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Meningitis- A real headache

Neil Pascoe RN BSN CIC

Epidemiologist

Infectious Disease Control Unit

TDH

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Acknowledgements

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Overview

DefinitionsEpidemiology DiagnosisControl MeasuresResources

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Considerations

Host factorsAge, race, sexUnderlying medical conditions,

genetics, medicationsOrganismInterventions/support

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Definitions

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Blood Brain Barrier Neurons of the brain and spinal cord are

protected from chemical damage and many biological substances by "blood brain barrier", interposed between the blood and the CSF by the endothelial cells of the capillaries and the choroid plexus.

Some drugs cannot penetrate the barrier. This protective device has many elements,

ranging from junctions between endothelial cells in the capillaries of the brain, restricting permeability of larger molecules to neuroglia.

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Meningitis (pl. meningitides)

Acute or chronic inflammation of the tissues that cover the brain and spinal cordPresentation hours to weeks or longerusually caused by a viral or bacterial infection. Less frequently, it can be caused by a parasites, fungi, chemicals, or drugs

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Meningismus (meningism)

Irritation of the brain and spinal cord with symptoms simulating meningitis, but without actual inflammation

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Encephalitis

Shares features with acute meningitisBoth often present with F, HA, AMSMental status ∆’s occur early in onsetBehavioral or speech disturbances Focal or diffuse (seizures/hemiparesis)Acute or chronic (usu. slower onset)Both may lead to disability/death

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Epidemiology

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Is meningitis contagious?

Possible, but not likelyIf causative organism is transmitted it usually manifests with the Sx and illness typically associated with the organismThe organisms that cause (aseptic) meningitis may be as contagious as the common cold

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Risk Factors

Persons who are colonized or recent acquisition of organismTwo groups of people have a greater chance of getting sick, as a result of direct contact to the infected case:

persons who share close living quarters where there is a case of meningitispreschool age children in day care centers where there is a case of meningitis

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Risk Factors cont’d

Persons having underlying medical conditionsSmokers and passive smokeAlcohol useCorticosteroid useStudents living in close quarters such as dormitoriesLifestyle behaviors

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Risk Factors cont’d

Virus can often be isolated from the stool of an infected personDiaper changing or providing personal hygiene for an infected person can be a risk to the caregiverHCWs at increased risk of contracting organism are those who come into direct (unprotected) contact with respiratory tract secretions eg intubation, suctioning, or respiratory therapy.

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Symptoms include (>1 yr):

FeverSevere headacheStiffness of the neck/backacheNausea and possible vomitingphotophobiaA skin rash that looks like small, purplish-red spotsConfusion, as well as coma is possible

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Diagnosis

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Diagnosis

Clinical determination (history, high risk group, risk behaviors…)

Lab findingsEpi linked

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Cerebrospinal Fluid (normal values)

50-195 mm H2OClearColorlessGlucose 50-85Protein 15-45RBC, CBC w dif, gram stain, Bact. CxLatex antigen, PCR,

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Typical CSF Findings by Cause*

Cause WBC (cell/mm3

)

Primary Cell Type

Glucose (mg/dL)

Protein (mg/dL)

Viral 50-1000

Mono. >45 <200

Bacterial

1000-5000

Neut. <40 100-500

TB 50-300 Mono. <45 50-300

Crypto. 20-500 Mono <40 >45*From Mandel 6th Ed.

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Viral agents

Many different viruses can cause meningitis.80-90% of identified organisms are enteroviruses.Most frequently spread by direct contact with respiratory secretions.

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Viral agents

Enteroviruses80 % of identified

isolates are echoviruses and coxsackie virus

Nonpolio enterovirusMumpsArbovirusesHerpesHIVAdenovirusPoliovirus

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Bacterial agents

N. meningitidisS. pneumoniaeS. agalactiaeListeria monocytogenesStaph species

E. coli, klebsiella, salmonella, M. tbH. fluOtherunknown

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Age 

Bacteria

Birth to one month of age S. agalactiae, E. coli, Listeria monocytogenes,Klebsiella pneumoniae, enterococcus species 

One to three months S. agalactiae, E. coli, L. monocytogenes,

H. influenzae, S. pneumoniae, N. meningitidis 

Three months to over 15 years 

N. meningitidis, S. pneumoniae, H. influenzae,   

Most Common Meningitis-Causing Bacteria by Patient Age

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Pathogenesis of bacterial meningitis

Mucosal colonization>Local penetration/invasion>Bacteremia>Meningeal invasion>Subarachnoid replication>Many pathologic and physiologic changes

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Course of Illness

Usually, viral meningitis is less severe than bacterial meningitisThe symptoms usually last about 7 to 10 days for viral meningitisBacterial meningitis can result in disability or death (seizures, behavioral) May take months to recover

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Seasonal variation

The enteroviruses are very common during the summer and early fall, although most infected people either have no symptoms or develop a cold or rash with low-grade fever.Meningococcal meningitis disease peaks late winter/early spring.

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Viral Meningitis in Texasby Month of Occurrence 2000-2004

0

20

40

60

80

100

120

140

160

Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec

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Meningococcal Disease in Texas by Month of Occurrence, 2000-2004

0

5

10

15

20

25

30

Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec

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Viral Meningitis in Texas,Rates per 100,000

0

12

3

45

67

8

910

2000 2001 2002 2003 2004

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Bacterial Meningitis in Texas, Rates per 100,000

0

12

3

45

67

8

910

2000 2001 2002 2003 2004

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Treatment:

There is no specific treatment for viral (aseptic) meningitis. Most infected persons recover completely on their own with supportive careBed rest, fluids, analgesics, antipyretics

Bacterial meningitis can be Rxd effective antibioticsTreatment must be started early in the course of disease.

