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Meningococcal disease and healthcare workers
Abstract
EDITOR—I read with interest the editorial by Pollard and Begg.1 For eight years, a vaccine for serogroup meningococcus B has been available in Latin America. This vaccine is produced in Cuba, and, although it may not be perfect, it has shown immunogenicity. The statement that there is no vaccine is incorrect. I would like to know whether Pollard and Begg are aware of this but think it is not a recommended vaccine, or if they are not aware of it.
References1.↵Pollard AJ, Begg N. Meningococcal disease and healthcare workers. BMJ 1999; 319: 1147–1148. (30 October.)OpenUrlFREE Full Text
Prophylaxis is not necessary
P Cowling, consultant microbiologist (peter.cowling@sgh.tr-trent.nhs.uk)Erfan Hospital, 21452 Jeddah, Saudi ArabiaScunthorpe and Goole Hospitals NHS Trust, Scunthorpe, South Humberside DN15 7BHSomerset Health Authority, Taunton TA2 7PQPublic Health Laboratory Service Communicable Disease Surveillance Centre (South West), Public Health Laboratory, Gloucestershire Royal Hospital, Gloucester GL1 3NNNorth Yorkshire Health Authority, Clifton Moor, York YO3 4GQNewcastle General Hospital, Newcastle upon Tyne, NE4 6BEDepartment of Microbiology, General Infirmary and University of Leeds, Leeds LS1 3EXDivision of Infectious Diseases and Immunology, British Columbia Children—s Hospital and British Columbia Research Institute for Children—s and Women—s Health, 950, Vancouver, BC V5Z 4H4, CanadaPublic Health Laboratory Service Communicable Disease Surveillance Centre, London NW9 5EQ
EDITOR—Traditionally, Monday mornings are depressing times for medical microbiologists. Until now, this has largely been a result of the handful of new cases of methicillin resistant Staphylococcus aureus discovered over the preceding weekend. In November, however, my usual gloom was turned to despair by a flurry of telephone calls from colleagues in various states of panic demanding prophylaxis for meningococcal disease. I am a consultant microbiologist and infection control doctor, and it has taken me a long time to convince healthcare workers at my trust that antimeningococcal prophylaxis is not necessary for healthcare workers, including ambulance crews, after nursing a patient with meningococcal disease. The only exception to this rule is after mouth to mouth resuscitation.
Pollard and Begg in their editorial are advising that antibiotics should be offered to healthcare workers with direct exposure to potentially infected secretions, despite their own assertions that few published reports exist of healthcare workers or laboratory staff developing invasive meningococcal disease.1 This advice seems to be based on a single case of a paediatrician in France, who developed meningococcaemia after intubating a child with meningococcal disease.2 I do not know whether or not a causal link was proved in this case. Such advice is contrary to national guidance.3
Furthermore, the risks of antibiotic chemoprophylaxis are not adequately covered in …
... Globally, IMD can occur as an endemic disease with sporadic cases or as epidemics with outbreaks, and its incidence therefore varies from less than 1 cases per 100,000 population every year (the typical incidence in many Western Countries, such as Italy) to over 1,000 cases (3,6). With a death rate of 6% to 10% of cases, and sequelae reported in 4.4% to 11.2% of cases, IMD represents a leading cause of morbidity and mortality worldwide (3,(6)(7)(8), being a leading infectious cause of death in childhood, and the third most common cause of death in children outside infancy (7,8). ...
... Globally, IMD can occur as an endemic disease with sporadic cases or as epidemics with outbreaks, and its incidence therefore varies from less than 1 cases per 100,000 population every year (the typical incidence in many Western Countries, such as Italy) to over 1,000 cases (3,6). With a death rate of 6% to 10% of cases, and sequelae reported in 4.4% to 11.2% of cases, IMD represents a leading cause of morbidity and mortality worldwide (3,(6)(7)(8), being a leading infectious cause of death in childhood, and the third most common cause of death in children outside infancy (7,8). ...
... Although usually associated with a high perceived risk among those who have had contact with a case, occupational transmission of IMD has been rarely reported, even among professionals having strict contact with cases (2,3,7,(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23): in this systematic review, available evidence about occupational epidemiology of IMD will be specifically described. ...
Methods:
The following key words were used to explore PubMed: Neisseria meningitidis, meningococcus, meningococcal, invasive meningococcal disease, epidemiology, outbreaks, profession(al), occupation(al).
