MENINGOCOCCAL MENINGITIS MCM AT NEW DELHI

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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_at_yahoo.com
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• PART-II
• CLINICAL DISEASE, EPIDEMIOLOGY AND CONTROL

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DEFINITION

• IT IS A PYOGENIC INFECTION OF
• MEMBRANES COVERING THE BRAIN
• AND SPINAL CORD ( DURA, PIA AND
• ARACNOID MEMBRANES) BY
• MENIINGO-COCCI
• ALSO CALLED CEREBROSPINAL FEVER

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CLINICAL PRESENTATIONS

• RESTRICTED TO NASOPHARYNX AS ASYMPTOMATIC CASES
  OR ONLY WITH LOCAL SYMPTOMS
• INVASIVE WITH ACUTELY ILL SEPTICEMIC AND TOXIC
• MENINGEAL

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CLINICAL PICTURE IN THE NEWBORN

• MINIMAL AND VARIABLE, HENCE DIAGNOSIS DIFFICULT
• SLUGGISH, LETHARGIC WITH UNUSUAL GAZE
• DOES NOT TAKE FEED WELL , MAY VOMIT
• HIGH PITCHED CRY AND CONVULSIONS
• HYPOTHERMIA SEEN USUALLY, FEVER MAY BE THERE
• TENSE AND BULGING ANTERIOR FONTANELLAE VERY
  USUAL

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CLINICAL PICTURE IN PRESCHOOL SCHOOL CHILD

• WIDE SPECTRUM OF SIGNS SYMPTOMS IN THIS AGE
  GROUP AND MORE OBVIOUS
• MODERATE TO HIGH FEVER
• HEADACHE, VOMITING, PHOTOPHOBIA,
  CONVULSIONS,
• NECK STIFFNESS,
• NEUROLOGICAL IRRITATION
• SKIN RASHES

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CLINICAL PICTURE IN lt 2 YEAR OLD

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

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CLINICAL PICTURE IN THE ADULT

• CLEARCUT PICTURE
• FEVER, INTENSE HEADACHE
• VOMITING, PHOTOPHOBIA,
• NECKPAIN AND STIFFNESS
• SIGNS OF MENINGEAL IRRITATION
• AND ALTERED SENSORIUM
• SKIN RASHES
• SIGNS AND SYMPTOMS OF SHOCK

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DIFFERENTIAL DIAGNOSIS

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

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DIAGNOSIS

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

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TREATMENT

• ISOLATION OR SEPARATION
• ALL PATIENTS NEED HOSPITALIZATION
• SPECIFIC TREATMENT
• - FLUIDS
• - CEFTRIAXONE/CEFOTOXIME
• - AMPICILLIN ( NOT TO BE GIVEN IF
• HYPERSENSITIVE TO PENICILLIN)
• - CHLORAMPHENICOL
• SUPPORTIVE THERAPY FOR SHOCK AND
• CONVULSIONS

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EPIDEMIOLOGICAL INTERACTION

• AGENT FACTORS

TIME DISRIBUTION

MCM
HOST FACTORS
ENVIRONMENT FACTORS
PERSON DISTRIBUTION
PLACE DISTRIBUTION
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THE CAUSATIVE AGENT

• NEISSERIA MENINGITIDIS
• (MENINGO COCCUS)
• BISCUIT SHAPED GRAM VE
• DIPLOCOCCUS
• SIZE SHAPE VARIATION IN OLDER CULTURES DUE TO
  AUTOLYSIS
• TRANSPARENT ,NON PIGMENTED, NONHEMOLYTIC COLONIES
  1-5 MM SIZE

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MENINGO COCCI
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SERO GROUP TYPING

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

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MODE OF TRANSMISSION

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

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PERSON FACTORS

• POOR NUTRITIONAL STATUS IMMUNITY
• DRY NASAL MUCOSA
• PHYSICAL EXERTION
• FATIGUE
• CARRIER STATE

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AGE PREDILICTION

• PRIMARILY A CHILD DISEASE
• BUT CAN AFFECT YOUNG
• ADULTS ALSO

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SEX PREDILICTION

• MORE MALES ARE AFFECTED THAN FEMALES

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PLACE DISTRIBUTION

• MCM IS ENDEMIC IN LARGE TOWNS
• MORE COMMONLY IN PEOPLE LIVING IN CROWDED
  CONDITIONS

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TIME DISTRIBUTION

• GREATEST INCIDENCE IN WINTER AND SPRING

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CARRIER STATE

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

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• CONTROL MEASURES

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VACCINATION

• 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.
• EFFICACY SEROGROUP A CLINICAL EFFICACY
  85-95
• 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.
• SEROGROUP Y AND W-135 ARE SAFE AND
• IMMUNOGENIC IN ADULTS AND CHILDREN ABOVE
  AGE OF 2 YEARS.

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VACCINATION LIMITATIONS

• LIMITED SHELF LIFE AFTER REVACCINATION
• NO VACCINE IS AVAILABLE AGAINST GROUP B
• SHORT INCUBATION PERIOD vis-à-vis MORE TIME TAKEN
  FOR THE DEVELOPMENT OF IMMUNITY
• 4.UNSATISFACTORY RESPONSE VACCINATION UNDER 2
  YEARS OF AGE WHICH IS THE HIGHEST SUSCEPTIBLE
  AGE-GROUP

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PRESENT STRATEGY FOR VACCINATION

• ONLY HIGH RISK PEOPLE (HEATH CARE WORKERS,
  TRAVELLERS, PEOPLE LIVING IN OVERCROWDED PLACES)
  AND CLOSE CONTACTS HAVE TO BE VACCINATED.

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VACCINATION FOR CONTACTS

• FORTUNATELY, WE HAVE QUADRIVALENT VACCINES AT
  PRESENT
• PROTECTION OCCURS ONLY AFTER 14 DAYS OF
  VACCINATION
• HENCE CHEMOPROPHYLAXIS IS PROVIDED WITH
  ANTIBIOTICS IN THE MEANTIME

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VACCINATION FOLLOWED BY CHEMOPROPHYLAXIS FOR
CLOSE CONTACTS

• HOUSEHOLD MEMBERS
• DAY-CARE CENTRE CONTACTS
• ANYONE DIRECTLY EXPOSED TO THE PATIENT'S ORAL
  SECRETIONS OR RESPIRATORY DROPLETS.

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CHEMOPROPHYLAXISFOR CLOSE CONTACTS

• WITHIN 24 HOURS FOR
• HOUSEHOLD
• CONTACTS
• CLOSE CONTACTS
• HIGH RISK PERSONS

• CIPROFLOXACIN,
• RIFAMPICIN,
• MINOCYCLINE,
• SPIRAMYCN,
• CEFTRIAXIONE

WITH
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RISK COMMUNICATION

• THROUGH PUBLIC EDUCATION REGARDING
• RISK FACTORS AND POSSIBLE CONTROL STRATEGIES
• NOTIFICATION OF CASES AT THE EARLIEST
• SURVEILLANCE

FOR ACTIVE AND SUSTAINED COMMUNITY
PARTICIPATION TO CONTROL THE EPIDEMIC
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PUBLIC EDUCATION

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