20221.ppt 1461KB Mar 29 2010 04:55:13 AM
MENINGOCOCCAL
MENINGITIS (MCM) AT
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
CLINICAL DISEASE,
EPIDEMIOLOGY AND
CONTROL
DEFINITION
IT IS A PYOGENIC INFECTION OF
MEMBRANES COVERING THE BRAIN
AND SPINAL CORD ( DURA, PIA AND
ARACNOID MEMBRANES) BY
MENIINGO-COCCI
ALSO CALLED CEREBROSPINAL
FEVER
CLINICAL PRESENTATIONS
RESTRICTED TO NASOPHARYNX
AS ASYMPTOMATIC CASES OR
ONLY WITH LOCAL SYMPTOMS
INVASIVE WITH ACUTELY ILL
SEPTICEMIC AND TOXIC
MENINGEAL
CLINICAL PICTURE IN THE
NEWBORN
•MINIMAL AND VARIABLE, HENCE
DIAGNOSIS DIFFICULT
•SLUGGISH, LETHARGIC WITH UNUSUAL
GAZE
•DOES NOT TAKE FEED WELL , MAY VOMIT
•HIGH PITCHED CRY AND CONVULSIONS
•HYPOTHERMIA SEEN USUALLY, FEVER
MAY BE THERE
•TENSE AND BULGING ANTERIOR
FONTANELLAE VERY USUAL
CLINICAL PICTURE IN
PRESCHOOL & SCHOOL CHILD
WIDE SPECTRUM OF SIGNS
& SYMPTOMS IN THIS AGE
GROUP AND MORE OBVIOUS
MODERATE TO HIGH FEVER
HEADACHE, VOMITING,
PHOTOPHOBIA,
CONVULSIONS,
NECK STIFFNESS,
NEUROLOGICAL IRRITATION
SKIN RASHES
CLINICAL PICTURE IN < 2 YEAR OLD
CLASSICAL SIGNS MAY NOT BE PRESENT BUT
HIGH DEGREE OF SUSPICION WHEN THE
FOLLOWING PICTURE IS SEEN
FEVER COMMON
MACULOPAPULAR PETECHIAL RASH IN
HALF OF THE CASES
REFUSAL OF FEEDS
VOMITINGS,
ALTERED SENSORIUM
IRRITABILITY
BULGING FONTANELLAE
NEUROLOGICAL DEFICIT (EITHER MONOPLEGIA,
HEMIPLEGIA AND SQUINT
CLINICAL PICTURE IN THE ADULT
CLEARCUT PICTURE
FEVER, INTENSE HEADACHE
VOMITING, PHOTOPHOBIA,
NECKPAIN AND STIFFNESS
SIGNS OF MENINGEAL IRRITATION
AND ALTERED SENSORIUM
SKIN RASHES
SIGNS AND SYMPTOMS OF SHOCK
DIFFERENTIAL DIAGNOSIS
IN NEONATE:
SEPTICEMIA, GASTROENTERITIS, BIRTH HYPOXIA,
BIRTH TRAUMA, RESPIRATORY INFECTIONS,
HYPOGLYCEMIA, METABOLIC DISORDERS
CAUSING CONVULSIONS AND KERNICTERUS
IN OLDER CHILDREN AND ADULTS:
ENCEPHALITIS, BRAIN ABSCESS, CEREBRAL
MALARIA, ASEPTIC MENINGITIS,
CARDIOVASCULAR ACCIDENTS, CRYPTOCOCCAL
MENINGIT IS AND TUBERCULAR MENINGITIS
DIAGNOSIS
MENINGOCOCCI ARE DEMONSTRATED BY
LUMBAR PUNCTURE AND EXAMINATION OF
CEREBRO SPINAL FLUID (CSF) & CULTURE
OF CSF
BLOOD CULTURE
CULTURE FROM NASOPHARYNX
EXAMINATION OF PETECHIAL SKIN LESIONS
IMMUNOLOGICAL METHODS FOR
ANTIBODIES (IFP, ELISA, CIEP)
TREATMENT
ISOLATION OR SEPARATION
ALL PATIENTS NEED HOSPITALIZATION
SPECIFIC TREATMENT
- FLUIDS
- CEFTRIAXONE/CEFOTOXIME
- AMPICILLIN ( NOT TO BE GIVEN IF
