1. MENINGOCOCCAL MENINGITIS (MCM) AT NEW DELHI & INDIA Dr. A. K. AVASARALA MBBS, M.D. PROFESSOR & HEAD DEPT OF COMMUNITY MEDICINE & EPIDEMIOLOGY PRATHIMA INSTITUTE OF MEDICAL SCIENCES, KARIMNAGAR, A.P. INDIA: +91505417 avasarala@yahoo.com

2. PART-II CLINICAL DISEASE, EPIDEMIOLOGY AND CONTROL

4. DEFINITION IT IS A PYOGENIC INFECTION OF IT IS A PYOGENIC INFECTION OF MEMBRANES COVERING THE BRAIN MEMBRANES 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 FEVER ALSO CALLED CEREBROSPINAL FEVER

5. CLINICAL PRESENTATIONS RESTRICTED TO NASOPHARYNX AS ASYMPTOMATIC CASES OR ONLY WITH LOCAL SYMPTOMS RESTRICTED TO NASOPHARYNX AS ASYMPTOMATIC CASES OR ONLY WITH LOCAL SYMPTOMS INVASIVE WITH ACUTELY ILL SEPTICEMIC AND TOXIC INVASIVE WITH ACUTELY ILL SEPTICEMIC AND TOXIC MENINGEAL MENINGEAL

6. CLINICAL PICTURE IN THE NEWBORN MINIMAL AND VARIABLE, HENCE DIAGNOSIS DIFFICULTMINIMAL AND VARIABLE, HENCE DIAGNOSIS DIFFICULT SLUGGISH, LETHARGIC WITH UNUSUAL GAZESLUGGISH, LETHARGIC WITH UNUSUAL GAZE DOES NOT TAKE FEED WELL, MAY VOMITDOES NOT TAKE FEED WELL, MAY VOMIT HIGH PITCHED CRY AND CONVULSIONSHIGH PITCHED CRY AND CONVULSIONS HYPOTHERMIA SEEN USUALLY, FEVER MAY BE THEREHYPOTHERMIA SEEN USUALLY, FEVER MAY BE THERE TENSE AND BULGING ANTERIOR FONTANELLAE VERY USUALTENSE AND BULGING ANTERIOR FONTANELLAE VERY USUAL

7. CLINICAL PICTURE IN PRESCHOOL & SCHOOL CHILD WIDE SPECTRUM OF SIGNS & SYMPTOMS IN THIS AGE GROUP AND MORE OBVIOUS WIDE SPECTRUM OF SIGNS & SYMPTOMS IN THIS AGE GROUP AND MORE OBVIOUS MODERATE TO HIGH FEVER MODERATE TO HIGH FEVER HEADACHE, VOMITING, PHOTOPHOBIA, CONVULSIONS, HEADACHE, VOMITING, PHOTOPHOBIA, CONVULSIONS, NECK STIFFNESS, NECK STIFFNESS, NEUROLOGICAL IRRITATION NEUROLOGICAL IRRITATION SKIN RASHES SKIN RASHES

8. CLINICAL PICTURE IN < 2 YEAR OLD CLASSICAL SIGNS MAY NOT BE PRESENT BUT HIGH DEGREE OF SUSPICION WHEN THE FOLLOWING PICTURE IS SEEN CLASSICAL SIGNS MAY NOT BE PRESENT BUT HIGH DEGREE OF SUSPICION WHEN THE FOLLOWING PICTURE IS SEEN FEVER COMMON FEVER COMMON MACULOPAPULAR PETECHIAL RASH IN MACULOPAPULAR PETECHIAL RASH IN HALF OF THE CASES HALF OF THE CASES REFUSAL OF FEEDS REFUSAL OF FEEDS VOMITINGS, VOMITINGS, ALTERED SENSORIUM ALTERED SENSORIUM IRRITABILITY IRRITABILITY BULGING FONTANELLAE BULGING FONTANELLAE NEUROLOGICAL DEFICIT (EITHER MONOPLEGIA, HEMIPLEGIA AND SQUINT NEUROLOGICAL DEFICIT (EITHER MONOPLEGIA, HEMIPLEGIA AND SQUINT