Results:
We identified a total of 12 IMD cases among healthcare workers (HCW), 44 involving biological laboratory workers (BLW), 8 among school personnel, and eventually 27 from other settings, including 3 large industrial working populations. Eventual prognosis of BLW, particularly the case/fatality ratio, was dismal. As clustered in time and space, data about school cases as well as industrial cases seem to reflect community rather than occupational outbreaks. In general, we identified a common pattern for HCW and BLW, i.e. the exposure to droplets or aerosol containing N meningitidis in absence of appropriate personal protective equipment (PPE) and/or microbiological safety devices (MSD) (e.g. cabinets). Post-exposure chemoprophylaxis (PEC) was rarely reported by HCW (16.7%) workers, and never by BLW. Data regarding vaccination status were available only for a case, who had failed requested boosters.
Conclusions:
The risk for occupational transmission of IMD appears relatively low, possibly as a consequence of significant reporting bias, with the exception of HCW and BLW. Improved preventive measures should be implemented in these occupational groups, in order to improve the strict use of PPE and MSD, and the appropriate implementation of PEC.
... English and Welsh guidelines recommend antibiotics for health-care workers after mouth-to-mouth resuscitation only, whereas North American guidance includes those who have done airway-management procedures such as endotracheal intubation. 1 We undertook a retrospective survey to measure the risk of meningococcal disease in health-care workers who had been in close contact with cases in England and Wales between 1982 and 1996. ...
... antibiotic treatment is started. 2 The few other documented health-care-worker cases record a similar pattern of contact. 1,4 The relative risk of infection in health-care workers is much lower than that in household contacts of a case, 5 and the low absolute risk reflects the low baseline incidence of meningococcal disease in people older than 20 years. Our estimates suggest that if all health-care-worker contacts received 90% effective chemoprophylaxis, 144 000 health-care workers would need to be treated to prevent one case. ...
... Suggested changes to UK guidelines were not based on evidence of risk. 1 Our data should be used to develop evidence-based guidance on staff prophylaxis and prevent the inappropriate use of prophylactic antibiotics. More accurate quantification of risk is unlikely to be obtained. ...
Based on new data on the risk of secondary meningococcal disease in health care workers, a review of published cases and an assessment of the available evidence, a change to the recommendations for giving chemoprophylaxis to health care workers in England and Wales is proposed. Previous guidance recommended prophylaxis only for those who had given mouth to mouth resuscitation. Chemoprophylaxis is now recommended for health care workers whose mouth or nose has been directly and heavily exposed to respiratory droplets/secretions from a case of meningococcal disease around the time of hospital admission. Wearing surgical face masks is encouraged to reduce risk of exposure.
... English and Welsh guidelines recommend antibiotics for health-care workers after mouth-to-mouth resuscitation only, whereas North American guidance includes those who have done airway-management procedures such as endotracheal intubation. 1 We undertook a retrospective survey to measure the risk of meningococcal disease in health-care workers who had been in close contact with cases in England and Wales between 1982 and 1996. ...
... antibiotic treatment is started. 2 The few other documented health-care-worker cases record a similar pattern of contact. 1,4 The relative risk of infection in health-care workers is much lower than that in household contacts of a case, 5 and the low absolute risk reflects the low baseline incidence of meningococcal disease in people older than 20 years. Our estimates suggest that if all health-care-worker contacts received 90% effective chemoprophylaxis, 144 000 health-care workers would need to be treated to prevent one case. ...
... Suggested changes to UK guidelines were not based on evidence of risk. 1 Our data should be used to develop evidence-based guidance on staff prophylaxis and prevent the inappropriate use of prophylactic antibiotics. More accurate quantification of risk is unlikely to be obtained. ...
Guidelines on chemoprophylaxis vary between countries and reflect uncertainty about the risk of meningococcal disease in healthcare workers. In a retrospective survey of risk in healthcare workers in England and Wales, three pairs of primary cases and health-care workers with secondary infections were identified between 1982 and 1996. Secondary infections were probably caused by exposure to primary cases' respiratory droplets around the time of admission. We estimated an attack rate of 0.8 per 100000 health-care workers at risk, a risk 25 times that in the general population (p=0.0003). The excess risk is small and inappropriate use of prophylactic antibiotics should be avoided.