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Meningococcal Disease

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Pennsylvania 2001, 2000

U.S. Meningococcal Outbreaks, 7/94-6/01

X Organization-based outbreak

Massachusetts 1995, 1997, 1998

Colorado 1997

Tennessee 1996, 1997, 1997

North Carolina 1996

X

X X

Community outbreak

Arizona 1997

X

Florida 1996

X

Central Texas 1994

NE Texas 1996NE Texas 2002

Minnesota 1995Minnesota 1998

NW New Mexico 1995

Illinois 1996

East Texas 1994

Illinois 1996

X

South Carolina 1996

New Hampshire 1995 1999

Virginia 1996, 1999, 2000

XX

Washington 1995, 1996

Missouri 1995

X

South Florida 1995

Alaska 1996

Wisconsin 1996Wisconsin 2000

East Texas 1995East Texas 2001East Texas 2001East Texas 2001

Virginia 1995, 1996

Southern CA 1995

Pennsylvania 1995, 2001

X

XX

X Maryland 1997

XX

New York 1995, 1997

X

North Carolina 1995

XX

Northern CA 1995

X

Central Florida 1995Central Florida 1997

Vermont 1995

Georgia 1995, 1997

X

Missouri 1997 Missouri 2002

XX

XX

Arkansas 1999

XCalifornia 2000

Northern CA 2000

X

X

Northern CA 2001

X

Louisiana 2001

XX

Connecticut 1997, 2001X

Florida 1998

Florida 1997

X

X

Iowa 2000

Iowa 1998

X

Kansas 2001Kentucky 1997

X

Michigan 2002

North Carolina 1997X

North Dakota 1999

X

Ohio 2000Ohio 2001

X XX

XXX

X

South Central Texas 2001

XX

X

Washington 2002

*Woods, IDSA 2003

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Meningococcal meningitis (disease)

Meningococcal meningitis is caused by Neisseria meningitidismost severe form of bacterial meningitis10-15% of infected persons will die, often within hours of onset May result in blindness, deafness, amputations, permanent brain damage

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• The “glass test” can be used to see if a rash might related to septicemia

• If you press the side of a clear drinking glass firmly onto the spots or bruises, they will not fade (blanch) 

• In a small number of cases, the rash may fade at first, but may later change into one that does not 

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Transition Slide

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Meningococcal CPx(Patti Grant’s slide)

Everyone who was in the ED at the time the patient came through the ED, was in the

hospital at the time of admission or heard of the case, knew the patient, thought they

knew the patient, wanted to know the patient, could have known the patient, was related to the patient, lived in the community, attended the same school, daycare, church, shopped at

the same store or worked with the case/patient, wants and perhaps should be considered for chemoprophylaxis… however

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Close contacts of a case:

A close contact is defined as person’s in the same household or day care Anyone with direct contact with a patient’s oral secretions (such as boyfriend or girlfriend, sharing utensils, food or drink etc)

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Prophylaxis of close contacts:

Antibiotics are recommended to prevent MD diseaseobservation of household, day care, and other intimate contacts for early signs of the illnessCases should also be vaccinated against MD

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Who develops meningococcal meningitis (disease)?

5-15% of normal healthy people are asymptomatic carriers of Neisseria meningitidis in the nasopharynx Endemic areas much higher carriage ratesIt is not clear why colonized persons become ill.

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R anterior leg lesion--postoperative debridement

R anterior leg lesion--postoperative debridement

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Right lateral-superiorleg lesion

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Control Measures

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Prevention:

Don’t share eating or drinking utensils, toothbrushes, or anything else that would include saliva exchangeCover your mouth when you cough or sneezeWash your hands frequently especially after coughing or sneezing or use an ETOH-based hand sanitizer

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Vaccines

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Pneumococcal VaccinesPolysaccharide (Pneumovax®)

23/90 serotypes (85% +disease)Over 642+ w chronic disease at risk for pneumo.

disease2+ immunocompromised at risk for

infection2+ w functional or anatomic asplenia

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Pneumococcal VaccinesConjugate (Prevnar®)

7-valent capsular vaccine (80% of disease in children <6yrs)

Children 2-59 months at risk for pneumococcal disease

Administered at 2, 4, 6 and 12-15 months

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Meningococcal VaccinesPolysaccharide (Menomune®)

MPSV4Covers serogroups A, C, Y, and W-135Does not protect against serogroup B diseaseProtective antibody levels are usually achieved within 7-10 days of vaccinationRoutine vaccination is not recommended College freshman, lab, military

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Meningococcal Vaccines(Conjugate-Menactra®)

MCV4 4/5 (A, C, Y &W-135) of major serogroups

causing disease Does not protect against serogroup B

disease Ages 11-55 especially 11-12 YO Others (military, HS/college students,

travelers)

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Isolation Precautions

Are they necessary??Isolation for 24 hours is

recommended with droplet precautions

Standard precautions alwaysDroplet/airborne may be indicated

for specific situations

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Reporting:

If meningococcal disease is suspected, report immediately to the DSHSIf bacterial or viral meningitis is suspected, report within one week to TDHTexas Health and Safety Code, Chapters 81, 84, and 87Texas Administrative Code, Chapter7, Title 25

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Resources

http://www.nlm.nih.gov/medlineplus/encyclopedia.html

http://www.dshs.state.tx.us/idcu/disease/meningitis/

http://www.cdc.gov/health/diseases.htm http://www.cdc.gov/nip/publications/aci

p-list.htm IDCU-Neil 512 458-7111 x2358 neil.pascoe@dshs.state.tx.us