MENINGOCOCALMENINGITIS

PRESENTED BY CLASS 6 B
COMMUNITY MEDICINE DEPARTMENT
OBJECTIVES
 Epidemiology of meningitis.
o Introduction.
o Epidemiology.
o Agent & host.
o Environment & transmission.
o Incubation period & Distribution & period of communicability
 Prevention and control of meningitis.
o Management.
o Prevention & Control
 Screening of meningitis.
o Clinical features.
o Diagnosis.
INTRODUCTION
 Meningitis
 Meningitis or inflammation of the meninges, it is an
acute specific disease caused by meningococci.

 Meningococcal meningitis or cerebro-spinal fever is "an

acute communicable disease caused by Neisseria
meningitidis because of its potential to cause epidemics".

 The disease can occur in endemic, epidemic from or in

sporadic cases.
EPIDEMIOLOGY
 Meningococcal meningitis occurs worldwide in
both endemic and endemic countries. It is
estimated to be responsible for more than 500,000
cases and approximately 135,000 deaths annually

 The first isolated Neisseria meningitidis in 1887

was to infect humans only with the human
nasophrynx mucosa as their natural habitat.
.EPIDEMIOLOGY CONT
 Most cases of nasophrynx colonization are
asymptomatic. However, the invasion of the
bloodstream by Neisseria meningitidis can lead to
meningitis and blood poisoning with severe
consequences. Even with appropriate treatment,
meningococcal meningitis has a mortality rate of
about 10% and about 15% of survivors due to
residual damage to the central nervous system.
.EPIDEMIOLOGY CONT
 Global serogroups A, B and C represent the majority of
cases. The dominant serogroups in Asia and Africa are A
and C while serogroups B and C are responsible for the
majority of cases in Europe and the Americas. Recent
outbreaks of epidemics among pilgrims have been
attributed to W135 serogroups.

 Epidemic rates of meningococcal disease range from

1 - 3 / 100,000 in many developed countries to 10 - 25 /
100,000 in some developing countries.
AGENT & HOST
 Host Age: Children and young adults , highest in 3-12
months infants

 Sex: Both

 Immunity: Susceptibility decreases by age, Immunity

acquired by subclinical(mostly),clinical disease or
vaccination.
.AGENT & HOST CONT
 No animal reservoir
 Environmental factors.
o dry season between Dec. to June, dust winds, cold night sand
upper respiratory tract infections combine to damage the
nasopharyngeal mucosa,
o Overcrowding
o large population displacements due to pilgrimages and
traditional markets.
o Low SESN.
o Meningitidis dies rapidly on exposure to heat or cold.
 Incubation Period: Range 2-10 days, Average 4 days9
.AGENT & HOST CONT
 Agent

o Neisseria meningitidis - large epidemics.

o 6 out of 12 serogroups of N. meningitidis(A, B, C, W135,

X and Y) can cause epidemics.

o In Africa - Group A most imp.

ENVIRONMENT
 Individuals acquire the infection if they are exposed to
virulent bacteria and have no protective bactericidal
antibodies .
 Smoking and concurrent viral infection of the upper
respiratory tract that diminish the integrity of the
respiratory mucosa and increase the likelihood of
invasive disease .
 crowding living condition .
 the dry and cold month of the year.
 The low socio-economic groups living under poor
housing conditions.
TRANSMISSION
 (transmitted from person to person)

o The portal of entry is the nasopharynx.

o direct contact like kissing & living in close quarters.

o Sharing of utensils & contaminated articles.

o Respiratory droplets like coughing & sneezing.

INCUBATION PERIOD & DISTRIBUTION
 Incubation period:-

o 2/10 days for sporadic cases during non-epidemic periods, and 1/3 days during epidemic.

 Distribution:-

A. Person distribution:
o Age: all members of the families has equal chance of exposure but the attack rate is 6/8 times
higher in infants and children as it is among older age.
o Sex: Both sexes are equally affected
o Social class: more in the lower social class.

B. Time distribution:
o The disease occurs throughout season but more in winter, and spring.

 Period of communicability:-

o until meningococci are no longer present in discharges from mouth and nose, 24 hours after
suitable antibiotic therapy.
CLINICAL FEATURES

Meningococcal Meningitis Meningococcal Meningitis

without Meningococcemia with Meningococcemia
CONT. CLINICAL FEATURES
 Meningitis without meningococcemia

1. Patients with meningococcalmeningitis have usually

been sick for >24 h before they seek medical attention.
.CLINICAL FEATURES CONT
 Meningitis without meningococcemia

1) Common presenting symptoms:

1. Fever ,Nausea and Vomiting
2. Headache.
3. Convulsions.
.CLINICAL FEATURES CONT
 Meningitis without meningococcemiaMeningitis

2) Common presenting symptoms:

1. Lethargy and Confusion, maybe Coma.

2. Neck Stiffness.
.CLINICAL FEATURES CONT
 Meningitis without meningococcemia

3) Petechial hemorrhages on skin and/or mucosa may be

seen.
.CLINICAL FEATURES CONT
 Meningitis without meningococcemia

4) The signs and symptoms of Meningococcal Meningitis

cannot be distinguished from those elicited by other
meningeal pathogens.
.CLINICAL FEATURES CONT
 Meningitis with meningococcemia

1. Pharyngitis.
2. Fever.
3. Weakness and Myalgia.
.CLINICAL FEATURES CONT
 Meningitis with meningococcemia

4. May develop maculopapular rash before other serious

signs develop.
5. Vomiting and Diarrhoea.
6. Headache.
.CLINICAL FEATURES CONT
 Meningitis with meningococcemia
7. Fulminate cases Rapid progression to shock
characterized by:
I. 1Hypotension.
II. DIC.
III. Acidosis.
IV. Adrenal hemorhage.
V. Renal failure.
VI. Myocardial failure.
VII. Coma.
.CLINICAL FEATURES CONT
 Other manifestations
1. Arthritis - Approx.10% patients.
2. Primary Meningococcal Pneumonia – Mainly in adults.
DEFINITIVE DIAGNOSIS
 Isolation of causative organism , its antigens , or its DNA from
normally sterile body fluid like blood , CSF , or synovial fluid

 Notes:

1. Isolation of organism from nasopharynx is not diagnostic for

invasive disease Serves only research or epidemiological
purposes.

