17. ANNEXURE D: FACT SHEET FOR HEALTH CARE WORKERS – for general distribution Meningococcal Disease
A rapid review of primary care and public health measures
Introduction
Neisseria meningitidis (the meningococcus) is an important cause of meningitis and septicaemia in children and young adults around the world. Meningococcal disease generally occurs sporadically in small clusters around the world with major epidemics limited to certain geographical areas. Meningococcal disease is caused by Neisseria meningitidis (meningococcus). Serogroups A, B, C, Y and W135 are recognised to cause epidemics. In South Africa cases occur year round with definite seasonal increases in late winter/early spring.
Humans are the only natural host of meningococcus. The transmission of N. meningitidis is directly from person to person by droplet spread. Asymptomatic carriage of meningococcus occurs at a rate of 10% in the general population and up to
25% in young adults. Nasopharyngeal carriage of meningococci is much more common than invasive meningococcal disease. The meningococcus does not survive for any significant period in the environment.
The response to a case or cases should be based on a clear understanding of how the organism spreads, produces disease, the clinical picture it presents, what health care is available and what the appropriate public health response is.
Over 95% of meningococcal cases are sporadic and have no identifiable contact. Nasopharyngeal carriers rather than patients with meningococcal disease are generally the source of new infections. 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 highest in people who live in the same household as a case of meningococcal disease. This is mostly likely to be due to infection spreading in the household from an asymptomatic carrier rather than from the index case. The incubation period is 3-4 days (range 2-10).
Clinical Clues
Early symptoms and signs include malaise, fever and vomiting. Headache, photophobia, drowsiness or confusion, joint pains and a typical haemorrhagic rash of meningococcal septicaemia may develop. A high index of suspicion should always be maintained. Fever and a low blood pressure or slow pulse should heighten the index of suspicion. Early on, the rash may look like rubella or measles. The classic rash is petechial or purpuric in nature and does not fade if you push a drinking glass against it. The rash may be absent.
Patients may present in a comatose state and disease can be very rapidly progressive. In some patients symptoms may be non-specific. Presentation in young infants may include vomiting, pyrexia, irritability and, if still patent, raised anterior fontanelle tension.
The most common serious clinical presentations of meningococcal disease include meningococcal meningitis and meningococcal septicaemia/ meningococcaemia.
Clinical Management
SUSPECTED MENINGOCOCCAL DISEASE IS A MEDICAL EMERGENCY AND TREATMENT SHOULD NOT BE DELAYED.
Wherever possible ceftriaxone or cefotaxime should always be used for empiric therapy for suspected bacterial meningitis. The recommended drug of choice for proven meningococcal septicaemia or meningitis is IV benzyl penicillin for 5-7 days.
Patients with known or suspected meningitis should be isolated at the time of admission in a single bedded ward with standard AND respiratory droplet precautions. These patients may be transferred to a general ward 24-48 hours after receiving adequate treatment with a drug that will reliably eliminate nasopharyngeal carriage [ceftriaxone/ cefotaxime]. Patients on penicillin alone can only be moved from isolation after being given chemoprophylaxis to eradicate nasopharyngeal carriage
Laboratory investigations
Do not delay treatment if a blood culture or CSF specimen cannot be immediately obtained.
Specimens should be kept at room or body temperature and away from direct sunlight. Do not refrigerate specimens
Blood culture:
Blood should be collected, using strict aseptic technique, from all suspected cases in blood culture specimen bottles and sent to the laboratory as quickly as possible. Specimens should if at all possible reach the laboratory within 3-4 hours, but not beyond
24 hours. Ideally two sets of blood cultures should be submitted prior to antibiotic therapy. Even in cases of meningitis, blood cultures are useful for diagnosis. About 1–3 ml of blood is needed in children and 5–10 ml in adults.
Cerebrospinal Fluid CSF:
If meningococcal disease is suspected a lumbar puncture is not indicated in the primary care setting and should be considered on arrival at a hospital.
Lumbar puncture should only be performed where no contraindications exist.
The classical clinical signs (bradycardia, papilloedema or hypertension indicating the presence or absence of raised intracranial pressure in children are notoriously inaccurate and should never be relied upon. A lumbar puncture should never be done in a child if there is any suggestion of an impaired level of consciousness. Adult patients with raised intracranial pressure, suspected focal intracranial pathology or who are immune compromised, should have a brain imaging before lumbar puncture. Contraindications for lumbar puncture include focal intracranial pathology or severe brain swelling on imaging, uncorrected bleeding tendency or a low blood pressure.
