North
Cumbria District Control of Infection Committee: Guidance for Health Professionals
on the Control of Invasive Meningococcal Disease
These guidelines are based on the findings of the PHLS Meningococcal Infections Working Group and Public Health Medicine Environmental Group and on the report by EB Kaczmarski and KAV Cartwright, both of which appeared in the Communicable Disease Review: 5(13); 8th December 1995.
Early management;
Case
Definitions;
Early
Notification;
Confirming
the Diagnosis;
Dealing
with Contacts;
Chemoprophylaxis;
Vaccination;
Management
of a Sporadic Single Case in a School or Nursery;
Management
of a Cluster of Cases in a School or Nursery;
Communications
Early management of suspected meningococcal disease
Doctors first seeing a suspected case of invasive meningococcal disease should consider treating immediately with intramuscular or intravenous benzyl penicillin, while arranging urgent hospital admission.
Suggested stat doses are:-
Adults and children over 9 years: 1,200mg
Children aged 1 to 9 years: 600mg
Children under 1 year: 300mg
If patients have a clear history of anaphylactic shock with penicillin, then parenteral chloramphenicol is recommended by the PHLS Working Group as follows:-
Adults: 1.2g
Children under 12yrs: 25mg/kg
It is strongly recommended that all GPs should carry benzylpenicillin in their bag. Pre-admission parenteral penicillin halves the mortality in meningococcal septicaemia.
It is important that details of any antibiotic treatment given to the case prior to admission should be passed by the GP to the admitting hospital doctor.
Case definitions for meningococcal disease
Confirmed Case
Clinical diagnosis of meningitis and/or septicaemia confirmed microbiologically as caused by Neisseria meningitidis.
- Meningococcal infection of joint, heart, or eye (including conjunctiva), should also be regarded as a confirmed case for public health action.
Probable Case
Clinical diagnosis of meningococcal meningitis and/or septicaemia, without microbiological confirmation, in which the CCDC or deputy, in consultation with the clinician managing the case, considers that meningococcal disease is the most likely diagnosis.
- In the absence of an alternative diagnosis, a feverish, ill patient with a petechial / purpuric rash should be regarded as a probable case.
Possible Case
As per 'Probable Case', but the CCDC or deputy, in consultation with the clinician managing the case, considers that diagnoses other than meningococcal disease are at least as likely.
- This category includes cases treated with antibiotics whose probable diagnosis is viral meningitis.
Confirmed and probable meningococcal disease cases require public health control action in the form of contact tracing and prophylaxis. Possible cases will not routinely require public health action unless the level of suspicion increases.
Good, timely liaison between clinicians, microbiology laboratories and the Public Health Department is the key to the successful control of invasive meningococcal disease.
Formal notification of all forms of meningitis and meningococcal septicaemia is a legal requirement. We very much appreciate an early telephone alert to the CCDC, or deputy, during 'waking' hours, of a suspected case of meningococcal. This enables appropriate prophylaxis of 'risk contacts' to be undertaken within the recommended 24 hour time period. Also early measures can be taken by the CCDC which will help to minimise potential public anxiety.
Notification should be made to the Consultant in Communicable Disease Control (CCDC), or deputy
Office hours: telephone (01228) 603542; Fax (01228) 603621
Out of hours: contact the duty public health doctor via either the Cumberland Infirmary switchboard (01228 523444) or the West Cumberland Hospital switchboard (01946 693181).
If a case is suspected through the night, a notification first thing the next morning would be greatly appreciated. Prophylaxis is best administered within 24 hours, and there is little that can usefully be done through the night in terms of arranging antibiotics, contacting schools etc.
Confirming the diagnosis - Laboratory tests
The precise identification of the causative organism is of utmost importance to the control management of both case and contacts.
This information is also crucial to the surveillance of clusters and outbreaks of invasive meningococcal disease and the observation of trends within North Cumbria and nationally.