9. CLINICAL PICTURE IN THE ADULT CLEARCUT PICTURE CLEARCUT PICTURE FEVER, INTENSE HEADACHE FEVER, INTENSE HEADACHE VOMITING, PHOTOPHOBIA, VOMITING, PHOTOPHOBIA, NECKPAIN AND STIFFNESS NECKPAIN AND STIFFNESS SIGNS OF MENINGEAL IRRITATION SIGNS OF MENINGEAL IRRITATION AND ALTERED SENSORIUM AND ALTERED SENSORIUM SKIN RASHES SKIN RASHES SIGNS AND SYMPTOMS OF SHOCK SIGNS AND SYMPTOMS OF SHOCK

10. DIFFERENTIAL DIAGNOSIS IN NEONATE: IN NEONATE: SEPTICEMIA, GASTROENTERITIS, BIRTH HYPOXIA, BIRTH TRAUMA, RESPIRATORY INFECTIONS, HYPOGLYCEMIA, METABOLIC DISORDERS CAUSING CONVULSIONS AND KERNICTERUS SEPTICEMIA, GASTROENTERITIS, BIRTH HYPOXIA, BIRTH TRAUMA, RESPIRATORY INFECTIONS, HYPOGLYCEMIA, METABOLIC DISORDERS CAUSING CONVULSIONS AND KERNICTERUS IN OLDER CHILDREN AND ADULTS: IN OLDER CHILDREN AND ADULTS: ENCEPHALITIS, BRAIN ABSCESS, CEREBRAL MALARIA, ASEPTIC MENINGITIS, CARDIOVASCULAR ACCIDENTS, CRYPTOCOCCAL MENINGIT IS AND TUBERCULAR MENINGITIS ENCEPHALITIS, BRAIN ABSCESS, CEREBRAL MALARIA, ASEPTIC MENINGITIS, CARDIOVASCULAR ACCIDENTS, CRYPTOCOCCAL MENINGIT IS AND TUBERCULAR MENINGITIS

11. DIAGNOSIS DIAGNOSIS MENINGOCOCCI ARE DEMONSTRATED BY LUMBAR PUNCTURE AND EXAMINATION OF CEREBRO SPINAL FLUID (CSF) & CULTURE OF CSF MENINGOCOCCI ARE DEMONSTRATED BY LUMBAR PUNCTURE AND EXAMINATION OF CEREBRO SPINAL FLUID (CSF) & CULTURE OF CSF BLOOD CULTURE BLOOD CULTURE CULTURE FROM NASOPHARYNX CULTURE FROM NASOPHARYNX EXAMINATION OF PETECHIAL SKIN LESIONS EXAMINATION OF PETECHIAL SKIN LESIONS IMMUNOLOGICAL METHODS FOR ANTIBODIES (IFP, ELISA, CIEP) IMMUNOLOGICAL METHODS FOR ANTIBODIES (IFP, ELISA, CIEP)

12. TREATMENT ISOLATION OR SEPARATION ISOLATION 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 AND SUPPORTIVE THERAPY: FOR SHOCK AND CONVULSIONS CONVULSIONS

13. EPIDEMIOLOGICAL INTERACTION AGENT FACTORS HOST FACTORS ENVIRONMENT FACTORS MCM TIME DISRIBUTION PLACE DISTRIBUTION PERSON DISTRIBUTION

14. THE CAUSATIVE AGENT NEISSERIA MENINGITIDIS NEISSERIA MENINGITIDIS (MENINGO COCCUS) (MENINGO COCCUS) BISCUIT SHAPED GRAM + VE BISCUIT SHAPED GRAM + VE DIPLOCOCCUS DIPLOCOCCUS SIZE & SHAPE VARIATION IN OLDER CULTURES DUE TO AUTOLYSIS SIZE & SHAPE VARIATION IN OLDER CULTURES DUE TO AUTOLYSIS TRANSPARENT,NON PIGMENTED, NONHEMOLYTIC COLONIES 1-5 MM SIZE TRANSPARENT,NON PIGMENTED, NONHEMOLYTIC COLONIES 1-5 MM SIZE