HYPERSENSITIVE TO PENICILLIN)
- CHLORAMPHENICOL
SUPPORTIVE THERAPY: FOR SHOCK AND
CONVULSIONS
EPIDEMIOLOGICAL INTERACTION
AGENT FACTORS
TIME DISRIBUTION
MCM
HOST
FACTORS
ENVIRONMENT PLACE
PERSON
FACTORS
DISTRIBUTION DISTRIBUTION
THE CAUSATIVE AGENT
NEISSERIA MENINGITIDIS
(MENINGO COCCUS)
BISCUIT SHAPED GRAM + VE
DIPLOCOCCUS
SIZE & SHAPE VARIATION IN OLDER
CULTURES DUE TO AUTOLYSIS
TRANSPARENT ,NON PIGMENTED,
NONHEMOLYTIC COLONIES 1-5 MM SIZE
MENINGO COCCI
SERO GROUP TYPING
DEPEND UPON THE POLYSACCHARIDE
CAPSULE
NINE SEROLOGICAL GROUPS IDENTIFIED
A, B, C, D, X , Y, Z , W-135, 29E
ALL THE SEROGROUPS ARE PATHOGENIC
BUT A, B, C, Y ARE MOST
NEUROVIRULENT
A AND C ARE MOST EPIDEMOGENIC
MODE OF TRANSMISSION
•
•
HUMAN CASES AND THE CARRIERS ARE THE
ONLY RESERVOIRS
TRANSMITTED BY DIRECT CONTACT
(DROPLETS,DISCARGE FROM THE NOSE
&THROAT OF THE PERSONS)
INCUBATION PERIOD = 3-4 DAYS
PERIOD OF COMMUNICABILITY IS AS LONG AS
THE MENINGOCOOCI ARE PRESENT IN
DISCARGES FROM NOSE, THROAT AND
NASOPHARYNX
PERSON FACTORS
POOR NUTRITIONAL STATUS &
IMMUNITY
DRY NASAL MUCOSA
PHYSICAL EXERTION
FATIGUE
CARRIER STATE
AGE PREDILICTION
PRIMARILY A CHILD
DISEASE
BUT CAN AFFECT YOUNG
ADULTS ALSO
SEX PREDILICTION
MORE MALES ARE
AFFECTED THAN FEMALES
PLACE DISTRIBUTION
•MCM IS ENDEMIC IN LARGE
TOWNS
•MORE COMMONLY IN PEOPLE
LIVING IN CROWDED
CONDITIONS
TIME DISTRIBUTION
GREATEST INCIDENCE IN
WINTER AND SPRING
CARRIER STATE
TRANSMISSION OCCURS MORE
OFTEN FROM CARRIERS RATHER
THAN CASES
BY AND LARGE HIGH CARRIER
RATE IS USUALLY ASSOCIATED
WITH OUTBREAKS
CONTROL MEASURES
VACCINATION
COMPOSITION: 50 MICRO GRAMS OF “A”
POLYSACHARIDE, 50 MICRO GRAMS OF “C” POLY
SACHARIDE, 1 MG OF LACTOSE.
DOSE - 0.5 ML OF IRRESPECTIVE OF AGE GIVEN
SUBCUTANEOUSLY.
EFFICACY– SEROGROUP “A’ CLINICAL EFFICACY
= 85-95%
SERO GROUP “A’ INDUCES ANTIBODY RESPONSE
IN CHILDREN AS YOUNG AS 3 MONTHS OLD.
BUT SEROGROUP “C” DOES NOT INDUCE
ANTIBODIES BEFORE 2 YEARS OF AGE.
SEROGROUP “Y” AND W-135 ARE SAFE AND
IMMUNOGENIC IN ADULTS AND CHILDREN
ABOVE AGE OF 2 YEARS.
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
VACCINATION UNDER 2 YEARS OF AGE
WHICH IS THE HIGHEST SUSCEPTIBLE
PRESENT STRATEGY FOR
VACCINATION
ONLY HIGH RISK PEOPLE
(HEATH CARE WORKERS,
TRAVELLERS, PEOPLE LIVING
IN OVERCROWDED PLACES)
AND CLOSE CONTACTS HAVE
TO BE VACCINATED.