It is recommended by the PHLS Meningococcal Reference Laboratory (http://www.phls.co.uk) that certain essential samples should be taken from every case of suspected meningococcal disease - as soon as possible after the patient is first seen in hospital (regardless of previous antibiotic treatment). These specimens should be urgently sent to the local microbiology laboratory or PHL.
The following samples are regarded as essential in every case of suspected invasive meningococcal disease:-
- Blood for culture
- EDTA blood specimen (2.5 to 5ml) - to be held in the hospital laboratory pending culture results. Specimens from culture-negative cases will then be sent to the MRU for PCR examination.
- Acute serum specimen (at least 0.5ml). If the diagnosis remains unconfirmed, it may be necessary to arrange a convalescent specimen after 14-21 days.
- If possible, a sample of CSF should be taken for microscopy, culture and latex agglutination.
NB: The above specimens should be processed urgently using 'on call' laboratory facilities if outside ordinary working hours.
In addition to these essential specimens it may be considered appropriate to obtain:-
- Haemorrhagic skin rash (petechiae, purpura, or larger areas of haemorrhage), if present, can be sampled for microscopy and culture.
- Throat Swabs and Faeces should be sent if viral infection is included in the differential diagnosis.
- Throat or Per-nasal Swabs taken from household family members before prophylaxis may help to identify the causative organism, especially when the index case is < 5 years of age. Careful counselling is advised under these circumstances to avoid possible feelings of guilt.
Dealing with at-risk contacts associated with a sporadic index case
The risk of other cases of meningococcal disease occurring, which are 'linked' to a probable or confirmed sporadic index case, may be reduced by the proper management of those who have had certain specific types of contact with that case.
An At-risk contact can be defined as:
Any person who, since 7 days prior to the onset of illness in the case, has lived and slept in the same household and/or had mouth-to-mouth kissing contact with a confirmed case or a probable case of meningococcal disease.
- In certain circumstances, there may be others who might be considered as 'at risk contacts' having had equivalent contact to the above. The CCDC can advise. Typically this type of contact might include regular child minders etc.
- It is important that only true 'risk contacts' are identified and given chemoprophylaxis, otherwise large numbers of persons may demand unnecessary medication.
The following would usually therefore be classed as close contacts, and be offered prophylaxis:
- People in the same household
- People not in the same household, but who have slept in the house during the seven days prior to the onset of the illness
- People not in the same household but who have spent a substantial period of time (i.e. several hours a day) in the house during the seven days prior to the onset of the illness
- "Kissing Contacts" i.e. boy/girlfriend
- Students sharing the same room or flat as the case
- Anyone who gave mouth-to-mouth resuscitation to the index case
- Children and adults who attended the same child minder as the index case in the seven days prior to the onset of the illness
The following categories of contact do not generally require prophylaxis:
- Health care staff, other than those who have given mouth-to-mouth resuscitation
- School, nursery or playgroup contacts
- Community contacts, other than those described above
- Students on the same course not in the above categories
- Students in the same hall of residence not in the above categories
- Teaching staff , and staff at a hall of residence not in the above categories
Routinely, all persons falling into the category of 'risk contact' should be offered chemoprophylaxis. The index case (unless treated with ceftriaxone or ciprofloxacin) and health staff who have performed mouth-to-mouth resuscitation on a case should also be offered chemoprophylaxis.
Other types of contact such as social, ambulance or ordinary clinical/nursing contact are not normally regarded as at risk contacts and therefore do not require chemoprophylaxis.
It is sometimes most practicable for certain risk contacts to receive chemoprophylaxis directly from the hospital ward and/or hospital pharmacy (e.g. mothers may be staying with their sick child on the ward). Arrangements should be in place at DGH pharmacies for 24 hour supplies of rifampicin tablets and syrup. GPs will usually be informed by the CCDC if chemoprophylaxis has been given to their patients in this way.