... The excess risk for physicians, nurses, or paramedics with intensive close contact during airway management or mouth-to-mouth resuscitation of infected cases is estimated 25 times that in the general population [8]. The majority of occupationally acquired meningococcal disease, however, occurred in the setting of improper precaution, i.e., unprotected exposure to infected patients without use of post-exposure chemoprophylaxis [9,10]. ...
... The majority of published meningococcal infections in health care workers, however, occurred in the setting of improper precautionary measures. Using appropriate personal protective equipment of any kind and post-exposure chemoprophylaxis, the risk for occupational meningococcal transmission resulting in either secondary meningococcal disease or carriage is estimated to be low [9,10]. ...
Pharyngeal carriage is the reservoir for Neisseria meningitidis in the population and the first step in disease transmission. Especially in young infants and adolescents, N. meningitidis can cause serious invasive infection with high fatality rates and high rates of long-term sequelae among survivors. The aim of this study was to determine N. meningitidis colonization rates in asymptomatic health care professionals at a tertiary university pediatric hospital and to identify risk factors for carriage. This cross-sectional meningococcal carriage survey was conducted between April and October 2018 at the Medical University of Vienna. Individuals working as nurses, pediatricians, or medical students were enrolled. Oropharyngeal swabs were directly plated onto selective agar plates and conventional culture was used for bacterial identification. Meningococcal isolates were further characterized using whole-genome sequencing. A total of 437 oropharyngeal specimens were collected. Overall, meningococcal carriage prevalence was 1.14% (5/437), with 0.7% (3/437) for capsular genotype B, and 0.5% (2/437) for capsular genotype W. Mean age of carriers was significantly lower than of non-carriers (24.2 vs. 35.8; p = 0.004). The highest carriage rate of 4.4% (4/91) was found in the age group 18-25. Carriage was negatively associated with age and timespan working in pediatrics. This is the first study evaluating the prevalence of Neisseria meningitidis carriage in health care professionals working in Pediatrics and Adolescent Medicine. Carriage was in general lower than expected for all age groups, implicating a low risk of meningococcal transmission via this population.
... Not surprisingly, research conducted in the past 2 decades has focused on the properties of N95 respirators 14,15,16 and surgical masks 17 . The occupational risks posed by droplets (e.g., Neisseria meningitidis 18 ) or aerosol-transmitted (e.g., Mycobacterium tuberculosis 19 ) pathogens have been matters of concern since the late 20 th century. This concern was amplified with the emergence of avian influenza (H5N1) and the H1N1 pandemic in 2009 20 . ...
Even though most current recommendations include the general use of masks to prevent community transmission of SARS-Cov-2, the effectiveness of this measure is still debated. The studies on this policy include physical filtering tests with inanimate microparticles, randomized clinical trials, observational studies, ecological analyses, and even computational modeling of epidemics. Much of the so-called evidence is inferred from studies on different respiratory viruses and epidemiological settings. Heterogeneity is a major factor limiting the generalization of inferences. In this article, we reviewed the empirical and rational bases of mask use and how to understand these recommendations compared to other policies of social distancing, restrictions on non-essential services, and lockdown. We conclude that recent studies suggest a synergistic effect of the use of masks and social distancing rather than opposing effects of the two recommendations. Developing social communication approaches that clarify the need to combine different strategies is a challenge for public health authorities.
... The few clinical cases that have been reported have been exposed to the respiratory secretions of infected patients through mouth-to-mouth resuscitation, intubation or emergency resuscitation. 20 The estimated attack rate from documented secondary cases in Britain is 0.8/100,000 at-risk health care workers. 21 Twenty four hours after the administration of ceftriaxone or cefotaxime the nasopharyngeal carriage of the patient is eliminated and contacts are no longer considered at risk. ...
Ambulance officers and other emergency service personnel may be exposed to the body fluids of their patients due to the unpredictable nature of their work. As it is not possible to predict which patients may have a communicable disease, standard precautions must be practiced at all times. This is part of an occupational health and safety strategy that includes appropriate immunisation, education, and post-exposure counselling of staff. The actual risk of acquiring blood-borne viruses or other communicable diseases is less than is generally perceived and post-exposure prophylaxis is available for several of these. Hepatitis B is the most transmissible of the blood-borne viruses but there is very effective pre- and post- exposure prophylaxis available. There is effective post-exposure prophylaxis available for HIV but not for hepatitis C. An ambulance officer exposed to tuberculosis or meningococcal disease should also be offered post-exposure counselling and protective therapy as appropriate, although the risk of subsequent disease is very small. Education of staff about the actual risks involved following an exposure and the correct procedures to follow will allay fears and allow the safe and efficient management of patients outside of the hospital.
