The Drama of Bacterial Meningitis

A Seinfeld character who needed to act out the symptoms of bacterial meningitis

declared, “It’s the Hamlet of diseases. Severe pain, nausea, delusions… it’s got everything.”

Hamlet, unlike Seinfeld, is a tragedy and so too is the sudden appearance of Neisseria

meningitidis, one the microbial world’s great thespians in the daily drama of infectious diseases.

Few other microbes can kill so quickly and as spectacularly as this one. Marylanders were

reminded of that ominous fact last month when a healthy nine-year-old girl in Carroll County

became sick one Saturday and died that Sunday. The cause: N. meningitidis.

Humans are its only host, and quite a few of us happily walk around with it living

unobtrusively in the back of our throats. It’s only when a subtle shift occurs in the barrier

between it and us that the drama begins.

Frequently, it is a one-act play in which the bacteria invade the bloodstream, quickly

multiplying, and spilling into the central nervous system. The meninges—the membranes

surrounding the brain and spinal cord—become infected and inflamed, and death can follow

rapidly. If there is a second act for the patient it often involves permanent brain damage or

amputation of infected limbs.

There are 1,400-2,800 cases of meningococcal disease in the U.S. each year. Ten to

fourteen percent of those cases are fatal. Another 11-15% results in some type of permanent

disability. Maryland reported eleven cases last year and 27 cases in 2003. The numbers may

seem small, but epidemics and outbreaks are not unknown as carriers can spread the bacteria by

respiratory droplets and other forms of close contact.

For example, an outbreak in New Delhi, India last month led to 405 cases and 48 deaths.

In February, China fought an outbreak that killed 16 and hospitalized 258. In both countries

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health officials had to track down patients’ close contacts and provided antibiotics and vaccines

to contain the spread of meningitis.

The worst epidemics occur in Africa’s Meningitis Belt. This is a hostile stretch of sub-

Saharan lands extending from Senegal to Ethiopia. Three hundred million people live within the

Belt, and during the six-month dry season, blowing dust, overcrowded housing and nomadic

tribes provide endless opportunities for the transmission of N. meningitidis. Nine years ago, this

region had the worst epidemic ever recorded: 250,000 cases and 25,000 deaths.

As with most bacterial infections, antibiotics are the first line of defense. But with a

high-speed killer like Neisseria, offense is better than defense. The trick is to keep an infection

from starting in the first place. That’s where vaccines come into play.

Neisseria meningitis bacteria invade, infect, maim and kill from behind the safety of a

self-made sugary shield called a polysaccharide capsule. It’s this protective capsule that the

body’s immune system sometimes beats itself against in futility. This same capsule is also the

key ingredient in making vaccines.

The first such vaccine was given to Army recruits in 1971. Not surprisingly, Army

barracks crowded with highly stressed men from diverse backgrounds can be frequent sites of

outbreaks. That first meningitis vaccine helped to reduce Army cases from about 30 per 100,000

soldiers to 1.4 cases per 100,000 per year.

It was an impressive reduction in morbidity and mortality and again showed the power of

vaccines as public health tools. But Neisseria is tricky; its protective capsule comes in a variety

of flavors. So, where one type of bacteria is blocked by the vaccine, others slip past. A

subsequent vaccine covered several important types of Neisseria, including types A, C, Y, and W-

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135. (There is also a type B, but it has been difficult to make a safe and effective vaccine from

the B polysaccharide.)

In January, the American Academy of Pediatrics recommended a newer meningitis

vaccine (Menactra) for pre-teens, high schoolers and college students living in dorms. The new

vaccine provides long-term immunity (8-10 years) to the four common types of Neisseria, and

helps eliminate Neisseria lurking in the noses and throats of carriers.

This vaccine is especially important for students living in dorms who are at greater risk

than Army recruits—if only because they can experience a greater range of risky behaviors. So

this September when you are loading up the car with laptops, printers, CDs, DVD players, hair

dryers and all the other trappings of academic life, stop and consider giving your kids a shot in

the arm. Better yet, have the doctor do it.

For more information about meningitis on campus see the National Meningitis

Association at www.nmaus.org.

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