Public Health Agency

Meningococcal disease

Meningitis is an inflammation of the meninges which can be caused by several bacteria, the most common of which is Neisseria meningitidis (meningococcal), TB or viruses.

Meningococcal disease

Introduction

There are several strains of Neisseria meningitidis, the causative organism of meningococcal disease. Infection, by some strains of the organism can be prevented by vaccination and meningococcal vaccines are included in the UK routine childhood vaccination programme.

The prognosis for patients with meningococcal meningitis is grave if diagnosis and treatment are delayed. Despite effective antimicrobial treatment, the overall mortality is still around 5%;  meningococcal disease is more common in children than in adults.

The organisms are harboured in, and excreted from the respiratory tract. Close contacts of a patient often carry the same organism. Meningococcal disease is spread primarily via droplets and outbreaks of disease may occur in groups of young people in close communities (e.g. in camps, boarding schools or universities).

Serogroups: capsular polysaccharide antigens separate meningococci into serogroups among which A, B, C, W and Y account for the overwhelming majority of invasive infections worldwide.

Other organisms can also present with symptoms of meningitis and/or septicaemia. Some of these organisms are also vaccine preventable.

Guidance on Immunisation against infectious diseases is available at:

https://www.gov.uk/government/collections/immunisation-against-infectious-disease-the-green-book


Meningococcal disease may manifest as meningitis (inflammation of the lining of the brain or spinal cord) or septicaemia (blood poisoning), or a combination of both.

The illness:

  • Occurs most frequently in young children and young adults.
  • Cases are defined as, possible, probable or confirmed
  • Increasing trend of W135 disease occurrence in the elderly
  • Chemoprophylaxis required for clearly defined “close contacts”
  • Transmission in hospitals or infection in healthcare workers rarely occurs.

See Appendix 1 for case definitions.

See Appendix 2 for treatment of Meningococcal disease.

Guidance on meningococcal disease is available at: https://www.gov.uk/search?q=meningococcal+guidance


Immediate management of suspected meningitis

For suspected meningococcal disease (meningitis with non-blanching rash or meningococcal septicaemia), parenteral antibiotics (intramuscular or intravenous benzylpenicillin) should be given at the earliest opportunity, either in primary or secondary care. Urgent transfer to hospital should not be delayed in order to give parenteral antibiotics.

See Appendix 2 for treatment of meningococcal disease.

NICE guidance available at:

https://www.nice.org.uk/guidance/cg102

Laboratory samples

  • Blood cultures,
  • CSF for microscopy and culture (if possible send 3 separate universal sterile containers of CSF following lumber puncture).  Inform the laboratory staff in advance of sending the specimen (CSF must be sent to laboratory within an hour). (CMV/EBV qRT-PCR may also be included in CSF where the patient is immunocompromised)
  • CSF for PCR to Regional Virology Laboratory (S. pneumoniae, H. influenza, N. meningitidis, Enteroviurs, Parechovirus, HSV1&2, VZV)
  • EDTA blood (in a full blood count bottle) for PCR to Regional Virology Laboratory (S. pneumoniae, H. influenza, N. meningitidis, Enteroviurs, Parechovirus).
  • Aspirate from other sterile sites suspected of being infected
  • Nasopharyngeal swab for PCR to Regional Virology Laboratory

Management

  • Appropriate antimicrobial treatment should be commenced immediately i.e. by the E.D. department if not already given
  • Isolate the patient in a single room with the door closed and contact/droplet precautions in place.
  • Wear a fluid shield mask if undertaking aerosol generating procedures such as suction or intubation.
  • Wear a fluid shield mask when carrying out close examination of the patient (e.g. eyes and throat) especially if they are coughing, sneezing or have a recent history of vomiting.
  • Notify the Public Health Agency (PHA) duty room immediately, phone 0300 555 0119.
  • PHA Medical/nursing staff will commence identification of “close contacts” and arrange antimicrobial prophylaxis for them either with hospital staff or GP.
  • Notification to the PHA should be as soon as possible and may be done on clinical suspicion only by the attending medical personnel; it is not necessary to wait for lab confirmation before contacting PHA duty room.
  • Visitors do not need to wear protective clothing unless they are at risk of exposure to naso-pharyngeal secretions, but should wash their hands before and after visiting.
  • Inform the trust Infection Prevention and Control Team.

Vaccination

The vaccination of identified “close contacts” who have received chemoprophylaxis is recommended to prevent late secondary cases where a vaccine is available.

The vaccination of contacts of serotype “B” is only recommended in an outbreak/cluster situation

Laboratory staff

Laboratory staff should exercise care when working with liquid broth form and/or agar cultures to reduce the risk of aeroloslation and occupational exposure. If there is an increased risk on assessment, staff should consult their local Occupational Health department. At risk laboratory staff, and related staff, should be vaccinated against meningococcal serogroups A, C, W and Y using a glycoconjugate MenACWY vaccine, as per the guidelines outlined in the Green Book. Furthermore, at risk laboratory staff and related staff should be vaccinated against meningococcal serogroups B with Bexsero vaccine, as per the guidelines outlined by the JVCI and Public Health England. At this stage it is unclear when regular booster doses for MenACWY and Bexsero should be given to laboratory workers to maintain protective titres of antibody.