15. MENINGO COCCI

16. SERO GROUP TYPING DEPEND UPON THE POLYSACCHARIDE CAPSULE DEPEND UPON THE POLYSACCHARIDE CAPSULE NINE SEROLOGICAL GROUPS IDENTIFIED NINE SEROLOGICAL GROUPS IDENTIFIED A, B, C, D, X, Y, Z, W-135, 29E A, B, C, D, X, Y, Z, W-135, 29E ALL THE SEROGROUPS ARE PATHOGENIC ALL THE SEROGROUPS ARE PATHOGENIC BUT A, B, C, Y ARE MOST NEUROVIRULENT BUT A, B, C, Y ARE MOST NEUROVIRULENT A AND C ARE MOST EPIDEMOGENIC A AND C ARE MOST EPIDEMOGENIC

17. MODE OF TRANSMISSION HUMAN CASES AND THE CARRIERS ARE THE ONLY RESERVOIRSHUMAN CASES AND THE CARRIERS ARE THE ONLY RESERVOIRS TRANSMITTED BY DIRECT CONTACT TRANSMITTED BY DIRECT CONTACT (DROPLETS,DISCARGE FROM THE NOSE &THROAT OF THE PERSONS) (DROPLETS,DISCARGE FROM THE NOSE &THROAT OF THE PERSONS) INCUBATION PERIOD = 3-4 DAYS INCUBATION PERIOD = 3-4 DAYS PERIOD OF COMMUNICABILITY IS AS LONG AS THE MENINGOCOOCI ARE PRESENT IN DISCARGES FROM NOSE, THROAT AND NASOPHARYNX PERIOD OF COMMUNICABILITY IS AS LONG AS THE MENINGOCOOCI ARE PRESENT IN DISCARGES FROM NOSE, THROAT AND NASOPHARYNX

18. PERSON FACTORS POOR NUTRITIONAL STATUS & IMMUNITY POOR NUTRITIONAL STATUS & IMMUNITY DRY NASAL MUCOSA DRY NASAL MUCOSA PHYSICAL EXERTION PHYSICAL EXERTION FATIGUE FATIGUE CARRIER STATE CARRIER STATE

19. AGE PREDILICTION PRIMARILY A CHILD DISEASE BUT CAN AFFECT YOUNG ADULTS ALSO

20. SEX PREDILICTION MORE MALES ARE AFFECTED THAN FEMALES MORE MALES ARE AFFECTED THAN FEMALES

21. PLACE DISTRIBUTION MCM IS ENDEMIC IN LARGE TOWNSMCM IS ENDEMIC IN LARGE TOWNS MORE COMMONLY IN PEOPLE LIVING IN CROWDED CONDITIONSMORE COMMONLY IN PEOPLE LIVING IN CROWDED CONDITIONS

22. TIME DISTRIBUTION GREATEST INCIDENCE IN WINTER AND SPRING GREATEST INCIDENCE IN WINTER AND SPRING

23. CARRIER STATE TRANSMISSION OCCURS MORE OFTEN FROM CARRIERS RATHER THAN CASES TRANSMISSION OCCURS MORE OFTEN FROM CARRIERS RATHER THAN CASES BY AND LARGE HIGH CARRIER RATE IS USUALLY ASSOCIATED WITH OUTBREAKS BY AND LARGE HIGH CARRIER RATE IS USUALLY ASSOCIATED WITH OUTBREAKS

24. CONTROL MEASURES CONTROL MEASURES

25. VACCINATION COMPOSITION: 50 MICRO GRAMS OF “A” POLYSACHARIDE, 50 MICRO GRAMS OF “C” POLY SACHARIDE, 1 MG OF LACTOSE. COMPOSITION: 50 MICRO GRAMS OF “A” POLYSACHARIDE, 50 MICRO GRAMS OF “C” POLY SACHARIDE, 1 MG OF LACTOSE. DOSE - 0.5 ML OF IRRESPECTIVE OF AGE GIVEN SUBCUTANEOUSLY. DOSE - 0.5 ML OF IRRESPECTIVE OF AGE GIVEN SUBCUTANEOUSLY. EFFICACY– SEROGROUP “A’ CLINICAL EFFICACY = 85-95% EFFICACY– SEROGROUP “A’ CLINICAL EFFICACY = 85-95% SERO GROUP “A’ INDUCES ANTIBODY RESPONSE IN CHILDREN AS YOUNG AS 3 MONTHS OLD. SERO GROUP “A’ INDUCES ANTIBODY RESPONSE IN CHILDREN AS YOUNG AS 3 MONTHS OLD. BUT SEROGROUP “C” DOES NOT INDUCE ANTIBODIES BEFORE 2 YEARS OF AGE. BUT SEROGROUP “C” DOES NOT INDUCE ANTIBODIES BEFORE 2 YEARS OF AGE. SEROGROUP “Y” AND W-135 ARE SAFE AND SEROGROUP “Y” AND W-135 ARE SAFE AND IMMUNOGENIC IN ADULTS AND CHILDREN ABOVE AGE OF 2 YEARS. IMMUNOGENIC IN ADULTS AND CHILDREN ABOVE AGE OF 2 YEARS.

