Guideline: Management, Prevention and Control of Meningococcal Disease in South Africa » Public Health Response
 

10. PUBLIC HEALTH RESPONSE

 

Every suspected case of meningococcal disease should prompt an urgent response to include:

  • Immediate telephonic notification to local health authority by health care worker in the facility (nurse or clinician); followed by written notification
  • Rapid investigation of the case
  • Classification of the case according to case definitions (see below)
  • Identification of close contacts for all confirmed and probable cases
  • Provision of required post exposure prophylaxis to close contacts
  • Identification of other cases in same institution or community that may suggest a cluster

 

10.1 Case definitions

 

Classification of cases using the following case definitions will determine the need for public health action. Confirmed and probable cases all require a public health response as outlined below.

10.1.2 Cases requiring public health action 

Confirmed case

Clinical diagnosis of meningitis, septicaemia or other invasive disease (e.g. orbital cellulitis, septic arthritis)*

AND at least one of the following:

  • Neisseria meningitidis isolated from a normally sterile site
  • Gram-negative diplococci in a normally sterile site
  • Meningococcal antigen in blood, CSF
  • Meningococcal DNA in normally sterile site

*Meningococcal conjunctivitis should also be managed as per invasive meningococcal disease

Probable case

Clinical diagnosis of meningitis and/or septicaemia where the public health physician, in consultation with the physician and microbiologist, considers that meningococcal infection is the most likely diagnosis.

NOTE: These definitions should be used by public health personnel in assessing requirements for further public health action. Health care workers are not required to classify cases as above but should rather notify ALL patients in whom a diagnosis of meningococcal disease is being considered. DO NOT WAIT for laboratory confirmation before notifying.

 

10.2 Cases not requiring public health action

 

Possible case

Clinical diagnosis of meningitis or septicaemia or other invasive disease where the doctor or nurse concerned, in consultation with the clinician and microbiologist, considers that diagnoses other than meningococcal disease are at least as likely. This category includes cases that may have been treated with antibiotics but whose probable diagnosis is viral meningitis.

In such cases, prophylaxis for contacts is not indicated.

Infection in non-sterile sites

Isolation of meningococci from sputum or from swabs taken from nasopharynx or genital tract is not by itself an indication for public health action as asymptomatic carriage in the respiratory and genital tract is common. However, when assessed together with other clinical and microbiological parameters, a positive throat swab may increase the index of suspicion of a probable case, especially if the isolate is a virulent strain. Meningococcal pneumonia alone is not an indication for public health action but may carry a low risk of transmission in healthcare settings especially to the immunocompromised. In SA, the majority of cases of meningococcal pneumonia reported to the RMPRU have been accompanied by evidence of invasion in blood or CSF and these would always require public health action. The response to a single case can usually be managed between the hospital staff and the local health department concerned based on the guidelines/ policy available. Consultation with a medical microbiologist and infectious disease specialist is recommended.

Management of contacts of a case requiring public health action

About 97% of cases are sporadic and have no identifiable contact. Meningococcal disease rarely spreads directly from person to person. The disease is the result of a complex interaction of the bacteria, the environment and the host. While the risk even for close contacts of cases is low, it is 400-800 times higher in people who live in the same household as the index case. This is mostly likely to be due to infection spreading in the household from an asymptomatic carrier to another family member rather than from the index case.

The increased risk in household members compared to the general population is thought to be likely due to genetic susceptibility in the family, increased exposure to virulent bacteria and environmental factors such as exposure to tobacco smoke. The risk is highest in the 48 hours after the index case presents. Close surveillance for household and intimate contacts is important so that early signs of possible disease, such as fever, are recognised and treated.

Indications for chemoprophylaxis (Defining close contacts)

The following information is based on published studies of disease incidence and risk. It must be remembered that taking drugs carries a risk of side effects which, although small, can be serious and may be greater than the risk of disease.

Chemoprophylaxis should be offered to close contacts of confirmed/probable cases, irrespective of vaccination status (see case definitions above).

