15/15/2015 Meningitis General Overview Presented by: Robert W. White II, RS, MPH Regional Epidemiologist

1104/18/2304/18/23

MeningitisMeningitisGeneral General

OverviewOverview

Presented by:Presented by:Robert W. White II, RS, MPHRobert W. White II, RS, MPH

Regional EpidemiologistRegional Epidemiologist

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Clinical descriptionClinical description

Meningitis is a disease caused by the Meningitis is a disease caused by the inflammation of the protective inflammation of the protective membranes covering the brain and membranes covering the brain and spinal cord known as the meninges. spinal cord known as the meninges. The inflammation is usually caused by The inflammation is usually caused by an infection of the fluid surrounding an infection of the fluid surrounding the brain and spinal cord. Meningitis is the brain and spinal cord. Meningitis is also referred to as spinal meningitis. also referred to as spinal meningitis.

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Causes of MeningitisCauses of Meningitis

- bacteriabacteria- virusesviruses- physical injuryphysical injury- cancer cancer - or certain drugsor certain drugs

Severity/treatment of illnesses differ Severity/treatment of illnesses differ depending on the cause. Thus, it is important depending on the cause. Thus, it is important to know the specific cause of meningitis. to know the specific cause of meningitis.

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For Public Health Response For Public Health Response Meningitis can be:Meningitis can be:

ViralViral OROR

BacterialBacterial

Both can create Public Health Both can create Public Health Problems but not all Problems but not all

Meningitis is created equalMeningitis is created equal

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Causes of MeningitisCauses of Meningitis

• BacterialBacterial

- Haemophilus - Haemophilus influenzae influenzae

- Listeria - Listeria

- Meningococcus - Meningococcus

- Mumps - Mumps

- Pneumococcus - Pneumococcus

- Group A Streptococcus - Group A Streptococcus

- Group B Streptococcus- Group B Streptococcus

• ViralViral

- Arboviral (mosquito-- Arboviral (mosquito-borne) diseasesborne) diseases

- Influenza - Influenza

- LaCrosse Encephalitis - LaCrosse Encephalitis virusvirus

- West Nile Virus- West Nile Virus

- Also enteroviral- Also enteroviral

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Symptoms can be the same for Symptoms can be the same for Viral and BacterialViral and Bacterial

• Fever and chills Fever and chills

• Mental status changes Mental status changes

• Nausea and vomiting Nausea and vomiting

• Sensitivity to light (photophobia) Sensitivity to light (photophobia)

• Severe headache Severe headache

• Stiff neckStiff neck

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Viral MeningitisViral MeningitisClinical description: Clinical description: A syndrome A syndrome

characterized by acute onset of meningeal characterized by acute onset of meningeal symptoms- fever, and cerebrospinal fluid symptoms- fever, and cerebrospinal fluid pleocytosis (white cells in the spinal fluid) pleocytosis (white cells in the spinal fluid) with bacteriologically sterile cultures. with bacteriologically sterile cultures.

ConfirmedConfirmed: a clinically compatible illness : a clinically compatible illness diagnosed as aseptic meningitis, diagnosed as aseptic meningitis,

with no laboratory evidence of with no laboratory evidence of bacterial or fungal meningitisbacterial or fungal meningitis

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Bacterial MeningitisBacterial Meningitis

What types are important in Public What types are important in Public Health Response?Health Response?

1.1. Neisseria meningitidis Neisseria meningitidis (also called (also called meningococcal meningitis) meningococcal meningitis)

2. 2. Haemophilus influenzaeHaemophilus influenzae Serotype b Serotype b (Hib) (Hib)

Why are they important?Why are they important?

