20221

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  • Author profile :-After medical graduation, worked for 17 years in the field as primary care physician in primary health centres, area hospitals, mobile medical units, cholera combat team, filarial control project, casualty department, divisional secondary care hospitals Then completed post graduation in public health medicine/preventive &social medicine &epidemiology and teaching medical graduates and post graduates, nursing students, physiotherapy students, primary care personnel for the last 15 years. At present ,working as Professor & Head of the department of Community medicine & Epidemiology contributing to the cause of epidemiological spread and growth in India as Indian super course epidemiology developer . Other TEN super course lectures of mine can be accessed at www. pitt.edu/~super1/faculty/lecturers/htm
  • JAUNDICE AND ABDOMINAL DISTENSION MAY BE PRESENT NO NECK RIGIDITY IRREGULAR BREETHING IN SOME CASES
  • SPECIFIC TREATMENT FOR 10 DAYS : IV PENICILLIN IS STILL THE DRUG OF CHOICE FOR FEW PHYSICIANS.
  • INCUBATION PERIOD=2-3 DAYS PERIOD OF COMMUNICABILITY= TILL MENINGOCOCCI ARE PRESENT IN PATIENT’S SECRETIONS
  • Optimum growth conditions:- moist environment of 30-35 degrees c 5-10% carbon dioxide atmosphere It is - Oxidase +VE and Ferments glucose and maltose but not sucrose. NO ANIMAL RESERVOIR NO INTERMEDIARY VECTOR.
  • CLOSE RELATIONSHIP BETWEEN THE CARRIER STATE OF THE POPULATION AND ORIGIN, PROGRESS AND DECLINE OF EPIDEMIC WAS RECOGNIZED. HOWEVER, BEHAVIOR OF CARRIER STATE IS ANAMOLOUS AND NO PREDICTION CAN BE MADE BASING ON THE CARRIER STATE.OUT- BREAKS CAN OCCUR EVEN WITH LOW CARRIER RATE <25%
  • DURATION- Good antibody levels are achieved within 10-15 days Protection lasts for 3 years. A & C decline markedly after the first 3 years of vaccination . Antibody decline is more rapid in infants and children SIDE EFFECTS mild and infrequent localized erythema transient fever Revaccinations :- children under 4 years of age who were first immunized Stability:- Shelf life at 2-8 0 c = 2 years After reconstitution = 5-6 hours
  • 5. NO ROLE OF VACCINATION IN ESTABLISHED NASOPHARYNGEAL CARRIERS OF MENINGO COCCI 6. ITS NON PRODUCTION IN THE COUNTRY 7. COST FACTOR
  • Mass vaccination not advised as :- wider age group is involved not effective in 2 year old cannot reduce nasopharyngeal carrier state requires frequent booster doses
  • 20221

    1. 1. 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 [email_address]
    2. 2. PART-II CLINICAL DISEASE, EPIDEMIOLOGY AND CONTROL
    3. 4. DEFINITION <ul><li>IT IS A PYOGENIC INFECTION OF </li></ul><ul><li>MEMBRANES COVERING THE BRAIN </li></ul><ul><li>AND SPINAL CORD ( DURA, PIA AND </li></ul><ul><li>ARACNOID MEMBRANES) BY </li></ul><ul><li>MENIINGO-COCCI </li></ul><ul><li>ALSO CALLED CEREBROSPINAL FEVER </li></ul>