VACCINATION FOR CONTACTS
1.
2.
3.
FORTUNATELY, WE HAVE
QUADRIVALENT VACCINES AT
PRESENT
PROTECTION OCCURS ONLY AFTER
14 DAYS OF VACCINATION
HENCE CHEMOPROPHYLAXIS IS
PROVIDED WITH ANTIBIOTICS IN
THE MEANTIME
VACCINATION FOLLOWED BY +
CHEMOPROPHYLAXIS FOR
CLOSE CONTACTS
HOUSEHOLD MEMBERS
DAY-CARE CENTRE CONTACTS
ANYONE DIRECTLY
EXPOSED TO THE PATIENT'S
ORAL SECRETIONS OR
RESPIRATORY DROPLETS.
CHEMOPROPHYLAXIS
FOR CLOSE CONTACTS
WITHIN 24 HOURS FOR
• HOUSEHOLD
CONTACTS
•CLOSE CONTACTS
•HIGH RISK
PERSONS
WITH
CIPROFLOXACIN,
RIFAMPICIN,
MINOCYCLINE,
SPIRAMYCN,
CEFTRIAXIONE
RISK COMMUNICATION
FOR ACTIVE
AND
SUSTAINED
COMMUNITY
PARTICIPATION
TO CONTROL
THE EPIDEMIC
THROUGH PUBLIC
EDUCATION
REGARDING
RISK FACTORS AND
POSSIBLE CONTROL
STRATEGIES
NOTIFICATION OF
CASES AT THE
EARLIEST
SURVEILLANCE
PUBLIC EDUCATION
AVOID OVERCROWDING.
DO NOT SHARE DRINKING BOTTLES,
GLASSES, CIGARETTES, LIPSTICKS
OR OTHER ITEMS THAT MAY BE
COVERED IN SALIVA.
AVOID SMOKY AND DUSTY PLACES.
TEACH CHILDREN NOT TO SHARE
CUPS, SOFT DRINK CANS OR SPORTS
WATER BOTTLES.
MENINGITIS (MCM) AT
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
CLINICAL DISEASE,
EPIDEMIOLOGY AND
CONTROL
DEFINITION
IT IS A PYOGENIC INFECTION OF
MEMBRANES COVERING THE BRAIN
AND SPINAL CORD ( DURA, PIA AND
ARACNOID MEMBRANES) BY
MENIINGO-COCCI
ALSO CALLED CEREBROSPINAL
FEVER
CLINICAL PRESENTATIONS
RESTRICTED TO NASOPHARYNX
AS ASYMPTOMATIC CASES OR
ONLY WITH LOCAL SYMPTOMS
INVASIVE WITH ACUTELY ILL
SEPTICEMIC AND TOXIC
MENINGEAL
CLINICAL PICTURE IN THE
NEWBORN
•MINIMAL AND VARIABLE, HENCE
DIAGNOSIS DIFFICULT
•SLUGGISH, LETHARGIC WITH UNUSUAL
GAZE
•DOES NOT TAKE FEED WELL , MAY VOMIT
•HIGH PITCHED CRY AND CONVULSIONS
•HYPOTHERMIA SEEN USUALLY, FEVER
MAY BE THERE
•TENSE AND BULGING ANTERIOR
FONTANELLAE VERY USUAL
CLINICAL PICTURE IN
PRESCHOOL & SCHOOL CHILD
WIDE SPECTRUM OF SIGNS
& SYMPTOMS IN THIS AGE
GROUP AND MORE OBVIOUS
MODERATE TO HIGH FEVER
HEADACHE, VOMITING,
PHOTOPHOBIA,
CONVULSIONS,
NECK STIFFNESS,
NEUROLOGICAL IRRITATION
SKIN RASHES
CLINICAL PICTURE IN < 2 YEAR OLD
CLASSICAL SIGNS MAY NOT BE PRESENT BUT
HIGH DEGREE OF SUSPICION WHEN THE
FOLLOWING PICTURE IS SEEN
FEVER COMMON
MACULOPAPULAR PETECHIAL RASH IN
HALF OF THE CASES
REFUSAL OF FEEDS
VOMITINGS,
ALTERED SENSORIUM
IRRITABILITY
BULGING FONTANELLAE
NEUROLOGICAL DEFICIT (EITHER MONOPLEGIA,
HEMIPLEGIA AND SQUINT
CLINICAL PICTURE IN THE ADULT
CLEARCUT PICTURE
FEVER, INTENSE HEADACHE
VOMITING, PHOTOPHOBIA,
NECKPAIN AND STIFFNESS
SIGNS OF MENINGEAL IRRITATION