GPs and hospital clinicians are quite free to distribute chemoprophylaxis to "at Risk" Contacts as defined above. The CCDC or deputy will always interview the case and / or family (either in person or over the telephone) and decide if anyone else has had an equivalent level of exposure.
In addition to chemoprophylaxis, it is also good practice for the prescribing doctor to give verbal advice and information in the form of leaflet material to At-risk contacts. Suitable material is available from the National Meningitis Trust and the National Meningitis Research Foundation.
A local North Cumbria Leaflet is available for download from the "Leaflets" section of this web site.
All At-risk contacts should be reminded of the persisting, but small, risk of disease, whether or not prophylaxis is given, and of the need to seek urgent medical advice if they develop symptoms suggestive of meningococcal disease.
Principles
It is important to realise that chemoprophylaxis is not designed to prevent disease in a contact who is already incubating invasive meningococcal disease. Nor will it prevent a person being re-colonised by a pathogenic Neisseria meningitidis after the short course of chemoprophylaxis is completed.
The theoretical underpinning which leads the PHL Working Group to recommend chemoprophylaxis is that the contemporaneous eradication of nasopharyngeal carriage of pathogenic N. meningitidis from the 'close contact network' is likely to reduce the otherwise increased statistical risk of invasive meningococcal disease in 'susceptible' persons within that contact group.
The risk of a second, linked case, in the immediate close contacts is about 1% if no chemoprophylaxis is given. The risk of 'linked' cases outside the 'close contact network' is statistically unlikely following a single sporadic case of meningococcal disease.
Choice of Drug
Unless contraindicated (e.g. jaundice or known hypersensitivity), rifampicin is the drug of choice for meningococcal chemoprophylaxis. Suggested doses are as follows.
Adults and children over 12 years of age: 600 mg 12 hourly on 2 consecutive days
Children aged 1 - 12 years: 10 mg/kg 12 hourly on 2 consecutive days
Infants under 1 year: 5mg/kg 12 hourly on 2 consecutive days
Approximate doses in infants and children (based on average weight for age) are:-
0-2 months 20mg (1ml syrup)
3-11 months 40mg (2ml syrup)
1-5 years 150mg (7.5ml syrup)
6-12 years 300mg (one tablet)
Persons who are prescribed rifampicin chemoprophylaxis should be given verbal advice and written information material by the person prescribing the antibiotic.
Warnings should include that:-
- The drug may cause urine and other body fluids to turn orange red.
- Soft contact lenses should not be worn until urine returns to normal colour.
- Those on the contraceptive pill should be advised to take additional precautions following the Family Planning Association's advice for a 'missed pill' as outlined in the British National Formulary.
Alternatives to rifampicin for adults (recommended by the PHLS Working Party) include:-
- Ciprofloxacin (single oral dose 500mg - the patient should be informed that this drug is not licensed for use in chemoprophylaxis)
- Ceftriaxone (250mg reconstituted with 2ml 1% lignocaine hydrochloride before single intramuscular injection).
Pregnancy
Pregnant women who are 'risk contacts' should be carefully considered with regard to risks and benefits. No drug can be regarded as absolutely safe in pregnancy. However, rifampicin and ceftriaxone are recommended in the USA as safe for certain uses in pregnancy and no resulting harmful effects to the foetus have been documented.
Options for pregnant women who are 'risk contacts' of meningococcal disease include:-
- No prophylaxis, but the patient should be watchful for the signs and symptoms of meningococcal disease
- Chemoprophylaxis with rifampicin or ceftriaxone
- Examination of a throat swab from the pregnant 'risk contact'. If the same strain of N. meningitidis as the index case is isolated - prophylaxis can be considered as above.
Exceptions to the above pharmacological guidance are best resolved on a case by case basis in consultation with the medical microbiologist and/or the hospital clinician involved.