26. VACCINATION 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

27. PRESENT STRATEGY FOR VACCINATION ONLY HIGH RISK PEOPLE (HEATH CARE WORKERS, TRAVELLERS, PEOPLE LIVING IN OVERCROWDED PLACES) AND CLOSE CONTACTS HAVE TO BE VACCINATED. ONLY HIGH RISK PEOPLE (HEATH CARE WORKERS, TRAVELLERS, PEOPLE LIVING IN OVERCROWDED PLACES) AND CLOSE CONTACTS HAVE TO BE VACCINATED.

28. VACCINATION FOR CONTACTS 1. 1.FORTUNATELY, WE HAVE QUADRIVALENT VACCINES AT PRESENT 2. 2.PROTECTION OCCURS ONLY AFTER 14 DAYS OF VACCINATION 3. 3.HENCE CHEMOPROPHYLAXIS IS PROVIDED WITH ANTIBIOTICS IN THE MEANTIME

29. VACCINATION FOLLOWED BY + CHEMOPROPHYLAXIS FOR CLOSE CONTACTS HOUSEHOLD MEMBERS HOUSEHOLD MEMBERS DAY-CARE CENTRE CONTACTS DAY-CARE CENTRE CONTACTS ANYONE DIRECTLY EXPOSED TO THE PATIENT'S ORAL SECRETIONS OR RESPIRATORY DROPLETS. ANYONE DIRECTLY EXPOSED TO THE PATIENT'S ORAL SECRETIONS OR RESPIRATORY DROPLETS.

30. CHEMOPROPHYLAXIS FOR CLOSE CONTACTS CIPROFLOXACIN, CIPROFLOXACIN, RIFAMPICIN, RIFAMPICIN, MINOCYCLINE, MINOCYCLINE, SPIRAMYCN, SPIRAMYCN,CEFTRIAXIONE WITHIN 24 HOURS FOR HOUSEHOLD HOUSEHOLD CONTACTS CONTACTS CLOSE CONTACTSCLOSE CONTACTS HIGH RISK PERSONSHIGH RISK PERSONS WITH

31. RISK COMMUNICATION THROUGH PUBLIC EDUCATION REGARDING THROUGH PUBLIC EDUCATION REGARDING RISK FACTORS AND POSSIBLE CONTROL STRATEGIES RISK FACTORS AND POSSIBLE CONTROL STRATEGIES NOTIFICATION OF CASES AT THE EARLIEST NOTIFICATION OF CASES AT THE EARLIEST SURVEILLANCE SURVEILLANCE FOR ACTIVE AND SUSTAINED COMMUNITY PARTICIPATION TO CONTROL THE EPIDEMIC

32. PUBLIC EDUCATION AVOID OVERCROWDING. AVOID OVERCROWDING. DO NOT SHARE DRINKING BOTTLES, GLASSES, CIGARETTES, LIPSTICKS OR OTHER ITEMS THAT MAY BE COVERED IN SALIVA. DO NOT SHARE DRINKING BOTTLES, GLASSES, CIGARETTES, LIPSTICKS OR OTHER ITEMS THAT MAY BE COVERED IN SALIVA. AVOID SMOKY AND DUSTY PLACES. AVOID SMOKY AND DUSTY PLACES. TEACH CHILDREN NOT TO SHARE CUPS, SOFT DRINK CANS OR SPORTS WATER BOTTLES. TEACH CHILDREN NOT TO SHARE CUPS, SOFT DRINK CANS OR SPORTS WATER BOTTLES.