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Neisseria meningitidis Neisseria meningitidis ProphylaxisProphylaxis

People who qualify as close contacts of People who qualify as close contacts of a person with meningitis caused by a person with meningitis caused by N. meningitidisN. meningitidis are are

- Family and household contactsFamily and household contacts- Child or nursery school contactsChild or nursery school contacts- Anyone exposed to patient’s oral Anyone exposed to patient’s oral

secretionssecretions

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Hib ProphylaxisHib Prophylaxis

The entire household, regardless of age, The entire household, regardless of age, should receive prophylaxis in these cases should receive prophylaxis in these cases if-if-

- There is 1 household contact younger than There is 1 household contact younger than 48 months who has not been fully 48 months who has not been fully immunized against Hib, or immunized against Hib, or

- An immunocompromised child (a child An immunocompromised child (a child with a weakened immune system) of any with a weakened immune system) of any age is in the household. age is in the household.

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So…you get a call from a So…you get a call from a Hospital ER at 4:00 on Hospital ER at 4:00 on ThursdayThursday

A patient has been intubated and the A patient has been intubated and the doctor believes that the symptoms doctor believes that the symptoms are consistent with Meningitisare consistent with Meningitis

Spinal fluid cultures are incompleteSpinal fluid cultures are incomplete

What should you do first?What should you do first?

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It’s now 4:05It’s now 4:05

Call your Regional Epidemiologist and the Division Call your Regional Epidemiologist and the Division of Infectious Disease Epidemiology (DIDE)of Infectious Disease Epidemiology (DIDE)

Get a copy of any lab results and fax them to Get a copy of any lab results and fax them to DIDEDIDE

Obtain patient demographics from the hospitalObtain patient demographics from the hospital

But…what are you dealing with?But…what are you dealing with?

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It’s 4:15- Rest easy for a It’s 4:15- Rest easy for a whilewhile

You have clinical symptoms of meningitis with You have clinical symptoms of meningitis with no laboratory confirmationno laboratory confirmation

You have notified the right individualsYou have notified the right individuals

Just in case the news gets worse, the hospital Just in case the news gets worse, the hospital has prophylaxed the entire familyhas prophylaxed the entire family

You don’t even have a reportable You don’t even have a reportable disease yetdisease yet

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Friday 8:00 AMFriday 8:00 AM

The hospital lab calls you to say the The hospital lab calls you to say the culture is growing Gram Negative culture is growing Gram Negative diplococcidiplococci

The patient has progressively gotten The patient has progressively gotten worseworse

Gram Negative Diplococci? So what?Gram Negative Diplococci? So what?

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ASSUMEASSUME

Neisseria MeningitisNeisseria Meningitis

If the lab would have been Gram If the lab would have been Gram positive cocci in pairs and positive cocci in pairs and

chains, then Strep Pneumoniae chains, then Strep Pneumoniae would have presented a problemwould have presented a problem

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Investigate Investigate

Assume 1 case is the start of an Assume 1 case is the start of an outbreak but remember- most cases outbreak but remember- most cases are single casesare single cases

Talk to the ICP and get as much Talk to the ICP and get as much information as possibleinformation as possible

Talk to family members to get historyTalk to family members to get historyDetermine if more individuals need Determine if more individuals need

prophylaxis treatmentprophylaxis treatment

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- Serogroups B, C, and Y account for Serogroups B, C, and Y account for 30% each of reported cases30% each of reported cases

- Serogroups C, Y, and W-135 are Serogroups C, Y, and W-135 are vaccine preventablevaccine preventable

- In infants, 50% of cases are caused In infants, 50% of cases are caused by serogroup B and are not by serogroup B and are not preventable by vaccinepreventable by vaccine

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Outbreak Steps /Case Outbreak Steps /Case ManagementManagement

1. Prepare for field work – go to 1. Prepare for field work – go to internet sites, internet sites, Red BookRed Book, and , and CCD in CCD in ManMan

2. Establish the existence of an 2. Establish the existence of an outbreak- is one case enough? outbreak- is one case enough?

3. Verify the diagnosis- try to get a lab 3. Verify the diagnosis- try to get a lab report report

4. Define and identify cases- is anyone 4. Define and identify cases- is anyone else exhibiting symptoms?else exhibiting symptoms?