Gram‐negative infections are a rare but potentially life‐threatening cause of cutaneous lesions, often requiring urgent recognition and treatment. This chapter discusses the pathophysiology, clinical features and management of the most common Gram‐negative infections. Neisseria meningitidis is a common human nasopharyngeal commensal. In a minority of individuals it causes invasive, life‐threatening disease. The cutaneous features are often recognizable at presentation and may cause significant morbidity. Pseudomonas aeruginosa can cause both localized primary skin lesions and systemic infection with cutaneous manifestations. Pseudomonal skin infections are more commonly, but not exclusively, seen in immunocompromised individuals.
Introduction:
As invasive meningococcal disease progresses rapidly, often affects youth, and has a fairly high mortality rate, such cases are likely to fall under medical examiner/coroner (ME/C) jurisdiction. Morgue personnel may be at risk of contracting secondary meningococcal disease. We review the current scientific literature regarding Neisseria meningitidis infection and provide recommendations for the prevention of meningococcal disease at autopsy.
Methods:
A PubMed search utilizing applicable medical subject heading terms was performed retrieving articles for review from the preceding two decades. Pertinent current guidelines from multiple national organizations were also retrieved.
Results:
Invasive meningococcal disease is transmitted by direct contact with large respiratory droplets or oral secretions. While a surgical mask would normally provide adequate protection from large droplet spread, it does not prevent inhalation of smaller aerosolized particles such as those generated at autopsy. Prosectors are advised to routinely wear N-95 respirator masks or powered respirator hoods. All published cases of secondary meningococcal disease transmission to healthcare workers invariably arose in scenarios in which face masks/respirators were not employed; none of these cases involved meningococcal disease transmission to ME/C or other morgue staff.
Discussion:
In the event that no mask-or inadequate coverage such as a surgical mask-is employed during autopsy of a decedent suspected/confirmed to have invasive meningococcal disease, antibiotic prophylaxis is advisable. Assuming appropriate personal protective equipment is utilized, chemoprophylaxis is unnecessary. Routine meningococcal vaccination is not recommended, except for ME/C with specified immunocompromising conditions or traveling to hyperendemic/endemic meningococcal regions. Acad Forensic Pathol. 2018 8(2): 328-339.
Voorafgaand aan de vraag naar de kinderen van gezondheidszorgwerkers gaat de vraag of gezondheidszorgwerkers zelf een verhoogde kans op het krijgen van een meningokokkeninfectie hebben. Als dat niet het geval is, lijkt het onwaarschijnlijk dat de kinderen wel een groter risico zouden lopen.
Bacterial meningitis is one of a select group of febrile illnesses that may rapidly progress unless suspected early by the family practitioner. Unless appropriate therapy is initiated without delay, the outcome is often fatal. This article provides the family practitioner with an overview of current best practice when treating bacterial meningitis. Emphasis is placed on a high index of suspicion, particularly in certain patient groups like children where unusual atypical presentations are common. Empirical treatment options by age group for immediate therapy is discussed and the useful array of diagnostic modalities available is cataloged. The issue of chemoprophylaxis for close contacts of meningococcal disease patients and the importance of immediate notification are succinctly discussed. On a prevention note, the appropriateness of providing vaccination to travelers is considered.