AND ALTERED SENSORIUM
SKIN RASHES
SIGNS AND SYMPTOMS OF SHOCK
DIFFERENTIAL DIAGNOSIS
IN NEONATE:
SEPTICEMIA, GASTROENTERITIS, BIRTH HYPOXIA,
BIRTH TRAUMA, RESPIRATORY INFECTIONS,
HYPOGLYCEMIA, METABOLIC DISORDERS
CAUSING CONVULSIONS AND KERNICTERUS
IN OLDER CHILDREN AND ADULTS:
ENCEPHALITIS, BRAIN ABSCESS, CEREBRAL
MALARIA, ASEPTIC MENINGITIS,
CARDIOVASCULAR ACCIDENTS, CRYPTOCOCCAL
MENINGIT IS AND TUBERCULAR MENINGITIS
DIAGNOSIS
MENINGOCOCCI ARE DEMONSTRATED BY
LUMBAR PUNCTURE AND EXAMINATION OF
CEREBRO SPINAL FLUID (CSF) & CULTURE
OF CSF
BLOOD CULTURE
CULTURE FROM NASOPHARYNX
EXAMINATION OF PETECHIAL SKIN LESIONS
IMMUNOLOGICAL METHODS FOR
ANTIBODIES (IFP, ELISA, CIEP)
TREATMENT
ISOLATION OR SEPARATION
ALL PATIENTS NEED HOSPITALIZATION
SPECIFIC TREATMENT
- FLUIDS
- CEFTRIAXONE/CEFOTOXIME
- AMPICILLIN ( NOT TO BE GIVEN IF
HYPERSENSITIVE TO PENICILLIN)
- CHLORAMPHENICOL
SUPPORTIVE THERAPY: FOR SHOCK AND
CONVULSIONS
EPIDEMIOLOGICAL INTERACTION
AGENT FACTORS
TIME DISRIBUTION
MCM
HOST
FACTORS
ENVIRONMENT PLACE
PERSON
FACTORS
DISTRIBUTION DISTRIBUTION
THE CAUSATIVE AGENT
NEISSERIA MENINGITIDIS
(MENINGO COCCUS)
BISCUIT SHAPED GRAM + VE
DIPLOCOCCUS
SIZE & SHAPE VARIATION IN OLDER
CULTURES DUE TO AUTOLYSIS
TRANSPARENT ,NON PIGMENTED,
NONHEMOLYTIC COLONIES 1-5 MM SIZE
MENINGO COCCI
SERO GROUP TYPING
DEPEND UPON THE POLYSACCHARIDE
CAPSULE
NINE SEROLOGICAL GROUPS IDENTIFIED
A, B, C, D, X , Y, Z , W-135, 29E
ALL THE SEROGROUPS ARE PATHOGENIC
BUT A, B, C, Y ARE MOST
NEUROVIRULENT
A AND C ARE MOST EPIDEMOGENIC
MODE OF TRANSMISSION
•
•
HUMAN CASES AND THE CARRIERS ARE THE
ONLY RESERVOIRS
TRANSMITTED BY DIRECT CONTACT
(DROPLETS,DISCARGE FROM THE NOSE
&THROAT OF THE PERSONS)
INCUBATION PERIOD = 3-4 DAYS
PERIOD OF COMMUNICABILITY IS AS LONG AS
THE MENINGOCOOCI ARE PRESENT IN
DISCARGES FROM NOSE, THROAT AND
NASOPHARYNX
PERSON FACTORS
POOR NUTRITIONAL STATUS &
IMMUNITY
DRY NASAL MUCOSA
PHYSICAL EXERTION
FATIGUE
CARRIER STATE
AGE PREDILICTION
PRIMARILY A CHILD
DISEASE
BUT CAN AFFECT YOUNG
ADULTS ALSO
SEX PREDILICTION
MORE MALES ARE
AFFECTED THAN FEMALES
PLACE DISTRIBUTION
•MCM IS ENDEMIC IN LARGE
TOWNS
•MORE COMMONLY IN PEOPLE
LIVING IN CROWDED
CONDITIONS
TIME DISTRIBUTION
GREATEST INCIDENCE IN
WINTER AND SPRING
CARRIER STATE
TRANSMISSION OCCURS MORE
OFTEN FROM CARRIERS RATHER
THAN CASES
BY AND LARGE HIGH CARRIER
RATE IS USUALLY ASSOCIATED
WITH OUTBREAKS
CONTROL MEASURES
VACCINATION
COMPOSITION: 50 MICRO GRAMS OF “A”
POLYSACHARIDE, 50 MICRO GRAMS OF “C” POLY
SACHARIDE, 1 MG OF LACTOSE.
