1. 15/15/2015 Meningitis General Overview Presented by: Robert W. White II, RS, MPH Regional Epidemiologist

2. 5/15/20152 Clinical description Meningitis is a disease caused by the inflammation of the protective membranes covering the brain and spinal cord known as the meninges. The inflammation is usually caused by an infection of the fluid surrounding the brain and spinal cord. Meningitis is also referred to as spinal meningitis.

3. 5/15/20153 Causes of Meningitis - bacteria - viruses - physical injury - cancer - or certain drugs Severity/treatment of illnesses differ depending on the cause. Thus, it is important to know the specific cause of meningitis.

4. 5/15/20154 For Public Health Response Meningitis can be: ViralORBacterial Both can create Public Health Problems but not all Meningitis is created equal

5. 5/15/20155 Causes of Meningitis Bacterial Bacterial - Haemophilus influenzae - Listeria - Meningococcus - Meningococcus - Mumps - Pneumococcus - Group A Streptococcus - Group A Streptococcus - Group B Streptococcus Viral Viral - Arboviral (mosquito- borne) diseases - Influenza - LaCrosse Encephalitis virus - West Nile Virus - Also enteroviral

6. 5/15/20156 Symptoms can be the same for Viral and Bacterial Fever and chills Fever and chills Mental status changes Mental status changes Nausea and vomiting Nausea and vomiting Sensitivity to light (photophobia) Sensitivity to light (photophobia) Severe headache Severe headache Stiff neck Stiff neck

7. 5/15/20157 Viral Meningitis Clinical description: A syndrome characterized by acute onset of meningeal symptoms- fever, and cerebrospinal fluid pleocytosis (white cells in the spinal fluid) with bacteriologically sterile cultures. Confirmed: a clinically compatible illness diagnosed as aseptic meningitis, with no laboratory evidence of bacterial or fungal meningitis

8. 5/15/20158 Bacterial Meningitis What types are important in Public Health Response? 1. Neisseria meningitidis (also called meningococcal meningitis) 2. Haemophilus influenzae Serotype b (Hib) Why are they important? Why are they important?

9. 5/15/20159 Neisseria meningitidis Prophylaxis People who qualify as close contacts of a person with meningitis caused by N. meningitidis are - Family and household contacts - Child or nursery school contacts - Anyone exposed to patient’s oral secretions

10. 5/15/201510 Hib Prophylaxis The entire household, regardless of age, should receive prophylaxis in these cases if- - There is 1 household contact younger than 48 months who has not been fully immunized against Hib, or - An immunocompromised child (a child with a weakened immune system) of any age is in the household.

11. 5/15/201511 So…you get a call from a Hospital ER at 4:00 on Thursday A patient has been intubated and the doctor believes that the symptoms are consistent with Meningitis Spinal fluid cultures are incomplete What should you do first?

12. 5/15/201512 It’s now 4:05 Call your Regional Epidemiologist and the Division of Infectious Disease Epidemiology (DIDE) Get a copy of any lab results and fax them to DIDE Obtain patient demographics from the hospital But…what are you dealing with?

13. 5/15/201513 It’s 4:15- Rest easy for a while You have clinical symptoms of meningitis with no laboratory confirmation You have notified the right individuals Just in case the news gets worse, the hospital has prophylaxed the entire family You don’t even have a reportable disease yet

14. 5/15/201514 Friday 8:00 AM The hospital lab calls you to say the culture is growing Gram Negative diplococci The patient has progressively gotten worse Gram Negative Diplococci? So what?

15. 5/15/201515 ASSUME Neisseria Meningitis If the lab would have been Gram positive cocci in pairs and chains, then Strep Pneumoniae would have presented a problem

16. 5/15/201516 Investigate Assume 1 case is the start of an outbreak but remember- most cases are single cases Talk to the ICP and get as much information as possible Talk to family members to get history Determine if more individuals need prophylaxis treatment

17. 5/15/201517 Neisseria Meningitis - Serogroups B, C, and Y account for 30% each of reported cases - Serogroups C, Y, and W-135 are vaccine preventable - In infants, 50% of cases are caused by serogroup B and are not preventable by vaccine

18. 5/15/201518 Outbreak Steps /Case Management 1. Prepare for field work – go to internet sites, Red Book, and CCD in Man 2. Establish the existence of an outbreak- is one case enough? 3. Verify the diagnosis- try to get a lab report 4. Define and identify cases- is anyone else exhibiting symptoms?