Der Mensch ist einziges Reservoir der Meningokokken. Der Erreger zeichnet sich durch eine hohe genetische und antigenetische Variabilitt aus. Bisher wurden 25 genetische Linien und ber 3000 so genannte Sequenztypen beschrieben, jedoch ist nur ein geringer Teil der den Menschen besiedelnden genetischen Linien als pathogen einzustufen. Die Besiedlung mit Meningokokken induziert eine klonspezifischen Immunitt. Die klonale Verbreitung einer Meningokokkenvariante fhrt zur Herdimmunitt und trgt zum Wechsel der endemischen oder epidemischen Klone bei. Die Mehrzahl invasiver Meningokokkeninfektionen tritt sporadisch auf, Cluster werden jedoch regelmig beobachtet. bertragungen der Infektion im Krankenhaus sind beraus selten. Im afrikanischen Meningitisgrtel werden regelmig groe Ausbrche beobachtet. Reise- und Impfberatungen mssen sich an den aktuellen epidemiologischen Entwicklungen orientieren.Neisseria meningitidis (a meningococcus) colonises the human nasopharynx. This pathogen is characterised by a high level of genetic and antigenetic variability. So far, 25 clonal lineages and more than 3,000 sequence types have been described, but only a few of these have pathogenic potential for humans. Strain-specific immunity is induced by colonisation with meningococci. Furthermore, herd immunity is observed after clonal spread of a strain within a human population. Herd immunity is responsible for changes in endemic or epidemic lineages. Most cases of meningococcal infection must be regarded as sporadic; nosocomial infections are rare, but clusters are observed on a regular basis in communities. The African meningitis belt regularly sees widespread and sometimes devastating epidemics. Recommendations on travel and vaccination must be made with due consideration for the current epidemiological developments in meningococcal disease at the time of any consultation.
La posibilidad de transmisión de enfermedades infecciosas por vía aerógena o por fomites, hace necesario la instauración de protocolos de limpieza y desinfección en los vehículos de transporte sanitario, y provoca que los recursos sanitarios estén inoperativos durante más o menos tiempo de acuerdo a los procedimientos empleados. Esta posibilidad de transmisión es mayor si cabe cuando nos referimos a enfermedades emergentes o reemergentes, y se hace crítica cuando debamos realizar transporte sanitario de personas que hayan resultado afectadas por agentes NBQ. Y de aquí surge la necesidad de utilizar sistemas de aislamiento más o menos complejos, que permitan incluso realizar ciertos actos médicos. Las ventajas de su uso irán desde reducirse los tiempos de asistencia sanitaria en la zona donde se haya producido un incidente NBQ, pasando por una optimización de recursos al disminuir los tiempos de inoperatividad de los transportes sanitarios, hasta reducir los niveles de estrés del personal sanitario al no tener que utilizar equipos de protección individual para sentirse seguros.
Based on new data on the risk of secondary meningococcal disease in health care workers, a review of published cases and an assessment of the available evidence, a change to the recommendations for giving chemoprophylaxis to health care workers in England and Wales is proposed. Previous guidance recommended prophylaxis only for those who had given mouth to mouth resuscitation. Chemoprophylaxis is now recommended for health care workers whose mouth or nose has been directly and heavily exposed to respiratory droplets/secretions from a case of meningococcal disease around the time of hospital admission. Wearing surgical face masks is encouraged to reduce risk of exposure.
Meningococcal infection is one of the very few severe bacterial infections, in this era, that still can kill a relatively healthy child within minutes. Fortunately, it is a relatively rare disease. Rural practitioners may see one affected child once every 2-3 years, but once seen they will never forget it. The present article gives some examples of case scenarios along with a brief overview of the problem, with emphasis on early diagnosis, prevention and possible future developments.
The answer to this frequently asked question is addressed in this review article, which focuses on common respiratory tract infections that are spread from person to person. The author concentrates on community-based contagion rather than nosocomial infections or agents that have received recent attention principally because of their actual or potential role in biologic terrorism.
In 2004, a consensus meeting of critical care and infectious disease experts was organized to review and make recommendations on current definitions of infections, sepsis, and organ failure for neonates and children and for the predisposing conditions leading to these diseases. Among the infections leading to sepsis, meningococcemia is so distinguishable that a separate article on its diagnosis and management was thought to be warranted.
The process included a modified Delphi method, a consensus conference, subsequent smaller meetings of subgroups and key individuals, and electronic-based discussion among subgroups. A systematic review of the literature was undertaken.
Early recognition and treatment of likely meningococcal sepsis has led to decreased mortality. Since the start of vaccination against serogroup C, the prevalence of this disease has decreased. Not only the possible presence of a meningococcal sepsis is important, but also the assessment of the shock state and the severity of disease and the possible presence of meningoencephalitis. There are also a number of genetic predispositions determining the severity of disease. The only three randomized trials in this disease have led to the conclusion that mortality is not a stable end point. Improvement in organ function, morbidity (including amputations), and functional outcome are better outcome measures.
