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DEFINITION

UPDATES: a disease caused by Gram negative


Meningococcal Disease aerobic spherical or kidney-shaped
intracellular diplococci called
Neisseria meningitidis
Xenia Jaramillo Fabay, MD, FPPS
Pediatric Infectious Disease Specialist
Baguio General Hospital and Medical Center

BC

EPIDEMIOLOGY* BC
BC
A
Y
Meningococcal disease can occur: BC
BC ACB AB
1. Sporadic cases A
AC A A
1-2/100,000 BC AC A A
A A AC
2. Localized/Institutional A A
BC
community-
community-based BC
BC
3. Large epidemic
10-
10-1,000/100,000 BC

* Averila, Thaddeus, The Menace of Meningococcemia, 2005


EPIDEMIOLOGY*
1996-
1996-97: largest epidemic
>300,000 cases with 30,000 deaths in Africa in
caused by Serogroup A
Europe*
Europe*: C & B outbreaks
2000*
2000*: W-
W-135 occurred in Muslim pilgrimage
to Mecca: Hajj
2002*
2002*: W-
W-135 occurred in Africa
2004 : Africa
2005 : Philippines and India
2006-
2006-2007 : Africa
outbreaks of A,B,C,W-
A,B,C,W-135 in Africa**
Africa**
* Gatchalian, S. Meningococcal Disease, Baguio City, 2005
** Coulson,GB,et.al.,Meningococcal disease in South Africa, 1999-2002, Emerging Infectious
Diseases, February 2007

BC
EPIDEMIOLOGY*
BC Y
C BC Philippines:
Philippines: Meningococcal Disease
Y A
YAW135
BC Outbreak
C BC Y
ACB AB
AA 1988: Mindanao - 36 cases
W135
A BA A
AC serogroup B
BC AC A A A A
W135 AA
AB C A AC 1989: Negros Occidental - 10 cases
A A

BC
BC serogroup A
BC San Lazaro Hospital
2002 = 30 cases
BC 2003 = 39 cases
2004 = 32 cases
* Averila, Thaddeus, The Menace of Meningococcemia, 2005
Meningococcal Disease Cases,
Cordillera Administrative Region
(1990-
(1990-2003)*
2003)*
30 29

25
c 20
a
s 15
e
s 10
2
5 0 0 0 1 0 0 0 0 0 0 0
0
0

90

91

92

93

94

95

96

97

98

99

00

01

02

03
19

19

19

19

19

19

19

19

19

19

20

20

20

20
* Incidence of Meningococcemia, RESU Report, DOH, CHD-CAR

Meningococcal Disease Cases, Meningococcal Disease Cases,


Cordillera Administrative Region, (2004-
(2004-2007)*
2007)* Cordillera Administrative Region, (1990-
(1990-2007)*
2007)*
400
400 376
376
350
350
300
300
C 250
250 a
200 s 200
e
150 s 150
57
100 36 100
57
13 4 29 36
50 50 0 0 1 0 0 2 0 0 0 0 0 13
0 4
0 0
2004 2005 2006 2007 'Feb 04,
91

92

93

94

95

96

97

98

99

00

01

02

03

04

05

06

Fe 007

8
'0
19

19

19

19

19

19

19

19

19

20

20

20

20

20

20

20

2008
2
4,
b

* Incidence of Meningococcemia, RESU Report, DOH, CHD-CAR


* Incidence of Meningococcemia, RESU Report, DOH, CHD-CAR
MENINGOCOCCAL
PATHOPHYSIOLOGY DISEASE PATHOGENESIS
Invasion/infection:
– bacterial pili important for organism colonizes nasopharynx
attachment to epithelial cells in some persons organism
– exact determinants of
invasion unknown invades bloodstream and causes
infection at distant site
Natural immunity:
– antibodies directed against antecedent URI may be a
capsular polysaccharides
and outer membrane contributing factor
proteins

CONTRIBUTING PATHOPHYSIOLOGY*
FACTORS* mucous membrane carriage or infection
(primarily oropharynx)

blood stream invasion


influenzae virus, Mycoplasma hominis, (meningococcemia)