19. 5/15/201519 Outbreak Steps (continued) 5. Describe and orient the data in terms of time, place, and person- organize your data, report on WVEDSS 6. Implement control and prevention measures- who else needs prophylaxis? 7. Communicate findings- The family will want some answers and the media will want all the details. Is a Health Alert to local physicians warranted? (Generally with Meningitis we are not going to do a great deal on Hypothesis testing)

20. 5/15/201520 What does the public know about meningitis? It’s bad and people die from it The word “meningitis” conjures up chilling memories of past deaths If a school is involved, be prepared to have protesters and news media on scene The next 2 slides are real life situations

21. 5/15/201521 Neisseria Meningitis

22. 5/15/201522 Streptococcus Pneumoniae

23. 5/15/201523 So let’s review- Viral Meningitis Incubation period is about 3 to 6 days Duration of the illness is approximately 7 to 10 days Infectious period can last several weeks after symptoms have resolved Diagnosed by laboratory tests of a patient’s spinal fluid Many times tests are done to rule out Bacterial Meningitis

24. 5/15/201524 Viral Meningitis- Review There is no specific treatment for viral meningitis. -Enteroviruses are most often spread through direct contact with an infected person’s stool. Enteroviruses and other viruses (such as mumps and varicella-zoster virus) can also be spread through -direct, or -indirect contact with respiratory secretions (saliva, sputum, or nasal mucus) of an infected person.

25. 5/15/201525 Viral Meningitis- Review Following good hygiene practices can reduce the spread of viruses and bacteria Wash your hands thoroughly and often Clean contaminated surfaces Cover your cough Avoid kissing or sharing a drinking glass, eating utensil, lipstick, or other such items

26. 5/15/201526 Viral Meningitis- Review Receiving vaccinations in the childhood vaccination schedule can protect children against diseases that can lead to viral meningitis (measles, mumps, and chickenpox) Avoid bites from mosquitoes and other insects that carry diseases that can infect humans

27. 5/15/201527 Viral Meningitis- Review Outbreaks are rare but if you are around someone with viral meningitis, you may be at risk of becoming infected with the virus that made them sick. But you have only a small chance of developing meningitis as a complication of the illness.

28. 5/15/201528 Bacterial Meningitis- Review Public Health Implications - Listeria - HiB - Group B Strep (Pregnant women and neonates) - Streptococcus pneumoniae - Meningococcal Meningitis (Neisseria meningitidis ) – individual cases

29. 5/15/201529 Bacterial Meningitis- Review -Bacterial meningitis is contagious. The bacteria are spread through the exchange of respiratory and throat secretions (i.e., coughing, kissing). -None of the bacteria that cause meningitis are as contagious as things like the common cold or the flu. -The bacteria are not spread by casual contact or by simply breathing the air where a person with meningitis has been.

30. 5/15/201530 Bacterial Meningitis- Review Assure all isolates are referred to OLS for serotyping Assure all high risk contacts are offered prophylaxis Assure all providers are educated to report suspect and confirmed cases of invasive meningococcal disease properly

31. 5/15/201531 Bacterial Meningitis- Review Keeping up to date with recommended immunizations is the best defense. Good hygiene is also an important way to prevent most infections. Rifampin, ceftriaxone, and ciprofloxacin are appropriate drugs for chemoprophylaxis in adults. The drug of choice for most children is rifampin. Chemoprophylaxis may be administered in conjunction with vaccinations.

32. 5/15/201532 Bacterial Meningitis- Review People who should be prophylaxed - household contacts - daycare center contacts - anyone with direct contact with a patient's oral secretions Media releases may be appropriate to assist in finding close contacts of the initial case. Working with news services may prevent public anxiety especially when investigations lead to schools, colleges, and workplaces.

33. 5/15/201533 Bacterial Meningitis- Review People who should not be prophylaxed - Casual contacts, no history of exposure to index case - Indirect contacts (2nd degree contact) - Health care professionals without direct exposure

34. 5/15/201534 Bacterial Meningitis- Outbreaks Local Health Departments 1. Investigate cases immediately 2. Report cases to Regional Epidemiologist and Infectious Disease Epidemiology 3. Determine who is at risk by interviewing physician, family or possibly the case 4. Organize notes and respond as though this will be an outbreak 5. Send isolates to OLS

35. 5/15/201535 Meningitis- For More Information http://www.cdc.gov/meningitis/index.html http://www.wvidep.org/AZIndexofInfectious Diseases/MeningococcalDiseaseInvasive/ta bid/1529/Default.aspx http://www.wvidep.org/AZIndexofInfectious Diseases/MeningococcalDiseaseInvasive/ta bid/1529/Default.aspx

36. 5/15/201536 Meningitis- Q and A Questions???? Questions????