Summary Table:
| Serogroup | Recommended Vaccine |
| A | "Plain" A/C Vaccine |
| B | None |
| C | Men C Conjugate |
| W135/Y | Quadrivalent vaccine (from SKB on a named patient basis) Tel 01707 325111 (please speak to CCDC first) |
Polysaccharide meningococcal immunisation
If the causative organism can be identified as serogroup C, A, W135 or Y, the CCDC will notify the GPs of the known At-risk contacts' (by fax and/or telephone), so that consideration can be given by the GPs to appropriate meningococcal immunisation.
There is little response to vaccine by those, with Group C, who are aged less than 18 months. Similarly, with Group A, below three months of age.
Vaccine should not be given to contacts of Group B cases.
Although the index case should receive chemoprophylaxis after treatment to eradicate nasopharyngeal carriage, it is not necessary for them to receive vaccine whatever the serogroup.
The use of vaccine in pregnancy is not routinely recommended by the manufacturers as the effect on the foetus is not known.
Conjugate Meningococcal Vaccine
Conjugate meningococcal C vaccine is more effective than polysaccharide vaccine and it should be used in preference to the polysaccharide vaccine for close contacts of Group C cases.
Sporadic single cases in educational settings
The following guidance applies, in term time only, to single sporadic cases in pre-school groups, primary schools, secondary schools, colleges and Universities.
On the basis of a single sporadic case in such an educational setting, prophylaxis with antibiotics or vaccine should not routinely be offered to staff and attenders/pupils/students etc. merely because of their attendance at the establishment.
If however, 'household-type' contact (e.g. 'dormitory' contacts in a boarding school) or mouth-to-mouth kissing contact has occurred within the educational establishment, then the involved individuals should be dealt with as standard At risk contacts.
Other At risk contacts not associated with the educational establishment should be managed in the usual way, as described above.
Reassurance, advice and information about meningococcal disease should be given to staff, parents/guardians and local GPs. In secondary schools, colleges and universities pupils should also be informed. The CCDC will work to achieve this in collaboration with the School Health Services, the Community Health Services and Primary Health Care Teams, as appropriate.
Management of a 'cluster' of cases in an educational setting
If two or more cases occur in the same educational establishment involving organisms with the same serogroups, within a four week time period, the CCDC will give advice regarding the need to offer meningococcal prophylaxis to certain 'institutional contacts' at the establishment in question. The circumstances prevailing at the time will dictate the details of the response. This activity will be in addition to the routine management of the usual At risk contacts.
An association like this, in time and place, means that further investigation is required to establish if the two cases are associated by chance or are genuinely linked. A definite cluster (ie two cases of the same serogroup) or a potential cluster (one confirmed case and another that could potentially be of the same group) will require wider public health action. Two cases of different serogroups are clearly unlinked sporadic cases.
In a serious emergency, it may be that local NHS Trust Provider Units will need to become involved. Community staff may need to be withdrawn from other more routine activity in the school health service and/or primary care sector to deal with a large-scale emergency. It is likely that this potential disruption to normal services would only be short term and rare.
Good communication is the key to the efficient control management of meningococcal incidents.
The admitting hospital doctor is responsible for initially alerting the CCDC (or deputy) by telephone about a probable or confirmed index case of invasive meningococcal disease. This doctor will then subsequently follow up this informal notification with a formal notification on the certificate provided. A fee is payable.
The involved Consultant Medical Microbiologist is responsible for timely liaison with the CCDC regarding laboratory findings both in the acute phase of the incident and subsequently. This includes the passing of reports from the Meningococcal Reference Laboratory regarding serogrouping and typing of organisms.
The Consultant in Communicable Disease Control is responsible for timely communication with GPs, schools and other relevant individuals and authorities, according to the circumstances of the incident. The CCDC will also deal with the 'public health' aspects of media liaison, if this becomes necessary (see Communicable Disease Media Policy).
The Department of Public Health Medicine keeps a local surveillance register relating to all cases of invasive meningococcal disease resident in the authority district.
Updated 30th April 2001