Mycoplasma pneumoniae*
pneumoniae*
climate: late winter, drought, dust storm transient
bacteremia
chronic
meningococcemi
invasion of
meninges,
fulminant
meningococcemia
with no a (rare) purulent (rapid spread of
respiratory infection: cough, sore throat, sequelae leptomeningitis, purpura, vascular
encephalitis. collapse)
colds: 18%**
18%** Other organs that
may be affected:
diarrhea: 17%**
17%** skin, joints,
pericardium,
heart, eyes,
adrenal glands
* Control of Epidemic Meningococcal Disease, WHO Practical Guidelines,
Guidelines, 1998 * Gorbach, S., et. al., Infectious Diseases, Third Edition, 2004
PATHOPHYSIOLOGY* CLINICAL
The two common presentations of MANIFESTATIONS
meningococcal infections are: CLINICAL MENINGOCOCCAL MENINGOCOCCAL
FEATURES MENINGITIS SEPTICAEMIA
– meningococcal meningitis: infection of Signs & Symptoms - fever - fever
- headache - rash: petechiae,
the membranes surrounding the brain & - stiff neck purpura ( fulminans
spinal cord - photophobia purpura)
- vomiting - low blood pressure
– meningococcemia: infection of the blood - bulging fontanelle in
children < 1 year
- altered mental status
- seizures
- coma
Appearance of CSF cloudy cloudy or clear
An infected individual may have one or Response to antibiotics good poor
(up to 10% may die (30% may die within 12 to
both clinical manifestations despite correct diagnosis 48 hours)
& treatment)
* Gorbach, S, et. al., Infectious Diseases, Third Edition, 2004
% during epidemic 80-90% of patients 10-20% of patients

CLINICAL CLINICAL
MANIFESTATIONS MANIFESTATIONS
Padilla,CB, et.al. Dacuycuy, F, et.al.
Meningococcemia Outbreak, Profile of Pediatric Patients with
the BGHMC Experience Meningococcal Disease at a Local
– fever: 83% headache: 24% Tertiary Hospital
– rashes: 58.9% body malaise: 20% – fever: 98.88% body malaise: 11.11%
– vomiting: 41% seizure: 11.5% – vomiting: 50% diarrhea: 8.88%
– headache: 32.22% neck pain: 8.88%
CLINICAL CLINICAL
MANIFESTATIONS MANIFESTATIONS
Aswat, RP, et.al.,
Fabay, XJ
Clinical Profile of Adult Menigococcal
Disease Patients Admitted at BGHMC Terror in the Air: Meningococcal
from November 2004 to June 2006 Disease Outbreak, the Philippine
– fever: 100% headache: 72.72% Experience
– purpuric rashes: 46.46% fever: 100%
- fever:
– myalgia and/or arthralgia: 40.40%
- rashes: 90%
- vomiting: 57%
- headache: 42%

TRANSMISSION
the causative agent, Neisseria
meningitidis is spread through:
– person to person
– droplets (infected person sneezing
or coughing)
– close contact
Close Contacts of Patients with Risk Factors for Invasive
Meningococcal Disease Meningococcal Disease
household members Host Factors
anyone especially hospital staff lack of bactericidal antibody to
exposed to respiratory secretions of acquired strain
infected individuals age: < 1 year or 15-
15-24 years of
individuals who have sat directly next age
to an index case on a prolonged travel household crowding
of more than 8 hours cigarette smoking, active or
passive

PROGNOSIS* PROGNOSIS*
mortality rate : 5-19%
case fatality rate: 21.2%*
21.2%*
endemic disease due to N. meningitidis:
meningitidis:
1 - 3 cases per 100,000 population in case fatality rate : 32.5%**
32.5%**
developed countries Meningococcemia: 26.9%
10 - 25 cases per 100,000 population in Meningococcal meningitis: 3.8%
developing countries
Meningococcemia
with meningitis: 1.2%
during epidemics:
epidemics:
4 - 1000 per 100,000 population *MMWR, RESU, DOH,CHD-CAR
**Padilla,CB, et.al. Meningococcemia Outbreak, the BGHMC Experience
* Gatchalian, S. Meningococcal Disease, Baguio City, 2005
PROGNOSIS* PROGNOSIS*
case fatality rate: 33.33%* case fatality rate: 25.25%*
25.25%*
33.33%*
Meningococcemia: 27 deaths Meningococcemia: 28.00%
Meningococcal meningitis: 1 Meningococcal meningitis:
no death
Meningococcemia with meningitis: 2
case fatality rate: 32%** Meningococcemia
32%**
with meningitis: 72.00%
* Dacuycuy, et.al., Profile of Pediatric Patients with Meningococcal
Meningococcal Disease in a Local
Tertiary Hospital * Aswat, RP, et.al. Clinical Profile of Adult Meningococcal Disease Patients Admitted
** Fabay, XJ, Terror in the Air: Meningococcal Disease Outbreak,
Outbreak, the Philippine at BGHMC from November 2004 to June 2006
Experience