Acute bacterial meningitis (ABM) is an acute inflammation of leptomeninges caused by bacteria, and has a case fatality rate of 10-30%. Prevention strategies, such as vaccination and prophylactic antibiotics, can prevent ABM and have substantial public health impact by reducing the disease burden associated with it. The aim of this paper is to summarize the main findings from Cochrane systematic reviews that have considered the evidence for measures to prevent ABM. We assessed the evidence available in the Cochrane Library. We found five Cochrane reviews focused on the prevention of ABM; three with use of vaccination and two with prophylactic antibiotics. Polysaccharide serogroup A vaccine is strongly protective for the first year, against serogroup A meningococcal meningitis in adults and children over 5 years of age. Meningococcal serogroup C conjugate (MCC) vaccine is safe and effective in infants. Haemophilus influenzae type b (Hib) vaccine is safe and effective against Hib-invasive disease at all ages. Ceftriaxone, rifampicin and ciprofloxacin are the most effective prophylactic antibiotics against Neisseria meningitidis. There is sufficient evidence to use polysaccharide serogroup A vaccine to prevent serogroup A meningococcal meningitis, MCC conjugate vaccines to prevent meningococcal C meningitis and Hib conjugate vaccine to prevent Hib infections. More studies are needed to evaluate the effects of Hib conjugate vaccine on mortality. Further, studies are required to compare the relative effectiveness of ceftriaxone, ciprofloxacin and rifampicin in chemoprophylaxis against meningococcal infection.
The public perception that mental disorder is strongly associated with violence drives both legal policy (eg, civil commitment) and social practice (eg, stigma) toward people with mental disorders. This study describes and characterizes the prevalence of community violence in a sample of people discharged from acute psychiatric facilities at 3 sites. At one site, a comparison group of other residents in the same neighborhoods was also assessed.
We enrolled 1136 male and female patients with mental disorders between the ages of 18 and 40 years in a study that monitored violence to others every 10 weeks during their first year after discharge from the hospital. Patient self-reports were augmented by reports from collateral informants and by police and hospital records. The comparison group consisted of 519 people living in the neighborhoods in which the patients resided after hospital discharge. They were interviewed once about violence in the past 10 weeks.
There was no significant difference between the prevalence of violence by patients without symptoms of substance abuse and the prevalence of violence by others living in the same neighborhoods who were also without symptoms of substance abuse. Substance abuse symptoms significantly raised the rate of violence in both the patient and the comparison groups, and a higher portion of patients than of others in their neighborhoods reported symptoms of substance abuse. Violence in both patient and comparison groups was most frequently targeted at family members and friends, and most often took place at home.
"Discharged mental patients" do not form a homogeneous group in relation to violence in the community. The prevalence of community violence by people discharged from acute psychiatric facilities varies considerably according to diagnosis and, particularly, co-occurring substance abuse diagnosis or symptoms.
I would be less than truthful were I to deny that I approached this assignment with anything but considerable trepidation. For one, this being the first Harry F. Dowling Lecture means that it should set the tone for those which follow. That Harry Dowling is here makes the occasion truly enjoyable but unavoidably adds to the usual anxieties of the student who wishes to perform well in the presence of his teacher. In our case, this relationship covers a span of almost 35 years. Should I succumb to the temptation to "tell it like it was" by substituting reminiscence for fact, then perhaps you will be charitable and will seek and find some purpose in such deviations.
I first met Harry Dowling in 1936. At that time, I was a medical student at the George Washington University School of Medicine, working in John Hanks's laboratory in the department of bacteriology.
To measure the effect of parenteral antibiotics given before admission to hospital on mortality and on bacteriological investigations in meningococcal disease.
Retrospective review of hospital notes and laboratory and public health medicine department records.
Three health districts in south west England.
Patients with meningococcal disease in Gloucester district presenting between 1 January 1982 and 31 December 1991 (n = 190); patients with meningococcal disease in Plymouth (n = 118) and Bath (n = 73) districts presenting between 1 January 1988 and 31 December 1991 (total = 381).
Number of deaths from meningococcal disease.
Parenteral antibiotic given by general practitioners was associated with a substantial reduction in mortality (from 9% to 5%; relative risk 0.6, 95% confidence interval 0.2 to 1.5); patients with a rash were more likely to be given parenteral antibiotics, and mortality was further reduced (from 12% to 5%; 0.5, 0.2 to 1.4). In a district where such treatment was regularly encouraged its use increased from 5% to 40% of cases over 10 years (p = 0.00001). Treatment with parenteral antibiotics before admission made isolation of meningococci from blood and cerebrospinal fluid less likely but did not affect nasopharyngeal cultures.
