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Meningococal menengitis presentation

This document provides an overview of meningococcal meningitis. It defines meningococcal meningitis as a bacterial form of meningitis caused by Neisseria meningitidis. The document discusses the global and national burden of the disease, including that the highest rates are found in the "meningitis belt" of sub-Saharan Africa. It provides details on the pathogenesis, clinical features, diagnosis, and public health response to meningococcal meningitis.

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 Introduction  Definition  History  Problem statement  Epidemiology  Global burden  National burden  Pathogenesis  Clinical features Total number of slides: 46 Time duration : 30-45 minutes  Diagnosis  Differential Diagnosis  Prevention and control  Public health response  Complication  Reference 7/14/2017 2DISEASE PRESENTATION
 Meningococcal meningitis is a bacterial form of meningitis, a serious infection of the thin lining that surrounds the brain and spinal cord.  The extended meningitis belt of sub-Saharan Africa, stretching from Senegal in the west to Ethiopia in the east (26 countries), has the highest rates of the disease.  Before 2010 and the mass preventive immunization campaigns, Group A meningococcus accounted for an estimated 80–85% of all cases in the meningitis belt, with epidemics occurring at intervals of 7–14 years. Since then, the proportion of the A serogroup has declined dramatically. 7/14/2017 3DISEASE PRESENTATION
 During the 2014 epidemic season, 19 African countries implementing enhanced surveillance reported 11 908 suspected cases including 1146 deaths, the lowest numbers since the implementation of enhanced surveillance through a functional network (2004).  Several vaccines are available to control the disease: a meningococcal A conjugate vaccine, C conjugate vaccines, tetravalent A, C, Y and W conjugate vaccines and meningococcal polysaccharide vaccines.  As of June 2015, over 220 million persons aged 1 to 29 years have received meningococcal A conjugate vaccine in 15 countries of the African belt. 7/14/2017 4DISEASE PRESENTATION
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• Meningitis is a disease caused by the inflammation of the meninges. • The inflammation is usually caused by an infection of the fluid surrounding the brain and spinal cord. 7/14/2017 6DISEASE PRESENTATION
 It may develop in response to a number of causes, usually bacteria, viruses, fungi, parasites but can also be caused by physical injury, cancer or certain drugs.  The severity of illness and the treatment for meningitis differ depending on the cause. Thus, it is important to know the specific cause of meningitis. 7/14/2017 7DISEASE PRESENTATION
• BACTERIAL MENINGITIS Bacteria, like Neisseria meningitidis and Streptococcus pneumoniae • VIRAL MENINGITIS caused by viruses, like enteroviruses, arboviruses and herpes simplex viruses. Meningitis • FUNGAL MENINGITIS caused by fungi like Cryptococcus and Histoplasma and 7/14/2017 8DISEASE PRESENTATION
• PARASITIC MENINGITIS caused by parasites like Angiostrongylus cantonensis, can contaminate food, water and soil. • NON-INFECTIOUS MENINGITIS Sometimes meningitis is not spread from person to person, but is instead caused by cancers, systemic lupus erythematosus (lupus), certain drugs, head injury, and brain surgery. 7/14/2017 9DISEASE PRESENTATION
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• It is a bacterial form of meningitis which is a serious infection of the meninges that affects the brain membrane. • Also called as Cerebrospinal fever. • It can cause severe brain damage and is fatal in 50% of cases if untreated.(WHO) 7/14/2017 11DISEASE PRESENTATION
 Meningococcal meningitis has been recognized as a serious problem for almost 200 years.  It was first identified by Vieusseux in Geneva in 1805.  The Italian pathologists Marchiafava and Celli (1884) first described intracellular oval micrococci in a sample of CSF.  However, Anton Weichselbaum in 1887 first identified bacterium causing meningococcal disease in the CSF of six of eight patients of bacterial meningitis and the bacterium was named Neisseria 7/14/2017 12DISEASE PRESENTATION
