcal disease was first described in 1805
when an outbreak swept through Geneva, Switzerland.
The causative agent, Neisseria meningitidis
(meningococcus), was identified in 1887.
WHO
Meningococcal disease is a potentially life-threatening bacterial infection. The disease most commonly is expressed as either meningococcal meningitis, an inflammation of the membranes surrounding the brain and spinal cord or meningococcemia, a presence of bacteria in the blood.
Meningitis is an infection of the meninges, the thin lining that surrounds the brain and the spinal cord. Several different bacteria can cause meningitis and Neisseria meningitidis is one of the most important because of its potential to cause epidemics. Meningococcal disease was first described in 1805 when an outbreak swept through Geneva, Switzerland. The causative agent, Neisseria meningitidis (the meningococcus), was identified in 1887.
Twelve subtypes or serogroups of N. meningitidis have been identified and four (N. meningitidis. A, B, C and W135) are recognized to cause epidemics. The pathogenicity, immunogenicity, and epidemic capabilities differ according to the serogroup. Thus the identification of the serogroup responsible of a sporadic case is crucial for epidemic containment.

3. Public Health Significance?
Leading cause of bacterial meningitis in children and young adults in the U.S
2,400 to 3,000 cases each year in U.S.
5% to 10% of patients die, typically within hours of onset of symptoms.
10 to 20% of survivors of bacterial meningitis may result in brain damage, permanent hearing loss, learning disability or other serious sequelae.
Meningococcal septicemia - rapid circulatory collapse.
WHO
Before the 1990s, Haemophilus influenzae type b (Hib) was the leading cause of bacterial meningitis, but new vaccines being given to all children as part of their routine immunizations have reduced the occurrence of invasive disease due to H. influenzae. Today, Streptococcus pneumoniae and Neisseria meningitidis are the leading causes of bacterial meningitis. 
Invasive meningococcal disease is of public health importance, is frequently a cause of public health alarm and receives a high level of media attention.
Meningococcal septicemia is characterized by a hemorrhagic rash and rapid circulatory collapse.
- Although the annual incidence of 0.8 to 1.3/ persons is relatively low, fatality rates and significant sequelae are appreciable. CDC MMWR
Neisseria meningitis causes both endemic and epidemic disease, principally meningitis and meningococcemia. Even when the disease is diagnosed early and adequate therapy instituted, 5% to 10% of patients die, typically within hours of onset of symptoms. Bacterial meningitis may result in brain damage, hearing loss, or learning disability in 10 to 20% of survivors. A less common but more severe (often fatal) form of meningococcal disease is meningococcal septicaemia which is characterized by a haemorrhagic rash and rapid circulatory collapse.

4. Meningococcal Disease
Etiologic Agent:
Neisseria meningitidis (Gram-negative diplococcus bacterium) with multiple serogroups ( A, B, C, D, 29E, H, I, K, L, W-135, X, Y, and Z).
Strains belonging to groups A, B, C, Y and W-135 are implicated most frequently in invasive disease.
Neisseria meningitidis is a Gram-negative diplococcus bacterium with multiple serogroups ( A, B, C, D, 29E, H, I, K, L, W-135, X, Y, and Z). Strains belonging to groups A, B, C, Y and W-135 are implicated most frequently in invasive disease.
N. meningitidis only infects humans; there is no animal reservoir. The bacteria can be carried in the pharynx and sometimes, for reasons not fully known, overwhelm the body’s defences allowing infection to spread through the bloodstream and to the brain. It is estimated that between 10 to 25% of the population carry N.meningitidis at any given time, but of course the carriage rate may be much higher in epidemic situations.
WHO

