Meningitis prevention

From Ganfyd

Introduction

The case definitions used are described here.

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Contacts who should be offered chemoprophylaxis

Prophylaxis comprising chemoprophylaxis and vaccination should be offered to the following contacts of confirmed or probable cases (and usually to no others):

• Contacts who were living in the same ‘household’ as the case during the seven days before the case became ill.
• Sexual partners and "kissing contacts" (which refers people with whom the case had had intimate contact - "snogging" or "wet kissing") during the seven days before the case became ill.
• Medical or nursing staff only require prophylaxis if:

• They have given mouth to mouth resuscitation to the case during the seven days before the case became ill; or
• Their mouth or nose has been directly contaminated (clearly felt) with respiratory droplets/¬secretions from a probable or definite case around the time of admission; or
• They develop conjunctivitis within 10 days of contact with a confirmed or probable case.

(US guidance differs from UK guidance.^[1][2][3])

See Chemoprophylaxis for details.

Identification and notification of cases

Checklists

A useful checklist can be found at Meningitis checklist

Why it is important to confirm cases, and to identify group and sub-type wherever possible

Identification of the causative organism is important for:

• The management of cases and contacts.
• Outbreak identification, in order to be able to intervene promptly when outbreaks arise, and to know when cases of possible meningococcal disease that are linked time and place are not linked cases (e.g. because they are different groups or sub-types, or not meningococcal disease at all).

It is also important to confirm cases, wherever possible, for the following reasons:

• Surveillance, in order to understand the epidemiology of the disease, and to plan and monitor vaccination programmes.
• Research, in order to better understand – and hence to prevent and treat – the disease.

In order to be sure of making the diagnosis wherever possible, the correct samples (see below) need to be taken at the earliest possible opportunity. If the clinician has any doubt, they should discuss the sampling requirements with the hospital microbiologist or with HPU.

The ‘gold standard’ is to culture N meningitidis from blood, cerebrospinal fluid (CSF), or other normally sterile site. When parenteral penicillin has been given before admission, the yield from blood culture is low, and CSF may not always be taken because of the dangers of lumbar puncture. The diagnosis may be confirmed in other ways: these include culture from throat swabs or rash aspirates, antigen detection, serodiagnosis, and polymerase chain reaction (PCR) testing on blood and CSF.

The yield of meningococci from throat swabs in cases is about 50% and is unaffected by prior administration of antibiotic; meningococcal strains isolated may be assumed to be the same as the invading strain. Positive microscopy or culture may be obtained from needle aspiration of an area of meningococcal skin rash. Serological testing for antibody response ideally requires paired specimens of serum. Tests to establish the presence of meningococcal infections and characterise the invading strain, based on PCR, are being evaluated at the meningitis reference unit (MRU).

Meningococcal strains isolated from throat swabs of household contacts are likely to be the same as the case strain, especially if the index case is a child.

Where there has been a recent case, and there is a possibility that this is the second case in a cluster, it is particularly important to isolate the germ wherever possible. In this situation HPU may advise that throat or pernasal swabs should be taken from close household contacts before they receive chemoprophylaxis, as it is likely that, if they are carrying a meningococcus there, it will be the same group and strain as that affecting the index case.

Prevention

Prevention (meningococcal disease)

Vaccination

Meningococcal vaccine is recommended for people who have been in contact with a case of vaccine-preventable meninogococcal disease, and who meet the criteria for chemoprophylaxis; and for people travelling to areas where they may be at risk.

Conjugate vaccine

In the UK a conjugate vaccine is available that works in infancy, and provides long-term (possibly life-long) protection against group C meningococcal disease. This vaccine is offered to all babies in the UK. It should also offered routinely to anybody below the age of 23 who has not yet been vaccinated, and to people above that age who enter higher or further education for the first time.

Certain at risk groups (including people with asplenism or hyposplenism should receive this vaccine.

Various"MCV4" conjugate vaccines which provide protection against A, C, W135, and Y meningococcal disease are in development or have been licensed. Menactra™, from Sanofi Pasteur, has been licensed in the USA since 2005, and recommended for all teenagers since and some other groups since 2007. ^[4][5] Menveo™, from Novartis, was licensed in Europe in March 2010. Another MCV4 vaccine from GSK is expected to be licensed shortly, if it hasn't already been licensed.

Formal advice on the use of Menveo™ in the UK has not yet been published, but the minutes of the JCVI meeting on 14 October 2009^[6] refer to advice from a subgroup as follows:

The subgroup also advised on the use of the MenACWY conjugate vaccine Menveo® when it is licensed and the use of the currently licensed MenACWY polysaccharide vaccine. The subgroup advised that:

• There should be no alteration to the current Green Book indications for the use of MenACWY vaccines for travel.
• There is good evidence for the efficacy of both the polysaccharide vaccine and Menveo® in individuals aged 11 years and older. When Menveo® is licensed, both vaccines can be used in individuals aged 11 years and older, but individuals should be advised that that Menveo® is likely to provide longer lasting immunity.
• When licensed, Menveo® should be used for children under five years of age ‘off label’, as the benefits of protection outweigh the risks of vaccination. Polysaccharide vaccine has limited immunogenicity in this age group and in children under the age of two, it has been shown to produce antibody hypo-responsiveness. Data on Menveo® demonstrates that this vaccine is safe and immunogenic in children.
• When licensed, Menveo® can be used for children aged five and up to 10 years of age ‘off label’. Polysaccharide vaccine can also be used in this age group, but individuals should be advised that that Menveo® is likely to provide longer lasting immunity.
• In preference, Menveo® vaccine should not be administered at the same time as other conjugate vaccines (for example, the conjugates Hib/MenC and PCV that are administered at 12 -13 months) until further data are available on concomitant administration of these vaccines. This advice is not based on

Polysaccharide vaccines

Polysaccharide vaccines available that provide protection against group A, or against groups A, C, W135, and Y meningococcal disease. As they are polysaccharide vaccines, however, they are less effective in younger children (little or no efficacy in under-twos; efficacy rising with age, and becoming equivalent to conjugate vaccine only in the mid teens). The immunity provided is relatively short-lived (two-three years), and there is no immune memory.

Chemoprophylaxis

• Prophylaxis of contacts is only indicated when meningococcal or Hib disease (rare) is the "probable" (most likely) or "confirmed" diagnosis (see Meningitis case definitions). It is not necessary in e.g. suspected viral cases being treated "just in case". Always discuss with CCDC/Public Health. Prophylaxis is not necessary in pneumococcal and viral meningitis.

See Meningitis Chemoprophylaxis for more details.

Prevention (pneumococcal disease)

Chemoprophylaxis is not required for cases of pneumococcal meningitis or their contacts.

When there is a case of invasive pneumococcal disease (including meningitis) in a child under five years of age, the child should (according to the November 2005 edition of the Immunisation "Green Book") be offered vaccination with the pneumococcal polysaccharide vaccine.

See also

• Meningitis
• Bacterial meningitis
• Meningitis case definitions
• Meningitis charities
• Meningitis checklist
• Meningitis chemoprophylaxis
• Meningitis prevention
• Viral meningitis

External links

• Information from the Health Protection Agency on meningitis here.
• Information from the Meningitis Research Foundation here.
• Information from the Meningitis Trust here.

References