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Outbreak Steps (continued)Outbreak Steps (continued)5. Describe and orient the data in terms of 5. Describe and orient the data in terms of

time, place, and person- organize your time, place, and person- organize your data, report on WVEDSSdata, report on WVEDSS

6. Implement control and prevention 6. Implement control and prevention measures- who else needs prophylaxis? measures- who else needs prophylaxis?

7. Communicate findings- The family will want 7. Communicate findings- The family will want some answers and the media will want all some answers and the media will want all the details. Is a Health Alert to local the details. Is a Health Alert to local physicians warranted?physicians warranted?

(Generally with Meningitis we are not (Generally with Meningitis we are not going to do a great deal on going to do a great deal on Hypothesis testing)Hypothesis testing)

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What does the public know What does the public know about meningitis?about meningitis?

It’s bad and people die from itIt’s bad and people die from it

The word “meningitis” conjures up chilling The word “meningitis” conjures up chilling memories of past deathsmemories of past deaths

If a school is involved, be prepared to have If a school is involved, be prepared to have protesters and news media on scene protesters and news media on scene

The next 2 slides are real life The next 2 slides are real life situationssituations

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Streptococcus PneumoniaeStreptococcus Pneumoniae

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So let’s review- Viral So let’s review- Viral MeningitisMeningitisIncubation period is about 3 to 6 daysIncubation period is about 3 to 6 daysDuration of the illness is approximately 7 to Duration of the illness is approximately 7 to

10 days10 daysInfectious period can last several weeks Infectious period can last several weeks

after symptoms have resolvedafter symptoms have resolvedDiagnosed by laboratory tests of a patient’s Diagnosed by laboratory tests of a patient’s

spinal fluidspinal fluidMany times tests are done to rule out Many times tests are done to rule out

Bacterial MeningitisBacterial Meningitis

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Viral Meningitis- ReviewViral Meningitis- Review

There is no specific treatment for viral There is no specific treatment for viral meningitis. meningitis.

-Enteroviruses are most often spread through -Enteroviruses are most often spread through direct contact with an infected person’s stool.direct contact with an infected person’s stool.

Enteroviruses and other viruses (such as mumps Enteroviruses and other viruses (such as mumps and varicella-zoster virus) can also be spread and varicella-zoster virus) can also be spread through through

-direct, or -direct, or -indirect contact with respiratory secretions -indirect contact with respiratory secretions

(saliva, sputum, or nasal mucus) of an infected (saliva, sputum, or nasal mucus) of an infected person. person.

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Following good hygiene practices can Following good hygiene practices can reduce the spread of viruses andreduce the spread of viruses and bacteriabacteria

Wash your hands thoroughly and often Wash your hands thoroughly and often

Clean contaminated surfaces Clean contaminated surfaces

Cover your cough Cover your cough

Avoid kissing or sharing a drinking glass, Avoid kissing or sharing a drinking glass, eating utensil, lipstick, or other such eating utensil, lipstick, or other such itemsitems

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Receiving vaccinations in the Receiving vaccinations in the childhood vaccination schedule can childhood vaccination schedule can protect children against diseases protect children against diseases that can lead to viral meningitis that can lead to viral meningitis (measles, mumps, and chickenpox) (measles, mumps, and chickenpox)

Avoid bites from mosquitoes and other Avoid bites from mosquitoes and other insects that carry diseases that can insects that carry diseases that can infect humans infect humans

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Outbreaks are rare but if you are Outbreaks are rare but if you are around someone with viral around someone with viral meningitis, you may be at risk of meningitis, you may be at risk of becoming infected with the virus that becoming infected with the virus that made them sick. But you have only a made them sick. But you have only a small chance of developing small chance of developing meningitis as a complication of the meningitis as a complication of the illness. illness.