6. Clinical Presentation
> 2 Years :
High fever, headache, and stiff neck.
Other symptoms include nausea, vomiting, discomfort looking into bright lights, confusion, and sleepiness.
Newborns and small infants:
Classic symptoms may be absent or difficult to detect.
In babies under one year of age, the soft spot on the top of the head (fontanel) may bulge upward.
Infant may only appear slow or inactive, or be irritable, have vomiting, or be feeding poorly.
CDC: What are the signs and symptoms of meningitis? High fever, headache, and stiff neck are common symptoms of meningitis in anyone over the age of 2 years. These symptoms can develop over several hours, or they may take 1 to 2 days. Other symptoms may include nausea, vomiting, discomfort looking into bright lights, confusion, and sleepiness. In newborns and small infants, the classic symptoms of fever, headache, and neck stiffness may be absent or difficult to detect, and the infant may only appear slow or inactive, or be irritable, have vomiting, or be feeding poorly. As the disease progresses, patients of any age may have seizures.
The incidence of meningococcal disease varies with age and is highest during the first year of life. MMWR CDC

8. The rash associated with meningococcal meningitis and meningococcal septicemia will not fade under pressure. If you press the side of a glass or tumbler against the rash, and examine it through the glass, it remains visible. Other rashes caused by viruses or allergies will fade under pressure. In early stages when the rash first appears it may fade, but as it develops it will no longer fade. It is helpful to advise worried parents to apply the "tumbler test" more than once if they are worried about a child who is ill and has a non-specific rash.
The rash is caused by bleeding into the skin. The bleeding occurs from very small blood vessels in the skin damaged by the infection.

9. Meningococcal Disease
Incubation Period:
The incubation period is variable, 2-10 days, but usually 3-4 days
Infectious Period:
An infected person is infectious as long as meningococci are present in nasal and oral secretions or until 24 hours after initiation of effective antibiotic treatment.
Incidence of meningococcal disease peaks in the late winter to early spring. Persons with certain medical conditions are at increased risk for developing meningococcal infection, including persons with complement deficiency; persons with anatomic or functional asplenia.
Infants and toddlers are by far the most at-risk for invasive disease. Asymptomatic colonization of the respiratory tract with meningococcus is extremely common; most individuals with colonization develop antibodies to the organism and do not become ill. Only a small minority of newly colonized individuals – for example, those with intercurrent viral illness – may develop invasive infections.
There is also a small increased risk of meningococcal disease in college freshmen living on campus. For that reason, it is recommended that providers discuss the meningococcal vaccine with entering freshmen.

10. Case Definition Clinical Description:
Meningococcal disease manifests most commonly as
meningitis and/or meningococcemia that may progress
rapidly to purpura fulminans, shock, and death. However,
other manifestations might be observed.
Laboratory criteria for diagnosis:
Isolation of Neisseria meningitidis from a normally sterile site
(e.g., blood or cerebrospinal fluid (CSF) or, less commonly,
joint, pleural, or pericardial fluid)

11. Case Definition Case Classification
Probable: a case with a positive antigen test in
cerebrospinal fluid or clinical purpura fulminans
in the absence of a positive blood culture.
Confirmed: a clinically compatible case that is
laboratory confirmed.
Comment
Positive antigen test results from urine or serum samples are unreliable for diagnosing meningococcal disease.
Laboratory Diagnosis of Meningococcal Meningitis
The diagnosis can be made by growing bacteria from a sample of spinal fluid, blood or other sterile fluids. The spinal fluid is obtained by performing a spinal tap, in which a needle is inserted into an area in the lower back where fluid in the spinal canal is readily accessible. Identification of the type of bacteria responsible is important for selection of correct antibiotics.
Serogrouping is performed by the office of laboratory services.

12. Epidemiology Reservoir: Mode of Transmission:
Humans are the only known reservoir of Neisseria
Meningitidis.
Mode of Transmission:
Person to person through droplets of respiratory
or throat secretions.
Close and prolonged contact e.g.,
(kissing, sneezing and coughing on someone,
living in close quarters or dormitories (military recruits,
students), sharing eating or drinking utensils, etc.)
The bacteria are transmitted from person to person through droplets of respiratory or throat secretions.
Risk GroupsRisk groups include general population, infants and young children (for endemic disease), refugees, household contacts of case patients, military recruits, college freshmen (who live in dormitories), microbiologists who work with isolates of N. meningitidis, and people exposed to active and passive tobacco smoke.
Mode of Transmission:
Person to person through droplets of respiratory or throat secretions.
Close and prolonged contact (e.g. kissing, sneezing and coughing on someone, living in close quarters or dormitories (military recruits, students), sharing eating or drinking utensils, etc.) facilitate the spread of the disease.