Close contacts requiring prophylaxis include:

  • Those who have had prolonged close contact with respiratory secretions of the case in a household type setting during the seven days before onset of illness. Examples of such contacts would be those living and/or sleeping in the same household, those such as pupils, students, members of the military or police sleeping in the same dormitory or, sharing a kitchen where they prepare food together or sharing the same bathroom in a hostel, barracks or residence.
  • Those who have had transient close contact with a case require prophylaxis only if they have been directly exposed to large droplets or secretions from the respiratory tract within 10 days of a case becoming ill or admitted to hospital. This also applies to health care staff and ambulance or emergency personnel.

Prophylaxis is NOT routinely indicated following a single case for (unless already identified as close contacts as above):

  • All staff and children attending same nursery school or crèche
  • All pupils or students in same school or classroom or tutorial group
  • All work or school colleagues
  • All friends
  • All residents of nursing/residential homes
  • Dry kissing on cheek or mouth (Intimate kissing would normally bring the contact into the respiratory contact category).
  • All individuals attending the same social function
  • All passengers travelling in same plane, train, bus, or car

Household contacts and overnight visitors

Those who live in the same household or are intimate contacts of the index case should all receive chemoprophylaxis. Chemoprophylaxis should be given as early as possible, preferably within 24 hours of identification of a case. It may still be effective if given up to 10 days after the presentation of the index case if delays are unavoidable. Overnight visitors to the home of the index case within 7 days before the onset of illness should also be given prophylaxis.

Educational settings Following a single case, chemoprophylaxis is recommended for close contacts only (see definitions above). This will usually include close friends who may share eating utensils or meet the other criteria for a close contact. Usually this does not mean the whole class, but only selected individuals within the class. It may be more difficult to define a close contact amongst younger children in preschools/crèches but where possible post exposure prophylaxis should be limited to those who meet these criteria. Clusters, even in preschools are rare. The naturally immunizing strains in the nasopharynx which provide protection and may be eradicated by indiscriminate use of chemoprophylaxis.

Workplace

The risk in the workplace is generally even less than in educational settings. Chemoprophylaxis is not recommended except in exceptional circumstances i.e.: individuals meeting the criteria for “close contacts” of the case.

Passengers on public transport

Transient contact such as sitting next to a case before an acute illness occurred, on a bus, train, taxi or aeroplane does not usually pose a special risk and does not justify routine prophylaxis. These situations should be discussed with experts and managed accordingly. Prophylaxis on aeroplanes and other public transport is sometimes given to passengers immediately adjacent, in front and behind the index case, especially if travelling times are prolonged. Passengers should also receive an information leaflet with information regarding signs and symptoms and informed to seek immediate medical attention if they become symptomatic. The degree of contact with the index case will guide decision-making in these cases.

Health care settings

Health care workers should reduce exposure to large particle droplets by wearing surgical masks and using closed suction systems, especially when carrying out mouth and airway procedures, so that chemoprophylaxis is not needed. Health care workers who have had contact with large particle droplets/secretions of patients during procedures such as mouth-to-mouth resuscitation or endotracheal intubation, at the time of hospital admission, should receive chemoprophylaxis.

Health care workers in contact with a patient but not exposed to droplets/secretions do not usually qualify for chemoprophylaxis. A hospital ward is not equivalent to a household setting. Balanced risk assessment should be done in a case of immunocompromised contacts that may be at increased risk for invasive disease such as those who have anatomical or functional asplenia. Such individuals should receive pre-exposure prophylaxis with quadrivalent meningococcal vaccine as well as post exposure chemoprophylaxis when indicated.

It is useful to remind anxious staff, especially those that do not qualify for post exposure prophylaxis, that all drugs carry side effects; and that this risk is likely to be greater than the risk of disease; and that overuse of antibiotics leads to the development of resistance.

Drugs used for chemoprophylaxis

Any of the three possible chemo-prophylactic treatments may be given (Table 3).

 
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