• The first successful treatment of meningitis with intravenous and intrathecal penicillin was reported in 1944, and the first clinical trials using high doses of intravenous penicillin as monotherapy for the treatment of meningitis were reported in 1950. • Since then, penicillin has remained the drug of choice for the treatment of meningococcal meningitis. However, current Infectious Disease Society of America (IDSA) guidelines list ceftriaxone or cefotaxime as the drugs of choice. 7/14/2017 13DISEASE PRESENTATION
 Despite effective antibiotics and partially effective vaccines, N. meningitidis is still a leading global cause of meningitis  It occurs worldwide in both endemic and epidemic forms.  It is estimated to be responsible for 300,000 to 500,000 cases per year.  There was large epidemics of meningococcal disease during the first half of the twentieth century, are now associated with recurring epidemics in sub-Saharan Africa region called as African meningitis bel region.  According to WHO here meningococcal epidemic is >100 cases per 100,000 population per year.  In the largest meningococcal epidemic recorded, >300,000 cases and 30,000 deaths due to serogroup A N. meningitidis occurred in sub-Saharan Africa in 1996–1997. 7/14/2017 14DISEASE PRESENTATION
• Since 1980, large epidemics and/or outbreaks meningococcal disease have also occurred in Europe, the United States, Canada, China, Nepal, Mongolia, New Zealand, Cuba, Brazil, Chile, Saudi Arabia, and South Africa. • In the United States and Canada during the 1990s, serogroup B was the most common cause of sporadic disease, while serogroup C was a more frequent cause of outbreaks. • In 2000, 2001, and 2002, worldwide epidemics of serogroup W-135 meningococcal disease occurred in association with the Muslim pilgrimage to Mecca (the Hajj) and in the meningitis belt of sub-Saharan Africa. • During the 2014 epidemic season, 19 African countries implementing enhanced surveillance reported 11908 suspected cases including 1146 deaths. 7/14/2017 15DISEASE PRESENTATION
 Here, in India there is a epidemic of this disease.  Cases of meningococcal meningitis are reported sporadically.  During 2013, about 3380 cases were reported with 176 deaths.  Majority of cases are seen in AP i.e 397 cases with 27 deaths. 7/14/2017 16DISEASE PRESENTATION
AGENT : Neisseria meningitidis ◦ Bean shaped gram negative, aerobic diplococci. ◦ surrounded by an outer membrane of lipids, membrane proteins and lipopolysaccharides. ◦ At least 12 serotypes have been described : A, B, C, 29E, H, I, K, L, W - 135, X, Y and Z based on the polysaccharides capsule, 6 of which (A, B,C, W135, X and Y) can cause epidemics.. ◦ found in the nasopharynx of cases and carriers 7/14/2017 17DISEASE PRESENTATION
SOURCE OF INFECTION : Clinical cases present a negligible source of infection . Carrier are the most important sources of infection. PERIOD OF COMMUNICABILITY : • When meningococci are discharge from nose and throat. EPIDEMIOLOGICAL FEATURES CONT.. 7/14/2017 18DISEASE PRESENTATION
IMMUNITY : • All the age group are susceptible. Younger group are more susceptible as their antibodies are lower. • Immunity is acquired by subclinical infection (mostly), clinical diseases or vaccination. • Infant derive passive immunity from the mothers ENVIRONMENTAL FACTORS • Outbreaks occur more frequently in the dry and cold months. • Mostly occurs in overcrowding place like school, barracks, refugee. • Incidence is also greater in the low socio-economic groups living poor housing conditions EPIDEMIOLOGICAL FEATURES CONT.. 7/14/2017 19DISEASE PRESENTATION
 Meningococcal disease is found worldwide, with the highest incidence of disease found in the ‘meningitis belt’ of sub-Saharan Africa. In this region, major epidemics occur every 5 to 12 years with attack rates reaching 1,000 cases per 100,000 population. Other regions of the world experience lower overall rates of disease and occasional outbreaks, with annual attack rates of around 0.3 to 3 per 100,000 population.  In the meningitis belt, serogroup A has historically accounted for 90% of meningococcal disease cases and the majority of large-scale epidemics. Starting in 2010, a monovalent serogroup A meningococcal conjugate vaccine (MenAfriVac™) has been progressively rolled out through mass vaccination campaigns of 1 through 29 year olds. This occurred in 16 of the 26 target countries as of December 2015, with introduction of the vaccine into the routine immunization program for children ongoing. Following vaccine introduction, epidemics due to serogroup A have been eliminated in vaccination areas, and recent epidemics have been primarily due to serogroups C and W. Serogroup X outbreaks have also been previously reported in this region. . 7/14/2017 20DISEASE PRESENTATION