General practitioners should carry benzylpenicillin in their emergency bags at all times and should administer it promptly, preferably intravenously, whenever meningococcal disease is suspected, unless the patient has had an anaphylactic reaction to penicillin. Specimens for culture should include a nasopharyngeal swab.
Between 1 October 1986 and 31 March 1987, 55 cases of meningococcal disease were identified in the South-West of England, an attack rate of 1·54 per 100000 during the study period. Antibiotics used in the treatment of the disease successfully eliminated nasopharyngeal carriage of meningococci in 13 out of 14 cases without use of rifampicin. The overall meningococcal carriage rate in 384 close contacts was 18·2% and the carriage rate of strains indistinguishable from the associated case strain was 11·1%. The carriage rate of indistinguishable strains in household contacts (16·0%) was higher than the carriage rate in contacts living at other addresses (7·0%, P > 0·05). A 2·day course of rifampicin successfully eradicated meningococci from 46 (98%) of 47 colonized contacts.
In one third of cases groupable meningococci were isolated from at least one household contact; 92% of these isolates were of the same serogroup as the associated case strain. When a meningococcus is not isolated from a deep site in a clinical case of meningococcal disease, culture of serogroup A or C strains from nasopharyngeal swabs of the case or of household contacts is an indication that the close contact group should be offered meningococcal A + C vaccine in addition to chemoprophylaxis. The failure in this and other studies to isolate meningococci from any household contact in the majority of cases may be due either to the relative insensitivity of nasopharyngeal swabbing in detecting meningococcal carriage or to the acquisition of meningococci by most index cases from sources outside the household.
To determine the incidence of secondary meningococcal infection in close family and household contacts of index patients and to review the efficacy of chemoprophylaxis the records of 3256 cases occurring from 1984 through 1987 were examined. Seventeen secondary cases (0.5%) of infection were identified among these groups. The median interval between index and secondary cases was seven weeks. Fourteen secondary cases occurred more than one week after the disease was diagnosed in the index case. Three secondary cases had not received chemoprophylaxis and in another case the infecting strain had acquired resistance to rifampicin. Prophylaxis for the close contacts of 10 out of 11 of the remaining index patients failed to fulfil all the criteria of an optimal regimen. Even after optimal chemoprophylaxis the medical practitioner and the family should be aware of the increased and prolonged risk of secondary meningococcal infection among close contacts of patients with the disease.
Two cases of laboratory-acquired infections due to Neisseria meningitidis were suspected to have occurred in two French hospitals. The first case occurred shortly, i.e., 3 days, after one strain had been handled by a laboratory technician, and the link between this strain and the strain causing meningitis was easily established. In the second case, infection occurred 3 weeks after 10 strains had been handled by a technician. In this case, it was necessary to use high-resolution markers in order to establish the link between the infecting strain and 1 of the 10 strains handled. The antigenic formulae of the two infecting strains (serogroup:serotype:subtype) were, respectively, C:NT:P1.12 and B:2a:P1.2. Outer membrane protein profile analysis and multilocus enzyme electrophoresis unequivocally confirmed the identity of the respective strains.
Information about the epidemiology of meningococcal disease case clusters and the risk of further cases is sparse. Data on clusters in household and educational settings from 1 January 1993 to 31 March 1995 was requested from consultants in communicable disease control in England and Wales through a retrospective postal survey. Ninety-three per cent (122/131) responded. Of the 114 cases in 45 reported clusters, 77 (67.5%) were microbiologically confirmed. The case fatality rate in index cases was higher than in associated cases (18.2% vs 4.5%; p = 0.02). Five out of 11 clusters in household settings consisted only of index and co-primary cases. No further cases occurred within two weeks after giving chemoprophylaxis to household contacts. The relative risks of further cases in the week after the index case arose were estimated to be 1200 for contacts in the household, 160 in secondary schools, 60 in primary schools, 1.8 in universities/colleges, and 0 in nurseries. Between seven and 30 days the relative risks were lower; 150 in households, and between 0 and 13 in all other settings. Beyond 30 days, the relative risk in the household setting was 8 and lower than this in all other settings. The absolute risk of further cases in the month following the index case was calculated as 210 per 100,000 in household members, 7-10/10(5) in pupils at the same school, and 0.6/10(5) in students at the same university or college. The current policy in England and Wales to recommend chemoprophylaxis for household members may prevent half of the further cases in this setting. Raised awareness may have contributed to the lower case fatality rate among household contacts who developed meningococcal disease, but the number of co-primary cases observed should prompt urgent enquiries about current illness in household contacts of index cases. The relative risk of further cases in preschool groups was low and apparently unaffected by changes in chemoprophylactic policy. The relative risk in school settings was raised in the month following a case, but the absolute risk was still low. Further study to quantify the risk in university settings is needed.