DOSE - 0.5 ML OF IRRESPECTIVE OF AGE GIVEN
SUBCUTANEOUSLY.
EFFICACY– SEROGROUP “A’ CLINICAL EFFICACY
= 85-95%
SERO GROUP “A’ INDUCES ANTIBODY RESPONSE
IN CHILDREN AS YOUNG AS 3 MONTHS OLD.
BUT SEROGROUP “C” DOES NOT INDUCE
ANTIBODIES BEFORE 2 YEARS OF AGE.
SEROGROUP “Y” AND W-135 ARE SAFE AND
IMMUNOGENIC IN ADULTS AND CHILDREN
ABOVE AGE OF 2 YEARS.
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
VACCINATION UNDER 2 YEARS OF AGE
WHICH IS THE HIGHEST SUSCEPTIBLE
PRESENT STRATEGY FOR
VACCINATION
ONLY HIGH RISK PEOPLE
(HEATH CARE WORKERS,
TRAVELLERS, PEOPLE LIVING
IN OVERCROWDED PLACES)
AND CLOSE CONTACTS HAVE
TO BE VACCINATED.
VACCINATION FOR CONTACTS
1.
2.
3.
FORTUNATELY, WE HAVE
QUADRIVALENT VACCINES AT
PRESENT
PROTECTION OCCURS ONLY AFTER
14 DAYS OF VACCINATION
HENCE CHEMOPROPHYLAXIS IS
PROVIDED WITH ANTIBIOTICS IN
THE MEANTIME
VACCINATION FOLLOWED BY +
CHEMOPROPHYLAXIS FOR
CLOSE CONTACTS
HOUSEHOLD MEMBERS
DAY-CARE CENTRE CONTACTS
ANYONE DIRECTLY
EXPOSED TO THE PATIENT'S
ORAL SECRETIONS OR
RESPIRATORY DROPLETS.
CHEMOPROPHYLAXIS
FOR CLOSE CONTACTS
WITHIN 24 HOURS FOR
• HOUSEHOLD
CONTACTS
•CLOSE CONTACTS
•HIGH RISK
PERSONS
WITH
CIPROFLOXACIN,
RIFAMPICIN,
MINOCYCLINE,
SPIRAMYCN,
CEFTRIAXIONE
RISK COMMUNICATION
FOR ACTIVE
AND
SUSTAINED
COMMUNITY
PARTICIPATION
TO CONTROL
THE EPIDEMIC
THROUGH PUBLIC
EDUCATION
REGARDING
RISK FACTORS AND
POSSIBLE CONTROL
STRATEGIES
NOTIFICATION OF
CASES AT THE
EARLIEST
SURVEILLANCE
PUBLIC EDUCATION
AVOID OVERCROWDING.
DO NOT SHARE DRINKING BOTTLES,
GLASSES, CIGARETTES, LIPSTICKS
OR OTHER ITEMS THAT MAY BE
COVERED IN SALIVA.
AVOID SMOKY AND DUSTY PLACES.
TEACH CHILDREN NOT TO SHARE
CUPS, SOFT DRINK CANS OR SPORTS
WATER BOTTLES.