18. MMWR Morb Mortal Wkly Rep. 2000;49(RR-7):13-20
The incidence of meningococcal disease varies with age and is highest during the first year of life.1 The age-specific incidence decreases thereafter but increases again in 15- to 24-year-olds
The number of cases in 15- to 24-year-olds also has increased in recent years.4 In 1991, 310 cases were reported to the National Notifiable Diseases Surveillance System of the Centers for Disease Control and Prevention (CDC), whereas the annual number reported from ranged from 602 to 621.
MMWR Morb Mortal Wkly Rep. 2000;49(RR-7):13-20

21. Public Health Actions Education: Public Providers Laboratories
Educate the public about meningococcal meningitis, especially its transmission. Educate providers and laboratories to report confirmed and probable cases of invasive meningococcal disease immediately to the local health department.
Educate laboratories to submit all invasive meningococcal isolates cultured from normally sterile sites to the West Virginia Office of Laboratory Services for serogrouping.
Educate providers about prophylaxis for high risk contacts.
With regards to Education. We Want to educate 1. The public 2. The providers 3. The laboratories regarding the disease . We need to educate them on what is expected from them for an effective case/outbreak management.
Educate providers and laboratories to report confirmed and probable cases of invasive meningococcal disease immediately to the local health department to assure follow-up of close contacts, recognize outbreaks, and facilitate community education. PREVENTION:
Meningococcus is spread through direct exposure to secretions ("sharing saliva" or "sharing nasal secretions") or very close personal contact such as that occurring in households, daycare centers, jails, or barracks. It is not spread through casual contact such as that occurring in workplaces or classrooms.
Preventive Interventions
To avoid further exposure advise individuals to:
Avoid sharing eating and drinking utensils
Avoid sharing food, drinks, cigarettes, or mouth pieces from musical instruments.
Take care to cover your mouth when coughing or sneezing.
Wash your hands frequently especially following exposure to respiratory secretions (coughing or sneezing).
To prevent additional cases:
Refer close contacts to health care providers for appropriate chemoprophylaxis
Advise contacts of signs and symptoms of illness and refer them to their health care provider should they experience any symptoms compatible with invasive meningococcal disease
Other preventive measures that would help protect individuals are:
Avoid smoking and smoky environments
Get plenty of sleep, exercise regularly
Eat a balanced diet and avoid excessive alcohol consumption
Meningococcal vaccine is available and should be offered to persons age > 2 years of age with:
complement deficiency;
functional or anatomic asplenia;
research, industrial and clinical laboratory personnel who may be routinely exposed to aerosol containing Neisseria meningitidis;
travelers visiting the "meningitis belt" in the sub-Saharan Africa (Senegal in the to Ethiopia in the East) during the "dry season" (December to June).
Upon receiving a report of invasive meningococcal disease:
Confirm that the reported case meets the case definition.
Assure that isolates are forwarded to the Office of Laboratory Services for serogrouping.
For invasive cases, identify all close contacts.
d. Alert close contacts (family, daycare, nursery school, etc.) to watch for early signs of illness, especially fever, and assure that close contacts are prophylaxed.

22. Public Health Actions
Upon receiving a report of invasive meningococcal
disease:
1. Determine if reported case is probable or
confirmed.
2. Assure that isolates are forwarded to the Office of Laboratory Services for serogrouping.
3. Determine if contacts need prophylaxis.
4. Recommend prophylaxis if indicated.
5. Complete appropriate report form(s).
6. Send completed forms to IDEP
When you receive a report of Inv Men Disases the following 4 things are enormously important. A. you want to make sure that the case meets the case definition because an organism cultured from a non-sterile site does not need to be reported and following the case definition helps to prevent undue work and effort put in filling the forms and yellow card etc.
B. Please assure that isolates are forwarded to OLS. Contact the lab, the [physicians office, the ID personell at the Hosp and educate them on the importance of testing fopr isolates.
C. Ofcourse identify all close contacts, cause based on your investigation you will need to recommend public health interventions such as prophylaxis for the contacts if necessary.
d. Educating public, family and community about the disease is the key to prevent new cases.

