1. Meningococcemia Cmdr. Modesto T. Kapuno, PN (Res) Medical Officer V, City Health Office N aval F orces for S outhern L uzon Rawis, Legazpi City January 21, 2005

2. What is Meningococcal infection? Meningococcal infection is brought by bacteria Neisseria meningitides. The most common form of disease due to meningococcal infection is meningitis and the less common is Meningococcemia.

3. NEISSERIA MENINGITIDIS (MENINGOCOCCUS) Gram Stain - Negative Anaerobic - CO 2 enhances growth Extracellular Features - diplococci - “coffee bean” or “kidney bean” appearance Colonies - small, transparent on chocolate agar

4. Cont. Non-motile Capsule & Glycocalyx - polysaccharide Exotoxins - NONE Endotoxin - Lipooligosaccharide (LOS) –Produces and sheds excessive amounts of LOS endotoxin as membrane fragments into the extracellular space –Stimulates release of cytokines TNF alpha & IL-1 which can lead to hypotension & septic shock

5. Incubation Period: The incubation period is variable, 2-10 days, but usually 3-4 days Infectious Period: An infected person is infectious as long as meningococci are present in nasal and oral secretions or until 24 hours after initiation of effective antibiotic treatment. Meningococcal Disease

6. What is Meningococcemia? Meningococcemia is a clinical form brought about by spread of the bacteria to bloodstream causing severe signs and symptoms. The most devastating form of meningococcemia is fulminant meningococcemia which consists of hemorrhagic rashes drop in blood pressure and circulating shock leading to death.

7. Case Definition Clinical Description: Meningococcal disease manifests most commonly as meningitis and/or meningococcemia that may progress rapidly to purpura fulminans, shock, and death. However, other manifestations might be observed. Laboratory criteria for diagnosis: Isolation of Neisseria meningitidis from a normally sterile site (e.g., blood or cerebrospinal fluid (CSF) or, less commonly, joint, pleural, or pericardial fluid)

8. Case Classification Probable: a case with a positive antigen test in cerebrospinal fluid or clinical purpura fulminans in the absence of a positive blood culture. Confirmed: a clinically compatible case that is laboratory confirmed. Case Definition

9. Epidemiology Reservoir: Humans are the only known reservoir of Neisseria Meningitidis. Mode of Transmission: Person to person through droplets of respiratory or throat secretions. Close and prolonged contact e.g., (kissing, sneezing and coughing on someone, living in close quarters or dormitories (military recruits, students), sharing eating or drinking utensils, etc.)

10. GRAM STAIN OF SPINAL FLUID

11. What are the signs and symptoms of Meningococcemia? fever  stiff neck  convulsion, in some  delirium  altered mental status  vomiting  cough, sore throat, other respiratory symptoms  pinpoint rashes then become wider and appear like bruises starting on the legs and arms  large map like bruise-like patches  severe skin lesions may lead to gangrene  unstable vital signs may or may not have signs of meningitis such as:  stiff neck,  convulsion,  delirium,  altered mental status,  vomiting

12. > 2 Years : High fever, headache, and stiff neck. Other symptoms include nausea, vomiting, discomfort looking into bright lights, confusion, and sleepiness. Clinical Presentation Newborns and small infants: Classic symptoms may be absent or difficult to detect. In babies under one year of age, the soft spot on the top of the head (fontanel) may bulge upward. Infant may only appear slow or inactive, or be irritable, have vomiting, or be feeding poorly.

15. How does meningococcal disease spread? Infection is spread by direct contact with discharges from the nose and throat which contain the bacteria. Although meningococcal bacteria are common, they are extremely delicate outside of the body and are not very contagious. The bacteria spread from an infected carrier to another person through close, direct physical contact and through coughing, and sneezing, kissing. It can also spread through saliva (spit) when sharing items such as food or drinks, cups, utensils and drinking straws. In general, people should not share anything that has been in their mouth. Exposure to cigarette smoke increases the risk of spread of meningococci, as well as other bacteria.