    4. 5. CLINICAL PRESENTATIONS <ul><li>RESTRICTED TO NASOPHARYNX AS ASYMPTOMATIC CASES OR ONLY WITH LOCAL SYMPTOMS </li></ul><ul><li>INVASIVE WITH ACUTELY ILL SEPTICEMIC AND TOXIC </li></ul><ul><li>MENINGEAL </li></ul>
    5. 6. CLINICAL PICTURE IN THE NEWBORN <ul><li>MINIMAL AND VARIABLE, HENCE DIAGNOSIS DIFFICULT </li></ul><ul><li>SLUGGISH, LETHARGIC WITH UNUSUAL GAZE </li></ul><ul><li>DOES NOT TAKE FEED WELL , MAY VOMIT </li></ul><ul><li>HIGH PITCHED CRY AND CONVULSIONS </li></ul><ul><li>HYPOTHERMIA SEEN USUALLY , FEVER MAY BE THERE </li></ul><ul><li>TENSE AND BULGING ANTERIOR FONTANELLAE VERY USUAL </li></ul>
    6. 7. CLINICAL PICTURE IN PRESCHOOL & SCHOOL CHILD <ul><li>WIDE SPECTRUM OF SIGNS & SYMPTOMS IN THIS AGE GROUP AND MORE OBVIOUS </li></ul><ul><li>MODERATE TO HIGH FEVER </li></ul><ul><li>HEADACHE, VOMITING, PHOTOPHOBIA, CONVULSIONS, </li></ul><ul><li>NECK STIFFNESS, </li></ul><ul><li>NEUROLOGICAL IRRITATION </li></ul><ul><li>SKIN RASHES </li></ul>
    7. 8. CLINICAL PICTURE IN < 2 YEAR OLD <ul><li>CLASSICAL SIGNS MAY NOT BE PRESENT BUT HIGH DEGREE OF SUSPICION WHEN THE FOLLOWING PICTURE IS SEEN </li></ul><ul><li>FEVER COMMON </li></ul><ul><li>MACULOPAPULAR PETECHIAL RASH IN </li></ul><ul><li>HALF OF THE CASES </li></ul><ul><li>REFUSAL OF FEEDS </li></ul><ul><li>VOMITINGS, </li></ul><ul><li>ALTERED SENSORIUM </li></ul><ul><li>IRRITABILITY </li></ul><ul><li>BULGING FONTANELLAE </li></ul><ul><li>NEUROLOGICAL DEFICIT (EITHER MONOPLEGIA, HEMIPLEGIA AND SQUINT </li></ul>
    8. 9. CLINICAL PICTURE IN THE ADULT <ul><li>CLEARCUT PICTURE </li></ul><ul><li>FEVER, INTENSE HEADACHE </li></ul><ul><li>VOMITING, PHOTOPHOBIA, </li></ul><ul><li>NECKPAIN AND STIFFNESS </li></ul><ul><li>SIGNS OF MENINGEAL IRRITATION </li></ul><ul><li>AND ALTERED SENSORIUM </li></ul><ul><li>SKIN RASHES </li></ul><ul><li>SIGNS AND SYMPTOMS OF SHOCK </li></ul>
    9. 10. DIFFERENTIAL DIAGNOSIS <ul><li>IN NEONATE: </li></ul><ul><li>SEPTICEMIA, GASTROENTERITIS, BIRTH HYPOXIA, BIRTH TRAUMA, RESPIRATORY INFECTIONS, HYPOGLYCEMIA, METABOLIC DISORDERS CAUSING CONVULSIONS AND KERNICTERUS </li></ul><ul><li>IN OLDER CHILDREN AND ADULTS: </li></ul><ul><li>ENCEPHALITIS, BRAIN ABSCESS, CEREBRAL MALARIA, ASEPTIC MENINGITIS, CARDIOVASCULAR ACCIDENTS, CRYPTOCOCCAL MENINGIT IS AND TUBERCULAR MENINGITIS </li></ul>
    10. 11. DIAGNOSIS <ul><li>MENINGOCOCCI ARE DEMONSTRATED BY LUMBAR PUNCTURE AND EXAMINATION OF CEREBRO SPINAL FLUID (CSF) & CULTURE OF CSF </li></ul><ul><li>BLOOD CULTURE </li></ul><ul><li>CULTURE FROM NASOPHARYNX </li></ul><ul><li>EXAMINATION OF PETECHIAL SKIN LESIONS </li></ul><ul><li>IMMUNOLOGICAL METHODS FOR ANTIBODIES (IFP, ELISA, CIEP) </li></ul>