 While all the risk factors for meningococcal disease outbreaks in Africa are not understood, dry and dusty conditions during the dry season between December to June, along with immunological susceptibility of the population, travel and large population displacements, and crowded living conditions create favorable conditions for meningococcal disease epidemics 7/14/2017 21DISEASE PRESENTATION
 In Europe, the Americas, and Australia, serogroups B, C, and Y together account for a large majority of cases, though increasing numbers of serogroup W have been observed in some areas. In temperate regions the number of cases increases in winter and spring. The annual Hajj pilgrimage has also been associated with outbreaks of meningococcal disease due to serogroups A and W. 7/14/2017 22DISEASE PRESENTATION
 As of 19 March 2017 (epidemiological week 11), a total of 1407 suspected cases of meningitis and 211 deaths (case fatality rate: 15%) have been reported from 40 local government areas (LGAs) in five states of Nigeria since December 2016.  Zamfara, Katsina and Sokoto account for 89% of these cases. Twenty-six LGAs from all five states reported 361 cases in epidemiological week 11 alone.  Twenty-two wards in 15 LGAs have crossed the epidemic threshold. Three of these LGAs share borders with Niger. NmC is the predominant serotype in this outbreak.
 In 1985 Bhutan was also hit by meningitis and 247 cases with 41 deaths were reported between September 1985 and March 1986. During 1982-1984 1475 cases occurred in Kathmandu valley, Nepal with highest mortality and morbidity in children less than one year of age. 7/14/2017 24DISEASE PRESENTATION
 Meningococcal meningitis occurs in small clusters throughout the world with seasonal variation and accounts for a variable proportion of epidemic bacterial meningitis.  The largest burden of meningococcal disease occurs in an area of sub- Saharan Africa known as the meningitis belt, which stretches from Senegal in the west to Ethiopia in the east. During the dry season between December to June, dust winds, cold nights and upper respiratory tract infections combine to damage the nasopharyngeal mucosa, increasing the risk of meningococcal disease. At the same time, transmission of N. meningitidis may be facilitated by overcrowded housing and by large population displacements at the regional level due to pilgrimages and traditional markets. This combination of factors explains the large epidemics which occur during the dry season in the meningitis belt. 7/14/2017 25DISEASE PRESENTATION
 Since 29 March 2005, 111 cases of meningococcal disease have been reported in Delhi till 10 am on 6 May 2005. To date 15 deaths have been reported. Majority of cases and all deaths have occurred in young adult population. The National Institute of Communicable Diseases (NICD) has demonstrated the presence of Neisseria meningitidis serogroup A in cerebrospinal fluid obtained from five cases. Most cases have been reported from Old Delhi.  The national authorities have established a coordination mechanism and an experts group to provide support in investigation, adaptation of guidelines and tools, response and to regularly review the disease situation as well as to provide advice on appropriate strategies. This group is comprised of MoHFW, Municipal Corporation of Delhi (MCD), New Delhi Municipal Committee (NDMC), Hospitals, the National Institute of Communicable Diseases (NICD), WHO and other relevant institutions. This meeting is chaired by the Director General of Health Services (DGHS), Union Ministry of Health and Family Welfare.  . 7/14/2017 26DISEASE PRESENTATION
 Surveillance for early detection of cases, case management and prevention of spread of the disease has been stepped up. A 24- hour control room is established in NICD. Technical guidelines are being distributed. A Newsletter (CD Alert) focusing on meningococcal disease is being made available to physicians. Media briefs are regularly released. Chemoprophylaxis of close contacts and vaccination of high-risk population groups is ongoing. Health professionals and workers are being oriented on prevention, appropriate case management and infection control practices.  WHO is working closely with the national authorities and providing technical support to the health authorities in the form of guidelines and tools, in monitoring of the situation, and epidemiological investigations. WHO is a member of the experts’ group chaired by DGHS 7/14/2017 27DISEASE PRESENTATION