17. Who is considered a close contact of a meningococcal disease? A close contact is someone who is likely to have had direct contact with saliva or mucous from the nose or throat of an infected person. those who live in the same house those who have kissed the infected person those who share a bed children in the same childcare center or nursery because they frequently put objects into their mouths those who share drinks, cigarettes, food, drinks, water, glasses, cups, musical instruments with mouthpieces, or anything else that has been in the mouth of the infected person

18. What happens when someone is a close contact?  Close contacts of a case of meningococcal disease may be given an antibiotic to protect them.  Classmates or co-workers of an infected person are not considered to be close contacts unless they have had direct contact with secretions from the mouth or nose of the sick person.  Those who are close contacts of the infected person do not pose a risk to others and may continue to attend school or work.  Siblings and other family members of close contacts do not require preventive treatment.  In most cases, classes, school-related or work- related activities will continue as planned.  Depending on the circumstances, public health officials may recommend that close contacts receive antibiotics, vaccine, or both in order to prevent additional cases of meningococcal disease.

19. Can meningococcemia and meningitis be treated? Penicillin kills meningococcal bacteria that have invaded the body. Early recognition of meningococcal infection and prompt treatment with penicillin greatly improves chances of survival. Prophylaxis is reserved for those who have intimate contact with the patient; household members, boyfriend/girlfriend, sexual partners, hospital personnel who did suctioning of secretions and/or mouth resuscitation. Rifampicin is the drug of choice and may be given to both children and adults.

21. How does one prevent meningococcemia? Wash hands frequently with soap and water. Avoid close contact with meningococcemia patients. Increase resistance by having healthy diet, regular exercise, adequate rest and sleep, no alcohol and cigarette smoking. Maintain clean environment/surroundings Don't share utensils, cups, water bottles, lipstick, cigarettes and other water bottles, dishes, glasses, cups, lipstick, musical instruments with mouthpieces, mouth guards, or anything else that has been in the mouth of the infected person Avoid crowded places.

22. Diagnosis Diagnosis is confirmed by demonstration of the bacteria in a gram-stained smear of the cerebro-spinal fluid (CSF) and the isolation of the bacteria from the CSF blood.

23. Occurrence The disease is usually sporadic (cases occur alone or may affect household members with intimate contact). Although primarily a disease of children, it may occur among adults especially in conditions of forced overcrowding such as institutions, jails and barracks. It occurs more in males than females.

24. Public Health Significance? Leading cause of bacterial meningitis in children and young adults in the U.S 2,400 to 3,000 cases each year in U.S. 5% to 10% of patients die, typically within 24- 48 hours of onset of symptoms. 10 to 20% of survivors of bacterial meningitis may result in brain damage, permanent hearing loss, learning disability or other serious sequelae. Meningococcal septicemia - rapid circulatory collapse.

25. VACCINE & TOXOID Polyvalent capsular antigens - Groups A and C

26. HOST DEFENSE & IMMUNITY Circulating antibodies to capsule and activation of complement are important PMNs abound in CSF Antibodies can cross-react to other strains Previous infection and vaccination confer long lasting immunity Endotoxin stimulates cytokines: TNF alpha and IL-1 which may mediate shock

27. Immunity to Meningococcus

28. Lab Tests Catalase = Positive Oxidase = Positive Sugar utilization = glucose & maltose Latex agglutination of CSF for rapid diagnosis DNA testing

29. Public Health Actions Upon receiving a report of invasive meningococcal disease: 1.Determine if reported case is probable or confirmed. 2.Assure that isolates are forwarded to the Office of Laboratory Services for serogrouping. 3.Determine if contacts need prophylaxis. 4.Recommend prophylaxis if indicated. 5.Complete appropriate report form(s). 6.Send completed forms to IDEP

30. Algorithm – Fever and Petechiae Riordan FAI,Arch Dis Child 2001;85 172-175

31. Evaluation of Purpura

32. Purpura – Diagnostic Consideration Platelet Disorders Coagulation Factor Deficiency Vascular Factors –Congenital Hereditary Telangectasia Ehrlos Danlos –Acquired Infectious HSP Mechanical Psychogenic Abuse

37. Case Study An 18-month-old infant is seen in the emergency room with a temperature of 105 o F, purpuric rash, and opisthotonos.

43. Fulminant Meningococcemia Most common in Winter and early Spring Extreme cases progress to sepsis Effects more than 2500 people/year –Half are <2 –While many individuals harbor the bacteria in their nose, throat and digestive tract, only a tiny portion develop the disease

44. Fulminant Meningococcemia Rare cases of treatment failure infected with N meningitidis that are moderately resistant to penicillin, a third generation cephalosporin is indicated for patients in whom penicillin appears to be ineffective.

45. Thank You…