COMPLICATIONS COMPLICATIONS
& SEQUELAE & SEQUELAE*
10-
10-15% pure musculoskeletal
deafness, ataxia, seizures, blindness, complication : 2.22%
musculoskeletal with psychotic
paresis of cranial nerves 3,4,6,7
complication: 1.11%
hemi or quadriparesis, obstructive
hydrocephalus
arthritis, myocarditis, pericarditis,
pneumonia, endophthalmitis, DIC
* Dacuycuy,F,et.al. Profile of Pediatric Patients with Meningococcal Disease at a Local Tertiary Hospital
COMPLICATIONS
& SEQUELAE*
DIAGNOSIS
perioral vesicular lesions: 11.11%
UGIB: 4.04% culture and sensitivity
pneumonia: 4.04% blood, CSF, skin lesions
arthritis: 4.04% CSF analysis
hematuria: 2.02% Gram’s stain
epistaxis: 2.02% rapid antigen detection test
unilateral ptosis: 2.02% PCR analysis
* Aswat, RP, et.al. Clinical Profile of Adult Meningococcal Disease Patients Admitted
at BGHMC from November 2004 to June 2006

VACCINES
Vaccines against N. meningitidis
serogroup A and C
serogroup A, C, W135 and Y
serogroup C
serogroup B, based on Outer
membrane proteins (OMP)
VACCINES VACCINES
Polysaccharide (MPSV) only a single intramuscular or deep
bivalent subcutaneous injection of 0.5 ml
quadrivalent
unit dose is the same for both
adults and children
Conjugated (MCV)
monovalent
revaccination should be given
bivalent 3 to 5 years after initial
quadrivalent vaccination

VACCINES ANTIBIOTIC
early vaccination:
vaccination: PROPHYLAXIS
> 6 months old even 3 months in Recommended ONLY for close contacts of
certain cases (during epidemics) patients with meningococcal disease
second dose needed 2- 2-3 months after
household members
anyone especially hospital staff
percentage of individuals who exposed to respiratory secretions of
responded (a four-
four-fold or higher infected individuals
increase in the haemagglutination titre) individuals who have sat directly
was 97.9% for polysaccharide A and next to an index case on a
94.8% for the polysaccharide C
prolonged travel of more than 8 hours
ANTIBIOTIC ANTIBIOTIC
PROPHYLAXIS PROPHYLAXIS
personnel who have had intensive Rifampicin:
close contact (e.g. mouth-
mouth-to-
to-mouth 5-10 mg/kg/day q12H x 2 days,
resuscitation, endotracheal intubation, maximum of 600mg/day
endotracheal tube management)
management) with a
patient with meningococcal disease Ceftriaxone:
before administration of antibiotics
125-
125-250 mg/day IM SD
without the use of proper precautions
IB*
Category IB* Ciprofloxacin:
* Bolyard,EA, etal. Guidelines for Infection control in Healthcare Personnel,
500 mg orally SD
1998. CDC Personnel Health Guidelines. p. 333.

Indication for Standard and Isolation STANDARD


Precautions*
Precautions*
Standard All patients PRECAUTIONS*
hemorrhagic fever such as Ebola,
Ebola, croup
ALL PATIENTS
Contact bronchiolitis, skin infections, cutaneous
infections, Herpes simpex virus, zoster apply when contact is possible with
meningitis with Haemophilus influenza type B or ruptured skin or mucous membranes,
Neiserria meningitidis,
meningitidis, diphtheria, M. blood & all body fluids, secretions, or
Droplet pneumoniae, pertussis, influenza, adenovirus,
pneumoniae, excretions except sweat
mumps, parvovirus B19,
B19, rubella, streptococcal
personal protective equipment
pharyngitis, pneumonia, scarlet fever.
(unsterile)
pulmonary or laryngeal (suspected) tuberculosis,
Airborne measles, varicella, disseminated zoster
* Gordts, B, A Guide to Infection Control in the Hospital 3rd ed, 2004, pp.38-44.
* Gordts, B, A Guide to Infection Control in the Hospital 3rd ed, 2004, pp.38-44.
DROPLET HOSPITAL-BASED
PRECAUTIONS* PREVENTIVE MEASURES
particles >5microns health education, re-orientation
travels <1meter/3feet
standard and droplet precautions
mask is worn if within 1 meter or 3 feet,
limit patient transport isolation procedures
meningitis: Hemophilus influenzae type B, cohorting
N. meningitidis;
meningitidis; diphtheria, M. pneumoniae,
pertussis, influenzae, adenovirus, parvovirus antibiotic prophylaxis
B19, streptococcal pharyngitis, pneumonia, immunization
scarlet fever
post-mortem care
* Gordts, B, A Guide to Infection Control in the Hospital 3rd ed, 2004, pp.38-44.