National Health Profile , India 2006-2015, Central Bureau of Health Intelligence. Available at http://cbhidghs.nic.in Meningococcal Meningitis Cases & Deaths in India
Meningococcal Meningitis (2006-2014) 9 years state wise data National Health Profile , India 2006-2015, Central Bureau of Health Intelligence. Available at http://cbhidghs.nic.in • >45,000 cases reported in India • West Bengal (East) & Andhra Pradesh (South) together accounts for 55% of all cases *states/UT with >100 cases in atleast one year from 2006 to 2014 *Bihar, Jharkhand, Assam & Chandigarh: Incomplete data Epidem ic 2005- 2008 Epidem ic 2008 Epidem ic 2009 13943 6391 4435 3681 2597
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MODES OF TRANSMISSION • Disease is spread from person to person. • The bacteria are spread by exchanging respiratory and throat secretions (saliva or spit) during close (for example, coughing or kissing) or lengthy contact. • Close contact like living same household, roommates, or anyone with direct contact with a patient's oral secretions INCUBATION PERIOD • 3 - 4 days with a range of 2 to 10 days. 7/14/2017 31DISEASE PRESENTATION
• Acute onset (within several hrs to 2 days) of intense headache, high fever, nausea, vomiting, photophobia, and stiff neck. • In infants and young children there is a slower onset of signs and symptoms with nonspecific symptoms and neck stiffness may be absent. • Seizures occur in 40% of children with meningitis. • Irritability and projectile vomiting may be the presenting features. 7/14/2017 32DISEASE PRESENTATION
 A more severe form of disease is meningococcal septicaemia, characterized by a haemorrhagic skin rash which usually indicates disease progression and rapid circulatory collapse  The Waterhouse - Friderichsen syndrome may develop in 10 - 20% of children with meningococcal infection, characterized by large petechial haemorrhages in the skin & mucous membranes, fever, septic shock  Even when the disease is diagnosed early and adequate therapy instituted, 5% to 10% of patients die, typically within 24 - 48 hours of onset of symptoms.  Bacterial meningitis may result in brain damage, hearing loss or learning disability in 10 to 20% of survivors CLINICAL FEATURES CONT.. 7/14/2017 33DISEASE PRESENTATION
 The diagnosis is supported or confirmed by growing the bacteria from specimens of spinal fluid or blood, by agglutination tests or by polymerase chain reaction PCR). Lumbar puncture to collect sample of cerebrospinal fluid 7/14/2017 34DISEASE PRESENTATION
• Viral meningo encephalitis: Herpes Simplex virus CSF: normal glucose and lymphocytosis • Rickettsial disease  fever, headache, nausea and vomiting Rash in 96 hrs • Focal suppurative CNS infection  subdural and epidural empyema Brain abscess • Viral Meningitis -ce of bacteria in CSF Cold runny nose, diarrhoea, vomiting, Generally 7-10 days 7/14/2017 35DISEASE PRESENTATION
 General poor feeling  Sudden high fever  Severe, persistent headache  Neck stiffness  Nausea or vomiting  Discomfort in bright lights  Drowsiness or difficulty awakening  Joint pain  Confusion or other mental changes 7/14/2017 36DISEASE PRESENTATION
• CASES : Antibiotics are started during the first two days of illness. – Drugs : Penicillin – for allergic patients Ceftriaxone , cephalosporins • CARRIERS - Rifampicin • CONTACT : Antibiotics are given to them who are close contact of person with confirmed this diseases • Mass Chemoprophylaxis: Mass treatment causes an immediate drop in the incidence rate of meningitis and in the proportion of carries. The efficacy of this preventive measure depends to a large extent of population coverage. Drugs : Ciprofloxacin, minocycline, spiramycin and ceftriaxone 7/14/2017 37DISEASE PRESENTATION