23. Chemoprophylaxis is not recommended for:
Casual contact with no history of direct exposure to the index patient's oral secretions, e.g. school or work mate
Indirect contact: only contact is with a high-risk contact, no direct contact with the index patient
Health care personnel without direct exposure to patient's oral secretions

24. Conclusion of the Study:
Comparison of incidence of meningococcal meningitis in Maryland college students to similar age group in the general population.
The average annual incidence among students
enrolled in four-year schools = per 100,000
The average annual incidence in the general
population of the same age = per 100,000
Incidence in students who were on-campus
residents = 3.24 per 100,000
Incidence in students in students living
off-campus = .96 per 100,000
Harrison LH, Dwyer DM, Maples CT, Billmann L: Risk of Meningococcal Infection in College Students.
JAMA. 1999;281(20)
JAMA May 26;281(20):
Conclusion of the Study:
The incidence of meningococcal infection in college students is similar to the incidence in the general population of the same age, but college students residing on campus appear to be at higher risk than those residing off campus.
Bacterial meningitis has traditionally been the concern of overseas travelers, especially in areas where an epidemic has arisen. It has been known for some time that bringing together large groups of young adults and adolescents, such as military recruits, has been associated with outbreaks of meningococcal meningitis.8 Military recruits are routinely vaccinated. Although clusters of cases are rare in the United States, the incidence of meningococcal meningitis has increased in the past few years on college campuses, particularly among students living in college housing. It is estimated that 100 to 125 cases of this form of the disease occur annually on college campuses across the country, with five to fifteen students dying each year as a result.1,4 In a recent five-year study, Harrison et al. compared the incidence of meningococcal meningitis in Maryland college students to a similar age group in the general population. The average annual incidence was 1.74 per 100,000 among students enrolled in four-year schools vs in the general population of the same age. They also found a 3.24 per 100,000 incidence in students who were on-campus residents vs. a .96 per 100,000 in students living off-campus. A similar study by Neal et al. found higher rates of the disease in colleges which provided dining hall facilities to greater than 10% of their student population. It appears that college students residing in on-campus housing are at higher risk. A recent American College Health Association recommendation suggests meningitis vaccinations be given to reduce the risk to college students. Harrison et al. state that it is reasonable for physicians to be proactive and provide college students, especially those in on-campus housing, with the vaccine. At present, many colleges' and universities' student health registration forms recommend meningococcal disease vaccinations, but none are known to require vaccination for admission. 1
Traditionally, vaccinations for adults were able to protect from two strains of meningococcal bacteria. They have only been recommended for areas experiencing epidemic or for travel to areas of the world where high rates of the disease are known to occur. Vaccines can now protect an individual from strains of Hib, some strains of meningococcal bacteria and many strains of pneumococcal bacteria. This pre-exposure vaccination protects from four strains of meningococcal disease, which are responsible for approximately 70% of the disease. Development of immunity after vaccination takes between seven and ten days.1 Its duration is three to five years with an efficacy rate of about 80-90%.
As of October 20, 1999, the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) recommends that individuals who provide medical care to college freshman, particularly those living in or planning to live in college dormitories, should provide information about meningococcal disease and the benefits of vaccination to these students and their parents. ACIP also recommends that immunization be made readily available to those students wishing to reduce their risk and who choose to be vaccinated. Information should be made readily available to college freshman and students living in dormitories. 1
These recent recommendations make it the responsibility of all Health Care Professionals who provide acute or preventative care to college students to increase their knowledge of bacterial meningitis. They must also disseminate that information, and make preventative measures available to these students, especially those living in college housing. As with any changes regarding the prevention of disease, it will take much effort in understanding the rationale for these changes in attempting to achieve compliance.
For further information on the use of vaccines and bacterial meningitis, visit the Centers for Disease Control at or the American College Health Association

25. QUESTIONS