POSTMORTEM CARE*
most of the microorganisms that kill people do
POSTMORTEM CARE*
not survive for long after their host dies use of protective clothing
whether dealing with old burials or with the – examination gloves
recently dead, and regardless of which
infectious agent may be present, the risk of – filter mask/ surgical mask
acquiring infection can be greatly reduced by: – visor/ respiratory protective masks
– covering cuts or lesions with waterproof – apron
dressings – rubber boots
– careful cleansing of any injuries sustained – gowns/coats/overall with hood
during procedures – other protective equipment: safety helmets, safety
– good personal hygiene glasses, work gloves to protect against mechanical
– the use of appropriate protective clothing injuries
* Wenzel, R, et.al. A Guide to Infection Control in the Hospital. 3rd ed. 2004. * Wenzel, R, et.al. A Guide to Infection Control in the Hospital. 3rd ed. 2004.
POSTMORTEM CARE*
While a person is alive, invading
pathogens can multiply and are readily
transmitted, for example by coughing or
sneezing. The patient is a continuing
source of infection. Once the host is dead,
most pathogens stop multiplying and die
rapidly,
rapidly, particularly as decomposition
proceeds, and dispersion of infectious
microbes is unlikely
* Wenzel, R, et.al. A Guide to Infection Control in the Hospital. 3rd ed. 2004.

OTHER OTHER
MEASURES MEASURES
avoid crowded places maintain a healthy lifestyle:
lifestyle: proper
sleep, proper diet and good nutrition,
strengthen your immune system/resistance enough rest, regular exercise
practice good personal hygiene/cough
etiquette (cover nose and/or mouth when individuals with signs and symptoms
sneezing or coughing; wash hands and have a positive history of exposure
to an infected individual should seek
frequently) immediate medical consultation
TREATMENT TREATMENT
Penicillin G Sodium Supportive Measures
250,000-
250,000-400,000 u/kg/day every 4-
4-6 fluids
hours, maximum of 12 million u/day
volume expanders
Alternative Drugs fresh frozen plasma
Chloramphenicol 100mg/kg/day q 6H packed RBC
Cefotaxime 100-
100-200mg/kg/day q 6H steroids
Ceftriaxone 100mg/kg/day q 12H other medications for concomitant
co-
co-morbid illnesses

REFERENCES
Gordts, B, A Guide to Infection Control in the Hospital 3rd ed, 2004, pp.38-
pp.38-44.
Gorbach, S, et. al., Infectious Diseases, Third Edition, 2004
City Epidemiology and Surveillance Unit, City Health Office, Baguio
Baguio City
William Atkinson, et.al., Epidemiology and Prevention of Vaccines
Vaccines-Preventable
Diseases, Center for Disease Control and Prevention, 7th ed., Jan
Jan 2002, page 11
Averila, Thaddeus, The Menace of Meningococcemia, 2005
RESU, DOH-
DOH-CHD, CAR, Update on Meningococcal Infection Cases, Morbidity
Mortality Weekly Report
Nicolas, P, Garnotel, E, Menigococcus Unit, Collaborating Centre for Reference and
Research, France, 2005
Gatchalian, Salvacion, Meningococcemia, 2005
Padilla, CB, et.al, Meningococcemia Outbreak, the BGHMC Experience
Experience
Dacuycuy, FA, et.al, Profile of Pediatric Patients with Meningococcal
Meningococcal Disease at a
Local Tertiary Hospital
Meningococcal Disease, Travelers’
Travelers’ Health: Yellow Book Health Information for
International Travel, 2005-
2005-2006
Meningococcal Disease, Pink book 2006, CDC
Aswat, RP, et.al., Clinical Profile of Adult Meningococcal Disease
Disease Patients Admitted at
BGHMC from November 2004 to June 2006
Emerging Infectious Diseases, CDC, February 2007
Redbook 2006
Meningococcal Disease Census, BGHMC
Wenzel, R, Brewer, T, Butzler, JP. A Guide to Infection Control in the Hospital.
49:257-265. 3rd ed. 2004.
49:257-
Bolyard,EA, e.tal. Guidelines for Infection Control in Healthcare
Healthcare Personnel, 1998.
CDC Personnel Health Guidelines. p. 333.

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