VACCINE : • At present two types of meningococcal vaccines are licensed 1.meningococcal polysaccharide vaccines : – Available are bivalent ( A,C ), trivalent (A,C,W135) and quadrivalent (A, C,W135 and Y) – single dose to person >2 years old subcutaneously . 2. meningococcal polysaccharide-protein conjugate vaccines : – Available are monovalent ( A or C ) or quadrivalent (A, C,W135 and Y) – Monovalent Men A should be given as single dose to 1-29 years old – Monovalent Men C should be given as single dose for children aged >12 months, teenagers and adults . Children 2- 11 months of age require 2 dose administration at an interval of at least 2 moths and a booster about a year there after. – Quardrivalent vaccines are administered as a single dose to individuals aged >2 years. 7/14/2017 38DISEASE PRESENTATION
 There are 3 types of vaccines available.  Polysaccharide vaccines have been available to prevent the disease for over 30 years. Meningococcal polysaccharide vaccines are available in either bivalent (groups A and C), trivalent (groups A, C and W), or tetravalent (groups A, C, Y and W) forms to control the disease.  For group B, polysaccharide vaccines cannot be developed, due to antigenic mimicry with polysaccharide in human neurologic tissues. The first vaccine against NmB, made from a combination of 4 protein components, was released in 2014.  Since 1999, meningococcal conjugate vaccines against group C have been available and widely used. Tetravalent A, C, Y and W conjugate vaccines have been licensed since 2005 for use in children and adults in Canada, the United States of America, and Europe. 7/14/2017 39DISEASE PRESENTATION
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WHO and partners including National Primary Health Care Development Authority, UNICEF, Nigeria Field Epidemiology and Laboratory Training Program, eHealth Africa, Médecins Sans Frontières, Rotary International, Nigeria Centre for Disease Control, and Gavi, the Vaccine Alliance (Gavi) are providing support to this outbreak.*  The following measures are being implemented:  Nigeria Centre for Disease Control, with support from the WHO, is taking the overall lead in coordinating the response at the national level.  Daily coordination meetings are being held at the state and LGA levels.  The rapid response teams are conducting active case finding, performing lumbar puncture of suspect cases and training local staff on case management. .
 Case management is being carried out at the public health centres at the LGA level.  19 600 persons were vaccinated with the meningococcal ACWY vaccine in Gora ward in Zamfara state.  500 000 doses of Gavi-supported meningococcal AC PS vaccines and injection supplies were approved by the International Coordination Group (ICG) for use in Zamfara State and arrived on 27 March 2017.  Katsina state is preparing an ICG request for submission 7/14/2017DISEASE PRESENTATION 42
 Meningococcal disease is endemic in Delhi and sporadic cases of meningococcal meningitis have been occurring in Delhi in previous years. In addition, outbreaks of meningococcal meningitis in and around Delhi, India have been documented during 1966 and 1985. During 1966, 616 cases of meningitis were reported with case- fatality rate of 20.9%. The highest proportion of cases and deaths occurred in age group less than 1 year followed by that in 1-4 years. The male to female ratio was almost 3:1. Because of non-availability of reagents, grouping of N.meningitides could not be performed.  The outbreak in 1985 was bigger in magnitude, both in terms of cases and the geographical area affected. 6133 cases with 799 deaths (13%) were reported. The male to female ratio of cases was 3:1. All the isolates of N. meningitides belonged to subgroup A.  Isolated cases of meningococcal meningitis during 1985 were also reported from several other parts of India namely Haryana, Uttar Pradesh, Rajasthan, Sikkim, Gujarat, Jammu & Kashmir, West Bengal, Chandigarh, Kerala and Orissa. 7/14/2017 43DISEASE PRESENTATION
• Patients with meningococcal meningitis may develop cranial nerve palsies, cortical venous thrombophlebitis, and cerebral edema. • Children may develop subdural effusions. • Permanent sequelae can include mental retardation, deafness, and hemiparesis. • The major long-term morbidity of fulminant meningococcemia is the loss of skin, limbs, or digits that results from ischemic necrosis and infarction. 7/14/2017 44DISEASE PRESENTATION
 Harrisons internal medicine  K. Park Text book of social medicine  www.accessmedicine.mhmedical.com  www.patients.com  www.cdc.com  www.WHO.com/meningococcal meningitis 7/14/2017 45DISEASE PRESENTATION
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