Cerebrospinal fluid should be sent for protein, glucose, direct microscopy (cell count and Gram stain) culture and antibiotic susceptibility. Rapid bacterial antigen detection tests should not be used routinely as they are not always reliable. They can be used for specific indications.
Skin scrapings
Skin scrapings/impression smears
Skin scrapings and impression smears for Gram stain from the petechial/purpuric site are not recommended as the test tends to give false positive and false negative results.
Notification
The name and household contact details of a case of the meningococcal disease should be reported immediately by telephone to the Local or District Health Department - for urgent contact follow up. The notification form (GW17/5) should also be completed.
Chemoprophylaxis
Non-pregnant adults: Ciprofloxacin, rifampicin and ceftriaxone are all effective in reducing the nasopharyngeal carriage rate and are therefore recommended for chemoprophylaxis. Ciprofloxacin offers a major advantage in terms of compliance. Ciprofloxacin is an effective drug for prophylaxis and is the drug of choice for non- pregnant adult contacts.
Children: Rifampicin is the drug of choice where it is available and four doses can be supervised. Ciprofloxacin and ceftriaxone are acceptable alternatives. Ceftriaxone is a painful injection (especially in children), which is often given with lignocain to children.
Pregnancy: Ceftriaxone is the first choice in pregnancy.
Management of contacts
Over 95% of cases of meningococcal disease occur in those without any contact with a case. This means the risk of disease even in close contacts is low, however it is slightly higher than the general population.
Chemoprophylaxis should be offered to all close respiratory contacts (defined as people who have had close, prolonged contact with the case), as soon as possible, i.e. preferably within 24 hours after the diagnosis of the index case, but can be effective up to 10 days. It is recommended in the following situations:
(a) Those who have had prolonged close respiratory type contact with 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 the same dormitory, sharing a kitchen where they prepare food together or sharing the same bathroom in a hostel, barracks or residence.
(b) Those who have had transient close contact with a case – only if they have been directly exposed to close coughing or intimate kissing contact with 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.
(c) Index case should also receive prophylaxis to eliminate nasopharyngeal carriage (unless they have already been treated with ceftriaxone/cefotaxime) as soon as they are able to take oral medication.
Prophylaxis is NOT generally indicated 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.)
• Food or drink sharing or similar low level of salivary contact
• All those attending the same social function
• All travellers on the same plane, train, bus, or car
Healthcare workers
Health care workers (HCWs) should avoid exposure to droplets by wearing surgical masks and using a suction which does not ventilate into the room, when carrying out airway procedures (i.e. endotracheal intubations/airway management, or examination of the oropharynx), on all patients with suspected meningococcal septicaemia or meningitis.
Chemoprophylaxis is recommended only for those HCWs who have been in direct contact with droplets of respiratory secretions (i.e. mouth or nose is directly exposed to large particle droplets/ secretions) and who have not used appropriate barrier precautions. General medical or nursing care of cases is not usually an indication for prophylaxis
Chemoprophylaxis: Antibiotic options
One of the following:
Non-pregnant Adults
1. Ciprofloxacin 500mg Single Dose/os.
2. Rifampicin 600mg 12 hourly/os x 4 doses
3. Ceftriaxone 250mg Single Dose Im
Pregnant adults
Ceftriaxone 250mg Single Dose Im
Children
1. Ciprofloxacin 10mg/kg single dose/os
2. Rifampicin 10mg/kg 12 hourly/os x 4 doses
3. < 12 years, 125mg Ceftriaxone single dose Im.
Immunization of contacts
If serogroup A, C W135 or Y has been isolated from a case, polysaccharide quadrivalent vaccine may extend the period of protection for close contacts ≥2 years of age that have already received chemoprophylaxis. The cost of such vaccination is at the person’s own expense.
Chemoprophylaxis must always be given regardless of vaccination status.
Surveillance
All contacts should be advised on the early symptoms and signs and advised to report these promptly.
Managing a cluster of cases
When two or more cases of meningococcal disease occur in any institution, such as a school or military barracks etc. within a 4-week period, and these are due to the same serogroup this should be considered an outbreak and managed accordingly. (See section 13 Management of Outbreaks in the main document).
Adapted with permission from: The Craigavon Infection Control Manual edited by
N Damani/J Keyes.