    11. 12. TREATMENT <ul><li>ISOLATION OR SEPARATION </li></ul><ul><li>ALL PATIENTS NEED HOSPITALIZATION </li></ul><ul><li>SPECIFIC TREATMENT </li></ul><ul><li>- FLUIDS </li></ul><ul><li>- CEFTRIAXONE/CEFOTOXIME </li></ul><ul><li>- AMPICILLIN ( NOT TO BE GIVEN IF </li></ul><ul><li>HYPERSENSITIVE TO PENICILLIN) </li></ul><ul><li>- CHLORAMPHENICOL </li></ul><ul><li>SUPPORTIVE THERAPY: FOR SHOCK AND </li></ul><ul><li>CONVULSIONS </li></ul>
    12. 13. EPIDEMIOLOGICAL INTERACTION AGENT FACTORS HOST FACTORS ENVIRONMENT FACTORS MCM TIME DISRIBUTION PLACE DISTRIBUTION PERSON DISTRIBUTION
    13. 14. THE CAUSATIVE AGENT <ul><li>NEISSERIA MENINGITIDIS </li></ul><ul><li>(MENINGO COCCUS) </li></ul><ul><li>BISCUIT SHAPED GRAM + VE </li></ul><ul><li>DIPLOCOCCUS </li></ul><ul><li>SIZE & SHAPE VARIATION IN OLDER CULTURES DUE TO AUTOLYSIS </li></ul><ul><li>TRANSPARENT ,NON PIGMENTED, NONHEMOLYTIC COLONIES 1-5 MM SIZE </li></ul>
    14. 15. MENINGO COCCI
    15. 16. SERO GROUP TYPING <ul><li>DEPEND UPON THE POLYSACCHARIDE CAPSULE </li></ul><ul><li>NINE SEROLOGICAL GROUPS IDENTIFIED </li></ul><ul><li>A, B, C, D, X , Y, Z , W-135, 29E </li></ul><ul><li>ALL THE SEROGROUPS ARE PATHOGENIC </li></ul><ul><li>BUT A, B, C, Y ARE MOST NEUROVIRULENT </li></ul><ul><li>A AND C ARE MOST EPIDEMOGENIC </li></ul>
    16. 17. MODE OF TRANSMISSION <ul><li>HUMAN CASES AND THE CARRIERS ARE THE ONLY RESERVOIRS </li></ul><ul><li>TRANSMITTED BY DIRECT CONTACT </li></ul><ul><li>(DROPLETS,DISCARGE FROM THE NOSE &THROAT OF THE PERSONS) </li></ul><ul><li>INCUBATION PERIOD = 3-4 DAYS </li></ul><ul><li>PERIOD OF COMMUNICABILITY IS AS LONG AS THE MENINGOCOOCI ARE PRESENT IN DISCARGES FROM NOSE, THROAT AND NASOPHARYNX </li></ul>
    17. 18. PERSON FACTORS <ul><li>POOR NUTRITIONAL STATUS & IMMUNITY </li></ul><ul><li>DRY NASAL MUCOSA </li></ul><ul><li>PHYSICAL EXERTION </li></ul><ul><li>FATIGUE </li></ul><ul><li>CARRIER STATE </li></ul>
    18. 19. AGE PREDILICTION <ul><ul><ul><ul><li>PRIMARILY A CHILD DISEASE </li></ul></ul></ul></ul><ul><ul><ul><ul><li>BUT CAN AFFECT YOUNG </li></ul></ul></ul></ul><ul><ul><ul><ul><li>ADULTS ALSO </li></ul></ul></ul></ul>
    19. 20. SEX PREDILICTION <ul><li>MORE MALES ARE AFFECTED THAN FEMALES </li></ul>
    20. 21. PLACE DISTRIBUTION <ul><li>MCM IS ENDEMIC IN LARGE TOWNS </li></ul><ul><li>MORE COMMONLY IN PEOPLE LIVING IN CROWDED CONDITIONS </li></ul>
    21. 22. TIME DISTRIBUTION <ul><li>GREATEST INCIDENCE IN WINTER AND SPRING </li></ul>
    22. 23. CARRIER STATE <ul><li>TRANSMISSION OCCURS MORE OFTEN FROM CARRIERS RATHER THAN CASES </li></ul><ul><li>BY AND LARGE HIGH CARRIER RATE IS USUALLY ASSOCIATED WITH OUTBREAKS </li></ul>
    23. 24. <ul><li>CONTROL MEASURES </li></ul>