2. Cultures may be negative if the patient has received prior

antibiotics.
.DEFINITIVE DIAGNOSIS CONT
 Laboratory Findings Blood :

1. Leukocytopenia
2. Thrombocytopenia.
3. Elevated ESR.
4. Hypoalbuminemia.
5. Hypocalcemia.
6. Elevated CRP.
7. Metabolic acidosis
.DEFINITIVE DIAGNOSIS CONT
 spinal tap (lumber puncture ), collection CSF.
 laboratory findings CSF :
 1. Hypoglycemia( <45 mg/dl)
 2. Elevated protein level ( >45 mg/dl)
 3.Neutrophilic Leukocytosis
 4.Gram's Stain of CSF reveals intra- or extra-cellular organisms in
approximately,

 Laboratory Findings Urine:

 1. Hematuria.
 2. Proteinuria.
.DEFINITIVE DIAGNOSIS CONT
 Investigation:

 1.Chest X-rays can reveal the presence of pneumonia, tuberculosis, or fungal infections .Meningitis
can occur after pneumonia.
 2.A CT scan of the head may show problems like a brain abscess or sinusitis. Bacteria can spread from
the sinuses to the meninges.

 Examination:
1) Eye exam (Fundus copic Exam) examing eyes by using an ophthalmoscope. This test allows the
doctor to see

1. swelling of the optic nerves

2. consequently an increase in pressure inside of the head.

2) Ear Exam: This can show signs of an underlying ear infection as the cause of the meningitis (more
common in children).
MANAGEMENT
 Meningococcal disease is potentially fatal and should always be viewed as a medical

emergency. Management of meningococcal disease requires early recognition of the disease,

prompt initial parentral antibiotic therapy and close monitoring with frequent repeated

prognostic evaluations. Admission to a hospital centre essential. Isolation of the patient is not

necessary. Antimicrobial therapy must be commenced as soon as possible after the lumbar

puncture has been carried out. Several antibiotics can be used for treatment including

penicillin, ampicillin, chloramphenicol and ceftriaxone. A single intramuscular dose of an oily

suspension of chloramphenicol has been shown to be as effective as a five - day course of

crystalline penicillin in the treatment of meningococcal meningitis. During epidemics, this may

offer a practical alternative to penicillin or ceftriaxone which require multiple injections.

.MANAGEMENT CONT
 The adult dose of penicillin is 4 million units IV four
times a day. The paediatric dose is 250,000 Units/Kg/day
given intravenously in divided doses. For Ceftriaxone,
the adult dose is four gram IV per day divided into two
doses. Paediatric dose is 50 mg/Kg IV divided into two
doses (not to exceed 4 g/d). The use of corticosteroids
has not been shown to be effective for meningococcal
meningitis
:PREVENTION AND CONTROL
 Cases:
o Treatment with antibiotics can save lives of 95% of cases ,
provided that the treatment is started within the first 2 days of
illness
o penicillin is the drug of choice.
o in penicillin_ allergic patients; Chloramphenicol and other 3rd
generation Cephalosporins should be substituted.

 Carriers:
o Treatment with penicillin doesn't eradicate carriers state .
o Powerful antibiotic like Rifampicin is needed for eradication.
CONTACTS
 Chemoprophylaxis is the preferred means of prevention of
disease among close contacts.

 Household contacts, contacts at day care centres and anyone else

directly exposed to an infected patient’s oral secretions should be
administered chemoprophylaxis as soon as possible (ideally
within 24 hours).

 Antibiotics that can be used for chemoprophylaxis are rifampin,

ciprofloxacin, ceftriaxone, minocycline, ofloxacin, and
spiramycin.
MENINGOCOCCAL VACCINES
 At present two types of meningococcal
 vaccines are licensed; meningococcal polysaccharide vaccines (bivalent
and quadrivalent) and meningococcal conjugated polysaccharide vaccine.

 1. Polysaccharide Vaccines :

 Bilvalent polysaccharide vaccines provide protection against serogroups

A and C, trivalent against A,C,W-135, while the quadrivalent
polysaccharide vaccines provide protection against serogroups A, C, Y
and W - 135.

 The dose for primary vaccination for both adults and children older than
two years is a single 0. 5 - ml subcutaneous injection .
.MENINGOCOCCAL VACCINES CONT

 2.Conjugated polysaccharide vaccine

 • Monovalent (A or C), quadrivalent A, C, Y and W - 135 conjugate
vaccine has been licensed since January 2005.
 • Conjugate vaccine should be given as intramuscular injection,
preferably in the deltoid muscle in children younger than 2 years.
CONTROL OF MENINGOCOCCAL MENINGITIS
 Control of Meningococcal meningitis

1. Notification to the local health authority.

2. Isolation in hospital is recommended for better medical care.

3. Prompt treatment using general and specific chemotherapy.

The early treatment ofthe case will eliminate infection within
24 hours and can be released after thatbased on the general
condition of the case, and his clinical cure.

4. Disinfection.
.CONTROL OF MENINGOCOCCAL MENINGITIS CONT

 Measures to contacts:

1. Listing of all contacts.

2. Chemoprophylaxis and active immunization.

3. Health education.

 Measures to environment:

1. Terminal disinfection.