definition, history, problem statement, pathogenesis , clinical feactures and management of meningococcal meningitis.

2. ⦁ 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
DISEASE PRESENTATION 7/14/2017 2

3. ⦁ 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 theAserogroup has declined dramatically.
DISEASE PRESENTATION 7/14/2017 3

4. ⦁ 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 theAfrican belt.
DISEASE PRESENTATION 7/14/2017 4

5. DISEASE PRESENTATION 7/14/2017 5

6. • Meningitis is a disease
DISEASE PRESENTATION 7/14/2017 6
the
of the
caused by
inflammation
meninges.
• The inflammation is
an
usually caused by
infection of the fluid
surrounding the brain
and spinal cord.

7. ⦁ 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.
DISEASE PRESENTATION 7/14/2017 7

8. • BACTERIALMENINGITIS
Bacteria, like Neisseria meningitidis and Streptococcus
pneumoniae
• VIRALMENINGITIS
caused by viruses, like enteroviruses, arboviruses and
herpes simplex viruses. Meningitis
• FUNGALMENINGITIS
caused by fungi like Cryptococcus and Histoplasma and
DISEASE PRESENTATION 7/14/2017 8

9. • 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.
DISEASE PRESENTATION 7/14/2017 9

10. DISEASE PRESENTATION 7/14/2017 10

11. • 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)
DISEASE PRESENTATION 7/14/2017 11

12. ⦁ 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
DISEASE PRESENTATION 7/14/2017 12

13. • 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.
DISEASE PRESENTATION 7/14/2017 13

14. ⦁ 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 asAfrican 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.
DISEASE PRESENTATION 7/14/2017 14

15. • 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, SaudiArabia, and SouthAfrica.
• 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-SaharanAfrica.
• During the 2014 epidemic season, 19 African countries implementing
enhanced surveillance reported 11908 suspected cases including 1146
deaths.
DISEASE PRESENTATION 7/14/2017 15

16. ⦁ 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 inAP i.e 397 cases with 27
deaths.
DISEASE PRESENTATION 7/14/2017 16

17. 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
DISEASE PRESENTATION 7/14/2017 17

18. 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.
DISEASE PRESENTATION 7/14/2017 18
EPIDEMIOLOGICAL FEATURES CONT..

19. IMMUNITY :
• All the age group are susceptible. Younger group are more susceptible
as their antibodies are lower.
DISEASE PRESENTATION 7/14/2017 19
• Immunity is acquired by subclinical infection
diseases or vaccination.
• Infant derive passive immunity from the mothers
(mostly), clinical
ENVIRONMENTALFACTORS
• 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..

20. ⦁ 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.
.
DISEASE PRESENTATION 7/14/2017 20

21. ⦁ 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
DISEASE PRESENTATION 7/14/2017 21

22. ⦁ 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
Aand W.
DISEASE PRESENTATION 7/14/2017 22

23. ⦁ 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.

24. ⦁ 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.
DISEASE PRESENTATION 7/14/2017 24

25. ⦁ 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.
DISEASE PRESENTATION 7/14/2017 25

26. ⦁ 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.
⦁ .
DISEASE PRESENTATION 7/14/2017 26

27. ⦁ 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
DISEASE PRESENTATION 7/14/2017 27

28. National Health Profile , India 2006-2015, Cent Bureau of Health Intelligence. Available at http://cbhidghs.nic.in
Meningococcal Meningitis
Cases & Deaths in India

29. Meningococcal Meningitis
National Health Profile , India 2006-2015, Centr Bureau of Health Intelligence. Available at http://cbhidghs.nic.in
*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
(2006-2014) 9 years state wise data
13943
• >45,000 cases reported in India
• West Bengal (East) & Andhra Pradesh (South)
together accounts for 55% of all cases
6391
4435
3681
2597

30. DISEASE PRESENTATION 7/14/2017 30

31. 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.
DISEASE PRESENTATION 7/14/2017 31

32. • 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.
DISEASE PRESENTATION 7/14/2017 32

33. ⦁ 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..
DISEASE PRESENTATION 7/14/2017 33

34. ⦁ The diagnosis is supported or
confirmed by
bacteria from
spinal fluid
growing the
specimens of
or blood, by
or by
tests
chain reaction
agglutination
polymerase
PCR).
Lumbar puncture to collect
sample of cerebrospinal fluid
DISEASE PRESENTATION 7/14/2017 34

35. • 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
DISEASE PRESENTATION 7/14/2017 35

36. ⦁ 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
DISEASE PRESENTATION 7/14/2017 36

37. • 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
DISEASE PRESENTATION 7/14/2017 37

38. 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 (Aor C ) or quadrivalent (A, C,W135 and Y)
– Monovalent MenAshould 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.
DISEASE PRESENTATION 7/14/2017 38

39. ⦁ 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 (groupsA, 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 ofAmerica, and Europe.
DISEASE PRESENTATION 7/14/2017 39

40. DISEASE PRESENTATION 7/14/2017 40

41. 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.
.

42. ⦁ 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
DISEASE PRESENTATION 7/14/2017 42

43. ⦁ 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 subgroupA.
⦁ 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.
DISEASE PRESENTATION 7/14/2017 43

44. • 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.
DISEASE PRESENTATION 7/14/2017 44

45. ⦁ 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
DISEASE PRESENTATION 7/14/2017 45

46. DISEASE PRESENTATION 7/14/2017 46