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