In the wake of the recommendations of the Fallon inquiry into the personality disorder unit at Ashworth Hospital 1 2 the government has now announced its own solution to the problems presented by people with antisocial3 or dissocial4 personality disorder.5 After a joint Home Office and Department of Health review which ran in parallel with the Fallon inquiry it has proposed for consultation new services and law. Although not prescriptive about the detail of its solution, both the government's philosophy and its resolve are clear. In pursuing, above all, public protection, it intends services which essentially hybridise punishment and health care, with law that allows preventive detention of even the unconvicted.
The uncertain treatability of antisocial personality disorder,6 consequent professional therapeutic ambivalence,7 and inherent uncertainty about the moral status of the condition (whether individuals “suffering” from it are mad or bad)8 combine sensibly to imply a hybrid service solution which is far more radical than that which emerged from the last government's attempt at a similar review.9 Reflecting its close look at various European service models, the present government seems to intend a “third way,” involving establishing new specialist institutions which would be hybrids of prison and hospital and would house only people with severe personality disorder.
This contrasts with the solution proposed by Fallon …
Vaccination provides a safe and effective means of reducing the risk of laboratory-acquired infection due to some Neisseria meningitidis serogroups. However, there is currently no serogroup B meningococcal vaccine licensed for use in the US. We used an investigational N. meningitidis serogroup B outer membrane vesicle (B:15:P1.7,16) vaccine produced by the National Institute of Public Health (NIPH) in Norway to immunize 20 researchers with occupational risk for disease. Three doses of vaccine were administered via intramuscular injection at 8-week intervals. The vaccine produced moderate or severe pain with 19 (33%) of the 58 doses administered. Reactions were similar following first, second and third doses. The number and severity of reactions peaked at 24 h postvaccination and then gradually waned. Of 16 vaccinees with results available from all blood draws, 12 (75%) showed a fourfold or greater rise in serum bactericidal activity (SBA) against the vaccine type-strain following two doses of vaccine, and 15 (94%) responded after three doses. Geometric mean titers increased by more than sixfold following two doses of vaccine when compared with prevaccination levels, and by more than 11-fold following a third dose. There was no significant difference between SBA measured using the vaccinee's own complement versus a donor complement source. The NIPH vaccine elicited an excellent bactericidal response against the vaccine type-strain in researchers with an occupational risk for disease. It may be useful for other laboratory personnel who routinely work with meningococcal strains containing similar outer membrane antigens. These findings reconfirm that the NIPH vaccine is immunogenic in adults and support the validity of using properly screened human donor complement in serum bactericidal assays against serogroup B meningococci.
We report the case of a pediatrician who developed meningococcal meningitis after performing endotracheal intubation without protection on a child who was suspected of having meningoencephalitis. This case emphasizes the necessity for healthcare workers who perform high-risk procedures to use personal protection devices (i.e., respirators and protective goggles). Unprotected healthcare workers with high exposure to Neisseria meningitidis should receive chemoprophylaxis.
8 Nosocomial meningococcemia—Wisconsin
8 Nosocomial meningococcemia—Wisconsin. MMWR 1978;27:358-63.
12 Control of meningococcal disease: guidance for consultants in communicable disease control. PHLS Meningococcal Infections Working Group and Public Health Medicine Environmental Group
12 Control of meningococcal disease: guidance for consultants in
communicable disease control. PHLS Meningococcal Infections Working
Group and Public Health Medicine Environmental Group. Commun Dis
Rep CDR Rev 1995;5:R189-95.
Introduction of immunisation against group C meningococcal infection
- L Donaldson
- Y Moores
- J Howe
Donaldson L, Moores Y, Howe J. Introduction of immunisation against group
C meningococcal infection. London: Department of Health, 1999:1-6.