Antimicrobial Prophylaxis for the patient
  • The aim of prescribing antimicrobial prophylaxis for the patient is to eradicate carriage from their throat, therefore minimising the risk of secondary transmission.
  • The patient should receive antimicrobial chemoprophylaxis even if they were successfully treated as the organism may not have been cleared from the throat. Ciprofloxacin or Rifampicin can be used (See Appendix 2). Those treated with cefotaxime should still receive prophylaxis because it is unknown whether cefotaxime eradicates carriage from the throat.
     
Antimicrobial Prophylaxis for close contacts
  • Antimicrobial prophylaxis may be advised for “close contacts” of patients with meningococcal disease
  • The antimicrobials of choice in are ciprofloxacin or rifampicin. Ciprofloxacin is the first line antibiotic because it may be given as a single dose and does not interact with oral contraceptives.
  • Each patient should be risk assessed prior to the prescription of prophylaxis
  • Antimicrobial prophylaxis is not usually given to healthcare staff caring for patients with meningococcal disease as the risk of acquiring the infection is low. An exception would be made for those exposed to a large dose of secretions (e.g. mouth-to-mouth resuscitation) or who were not wearing appropriate PPE. In this case staff should be risk assessed by their Occupational Health Department for prophylactic antimicrobials if the mouth or nose of the staff member has been directly and heavily exposed to respiratory droplets and/or secretions from a probable or confirmed case of meningococcal disease within the first 48hrs of the patient’s treatment.

For example intubation or nasopharyngeal suction or other prolonged close contact with the case where the staff member has not been wearing correct PPE.

Other Bacterial Causes of Meningitis

In neonates, Group B streptococci, Escherichia coli and Listeria monocytogenes can also cause meningitis.

In other age groups many bacteria can cause meningitis as part of a septic illness involving blood spread.

Haemophilus influenzae

The main strain encountered is capsular type B (HIB)

  • Almost always occurs in young children (3 months to 6 years of age).
  • It is less common in the UK since the introduction of Hib vaccine.
  • Antimicrobial prophylaxis may be advised for siblings of those with Haemophilus influenza type B (Hib)

Guidance on haemophilus influenzae is available at:

https://www.gov.uk/search?q=Revised+recommendations+for+the+prevention+of+secondary+Haemophilus


Streptococcus pneumoniae
  • Invasive disease includes septicaemia and meningitis
  • Common in the very young and elderly patients.
  • Often virulent capsulated strains.
  • Infection follows viral infection.
  • Chemoprophylaxis is not required for “close contacts”

Mycobacterium tuberculosis meningitis

This is now very rare in the UK, but should be suspected in certain populations and on the results of the CSF examination.

Immediate management

For children and young people with suspected bacterial meningitis but without a non-blanching rash, NICE recommends that they should be transferred directly to secondary care without giving parenteral antibiotics. If urgent transfer to hospital is not possible (for example in remote locations or adverse weather conditions) antibiotics should be administered to children and young people with suspected bacterial meningitis.


Viral Meningitis

Transmission

The organisms are harboured in, and excreted from the respiratory tract and/or intestinal tract.

Viruses can be transmitted by the faecal-oral, the respiratory route.

Common Organisms

  • Enteroviruses, particularly echoviruses which are most common in late summer; a different serotype predominates each year.
  • Coxsackie virus (also an Enteroviurs)
  • Mumps virus (often with encephalitis)
  • Herpes simplex virus(particularly type 2)
  • Varicella-zoster virus

Management

  • Isolate the patient in a single room with the door closed and contact/droplet precautions in place
  • Statutory notification to PHA duty room
  • Visitors need not wear protective clothing unless they are at risk of exposure to naso-pharyngeal secretions, but should wash their hands before and after visiting.
  • Inform the Infection Prevention and Control Team.

References

  1. The Green book the complete current edition. Available from: https://www.gov.uk/government/publications/immunisation-of-healthcare-and-laboratory-staff-the-green-book-chapter-12
  2. JCVI interim position statement on use of Bexsero® meningococcal B vaccine in the UK July 2013 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/224896/JCVI_interim_statement_on_meningococcal_B_vaccination_for_web.pdf
  3. Vazquez JA, Taha MK, Findlow J, Gupta S, Borrow R. Global Meningococcal Initiative: guidelines for diagnosis and confirmation of invasive meningococcal disease. Epidemiology & Infection 2016; 30: 1-6.
  4. Patient Group Direction (PGD). Available from: https://www.gov.uk/government/publications/menb-vaccine-bexsero-patient-group-direction-pgd-template.

Appendix 1

Appendix 2

*Note: please consult local policy*

Appendix 2

*Note: please consult local policy*