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Bacterial Meningitis- ReviewBacterial Meningitis- Review

Public Health ImplicationsPublic Health Implications- ListeriaListeria- HiBHiB- Group B Strep (Pregnant women and Group B Strep (Pregnant women and

neonates)neonates)- Streptococcus pneumoniaeStreptococcus pneumoniae- Meningococcal Meningitis (Neisseria Meningococcal Meningitis (Neisseria

meningitidis ) – individual casesmeningitidis ) – individual cases

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-Bacterial meningitis is contagious. The bacteria -Bacterial meningitis is contagious. The bacteria are spread through the exchange of are spread through the exchange of respiratory and throat secretions (i.e., respiratory and throat secretions (i.e., coughing, kissing). coughing, kissing).

-None of the bacteria that cause meningitis are -None of the bacteria that cause meningitis are as contagious as things like the common cold as contagious as things like the common cold or the flu. or the flu.

-The bacteria are not spread by casual contact -The bacteria are not spread by casual contact or by simply breathing the air where a person or by simply breathing the air where a person with meningitis has been. with meningitis has been.

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Assure all isolates are referred to OLS Assure all isolates are referred to OLS for serotypingfor serotyping

Assure all high risk contacts are Assure all high risk contacts are offered prophylaxisoffered prophylaxis

Assure all providers are educated to Assure all providers are educated to report suspect and confirmed cases report suspect and confirmed cases of invasive meningococcal disease of invasive meningococcal disease properlyproperly

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Keeping up to date with recommended Keeping up to date with recommended immunizations is the best defense. immunizations is the best defense.

Good hygiene is also an important way to Good hygiene is also an important way to prevent most infections. prevent most infections.

Rifampin, ceftriaxone, and ciprofloxacin are Rifampin, ceftriaxone, and ciprofloxacin are appropriate drugs for chemoprophylaxis in appropriate drugs for chemoprophylaxis in adults. The drug of choice for most adults. The drug of choice for most children is rifampin.children is rifampin.

Chemoprophylaxis may be administered in Chemoprophylaxis may be administered in conjunction with vaccinations.conjunction with vaccinations.

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People who should be prophylaxedPeople who should be prophylaxed- household contactshousehold contactsdaycare center contactsdaycare center contacts- anyone with direct contact with a patient's anyone with direct contact with a patient's

oral secretions oral secretions Media releases may be appropriate to assist Media releases may be appropriate to assist

in finding close contacts of the initial case. in finding close contacts of the initial case. Working with news services may prevent Working with news services may prevent public anxiety especially when public anxiety especially when investigations lead to schools, colleges, investigations lead to schools, colleges, and workplaces.and workplaces.

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People who should not be prophylaxedPeople who should not be prophylaxed

- Casual contacts, no history of Casual contacts, no history of exposure to index caseexposure to index case

- Indirect contacts (2nd degree Indirect contacts (2nd degree contact)contact)

- Health care professionals without Health care professionals without direct exposuredirect exposure

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Bacterial Meningitis- OutbreaksBacterial Meningitis- OutbreaksLocal Health DepartmentsLocal Health Departments

1.1. Investigate cases immediately Investigate cases immediately 2.2. Report cases to Regional Epidemiologist Report cases to Regional Epidemiologist

and Infectious Disease Epidemiology and Infectious Disease Epidemiology 3.3. Determine who is at risk by interviewing Determine who is at risk by interviewing

physician, family or possibly the casephysician, family or possibly the case4.4. Organize notes and respond as though Organize notes and respond as though

this will be an outbreakthis will be an outbreak5.5. Send isolates to OLSSend isolates to OLS

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Meningitis- For More Meningitis- For More InformationInformation

http://www.cdc.gov/meningitis/index.html

http://www.wvidep.org/AZIndexofInfectiousDiseases/MeningococcalDiseaseInvasive/tabid/1529/Default.aspx






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Meningitis- Q and AMeningitis- Q and A

Questions????Questions????

Documents

15/15/2015 Meningitis General Overview Presented by: Robert W. White II, RS, MPH Regional Epidemiologist