    24. 25. VACCINATION <ul><li>COMPOSITION: 50 MICRO GRAMS OF “A” POLYSACHARIDE, 50 MICRO GRAMS OF “C” POLY SACHARIDE, 1 MG OF LACTOSE. </li></ul><ul><li>DOSE - 0.5 ML OF IRRESPECTIVE OF AGE GIVEN SUBCUTANEOUSLY. </li></ul><ul><li>EFFICACY– SEROGROUP “A’ CLINICAL EFFICACY = 85-95% </li></ul><ul><li>SERO GROUP “A’ INDUCES ANTIBODY RESPONSE IN CHILDREN AS YOUNG AS 3 MONTHS OLD. </li></ul><ul><li>BUT SEROGROUP “C ” DOES NOT INDUCE ANTIBODIES BEFORE 2 YEARS OF AGE. </li></ul><ul><li>SEROGROUP “Y” AND W-135 ARE SAFE AND </li></ul><ul><li>IMMUNOGENIC IN ADULTS AND CHILDREN ABOVE AGE OF 2 YEARS. </li></ul>
    25. 26. VACCINATION LIMITATIONS <ul><li>LIMITED SHELF LIFE AFTER REVACCINATION </li></ul><ul><li>NO VACCINE IS AVAILABLE AGAINST GROUP B </li></ul><ul><li>SHORT INCUBATION PERIOD vis-à-vis MORE TIME TAKEN FOR THE DEVELOPMENT OF IMMUNITY </li></ul><ul><li>4.UNSATISFACTORY RESPONSE VACCINATION UNDER 2 YEARS OF AGE WHICH IS THE HIGHEST SUSCEPTIBLE AGE-GROUP </li></ul>
    26. 27. PRESENT STRATEGY FOR VACCINATION <ul><li>ONLY HIGH RISK PEOPLE (HEATH CARE WORKERS, TRAVELLERS, PEOPLE LIVING IN OVERCROWDED PLACES) AND CLOSE CONTACTS HAVE TO BE VACCINATED. </li></ul>
    27. 28. VACCINATION FOR CONTACTS <ul><li>FORTUNATELY, WE HAVE QUADRIVALENT VACCINES AT PRESENT </li></ul><ul><li>PROTECTION OCCURS ONLY AFTER 14 DAYS OF VACCINATION </li></ul><ul><li>HENCE CHEMOPROPHYLAXIS IS PROVIDED WITH ANTIBIOTICS IN THE MEANTIME </li></ul>
    28. 29. VACCINATION FOLLOWED BY + CHEMOPROPHYLAXIS FOR CLOSE CONTACTS <ul><li>HOUSEHOLD MEMBERS </li></ul><ul><li>DAY-CARE CENTRE CONTACTS </li></ul><ul><li>ANYONE DIRECTLY EXPOSED TO THE PATIENT'S ORAL SECRETIONS OR RESPIRATORY DROPLETS. </li></ul>
    29. 30. CHEMOPROPHYLAXIS FOR CLOSE CONTACTS <ul><li>CIPROFLOXACIN, </li></ul><ul><li>RIFAMPICIN, </li></ul><ul><li>MINOCYCLINE, </li></ul><ul><li>SPIRAMYCN, </li></ul><ul><li>CEFTRIAXIONE </li></ul><ul><li>WITHIN 24 HOURS FOR </li></ul><ul><li>HOUSEHOLD </li></ul><ul><li>CONTACTS </li></ul><ul><li>CLOSE CONTACTS </li></ul><ul><li>HIGH RISK PERSONS </li></ul>WITH
    30. 31. RISK COMMUNICATION <ul><li>THROUGH PUBLIC EDUCATION REGARDING </li></ul><ul><li>RISK FACTORS AND POSSIBLE CONTROL STRATEGIES </li></ul><ul><li>NOTIFICATION OF CASES AT THE EARLIEST </li></ul><ul><li>SURVEILLANCE </li></ul>FOR ACTIVE AND SUSTAINED COMMUNITY PARTICIPATION TO CONTROL THE EPIDEMIC
    31. 32. PUBLIC EDUCATION <ul><li>AVOID OVERCROWDING. </li></ul><ul><li>DO NOT SHARE DRINKING BOTTLES, GLASSES, CIGARETTES, LIPSTICKS OR OTHER ITEMS THAT MAY BE COVERED IN SALIVA. </li></ul><ul><li>AVOID SMOKY AND DUSTY PLACES. </li></ul><ul><li>TEACH CHILDREN NOT TO SHARE CUPS, SOFT DRINK CANS OR SPORTS WATER BOTTLES. </li></ul>

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