Download X - TSICP

Meningitis- A real headache
Neil Pascoe RN BSN CIC
Epidemiologist
Infectious Disease Control Unit
IDEAS
Acknowledgements
IDEAS
Overview
Definitions
Epidemiology
Diagnosis
Control Measures
Resources
IDEAS
Considerations
Host factors
Age, race, sex
Underlying medical conditions,
genetics, medications
Organism
Interventions/support
IDEAS
Definitions
IDEAS
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.
IDEAS
Meningitis
(pl. meningitides)
Acute or chronic inflammation of the
tissues that cover the brain and spinal
cord
Presentation hours to weeks or longer
usually caused by a viral or bacterial
infection. Less frequently, it can be
caused by a parasites, fungi, chemicals,
or drugs
IDEAS
Meningismus (meningism)
Irritation of the brain and spinal
cord with symptoms simulating
meningitis, but without actual
inflammation
IDEAS
Encephalitis
Shares features with acute meningitis
Both often present with F, HA, AMS
Mental status ∆’s occur early in onset
Behavioral or speech disturbances
Focal or diffuse (seizures/hemiparesis)
Acute or chronic (usu. slower onset)
Both may lead to disability/death
IDEAS
IDEAS
IDEAS
IDEAS
IDEAS
IDEAS
IDEAS
IDEAS
IDEAS
IDEAS
Epidemiology
IDEAS
Is meningitis contagious?
Possible, but not likely
If causative organism is transmitted it
usually manifests with the Sx and illness
typically associated with the organism
The organisms that cause (aseptic)
meningitis may be as contagious as the
common cold
IDEAS
Risk Factors
Persons who are colonized or recent acquisition of
organism
Two 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 meningitis
preschool age children in day care centers
where there is a case of meningitis
IDEAS
Risk Factors cont’d
Persons having underlying medical
conditions
Smokers and passive smoke
Alcohol use
Corticosteroid use
Students living in close quarters such as
dormitories
Lifestyle behaviors
IDEAS
Risk Factors cont’d
Virus can often be isolated from the stool of
an infected person
Diaper changing or providing personal
hygiene for an infected person can be a risk
to the caregiver
HCWs at increased risk of contracting
organism are those who come into direct
(unprotected) contact with respiratory tract
secretions eg intubation, suctioning, or
respiratory therapy.
IDEAS
Symptoms include (>1 yr):
Fever
Severe headache
Stiffness of the neck/backache
Nausea and possible vomiting
photophobia
A skin rash that looks like small, purplish-red
spots
Confusion, as well as coma is possible
IDEAS
Diagnosis
IDEAS
Diagnosis
Clinical determination (history, high risk
group, risk behaviors…)
Lab findings
Epi linked
IDEAS
Cerebrospinal Fluid (normal values)
50-195 mm H2O
Clear
Colorless
Glucose 50-85
Protein 15-45
RBC, CBC w dif, gram stain, Bact. Cx
Latex antigen, PCR,
IDEAS
Typical CSF Findings by Cause*
Cause
Viral
WBC
Primary
(cell/mm3) Cell
Glucose Protein
(mg/dL) (mg/dL)
Type
50-1000 Mono.
>45
<200
Bacterial 10005000
TB
50-300
Neut.
<40
100-500
Mono.
<45
50-300
Crypto.
Mono
<40
>45
20-500
IDEAS
*From Mandel 6th
Viral agents
Many different viruses can cause
meningitis.
80-90% of identified organisms are
enteroviruses.
Most frequently spread by direct contact
with respiratory secretions.
IDEAS
Viral agents
Enteroviruses
80 % of identified
isolates are
echoviruses and
coxsackie virus
Nonpolio enterovirus
Mumps
Arboviruses
Herpes
HIV
Adenovirus
Poliovirus
IDEAS
IDEAS
Bacterial agents
N. meningitidis
S. pneumoniae
S. agalactiae
Listeria
monocytogenes
Staph species
E. coli, klebsiella,
salmonella, M. tb
H. flu
Other
unknown
IDEAS
Most Common Meningitis-Causing
Bacteria by Patient Age
Age
Birth to one month of age
One to three months
Bacteria
S. agalactiae, E. coli,
Listeria monocytogenes,
Klebsiella pneumoniae, enterococcus
species
S. agalactiae, E. coli,
L. monocytogenes,
H. influenzae, S. pneumoniae,
N. meningitidis
Three months to over 15
years
N. meningitidis, S. pneumoniae,
H. influenzae,
IDEAS
Pathogenesis of bacterial
meningitis
Mucosal colonization>
Local penetration/invasion>
Bacteremia>
Meningeal invasion>
Subarachnoid replication>
Many pathologic and physiologic
changes
IDEAS
IDEAS
Course of Illness
Usually, viral meningitis is less severe
than bacterial meningitis
The symptoms usually last about 7 to
10 days for viral meningitis
Bacterial meningitis can result in
disability or death (seizures, behavioral)
May take months to recover
IDEAS
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.
IDEAS
Viral Meningitis in Texas
by Month of Occurrence 2000-2004
160
140
120
100
80
60
40
20
0
Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec
IDEAS
Meningococcal Disease in Texas by Month
of Occurrence, 2000-2004
30
25
20
15
10
5
0
Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec
IDEAS
Viral Meningitis in Texas,
Rates per 100,000
10
9
8
7
6
5
4
3
2
1
0
2000
2001
2002
IDEAS
2003
2004
Bacterial Meningitis in Texas,
Rates per 100,000
10
9
8
7
6
5
4
3
2
1
0
2000
2001
2002
IDEAS
2003
2004
Treatment:
There is no specific treatment for viral
(aseptic) meningitis. Most infected persons
recover completely on their own with
supportive care
Bed rest, fluids, analgesics, antipyretics
Bacterial meningitis can be Rxd effective
antibiotics
Treatment must be started early in the course
IDEAS
of disease.
Meningococcal Disease
IDEAS
IDEAS
U.S. Meningococcal Outbreaks, 7/94-6/01
Minnesota 1995
Minnesota 1998
Alaska 1996
Ohio 2001
Iowa 2000
Washington 1995,
1996
Wisconsin 1996
Wisconsin 2000
Iowa 1998
Kansas 2001
Washington 2002
New York 1995, 1997
Illinois 1996 Michigan 2002 Kentucky 1997
XX X
North Dakota 1999
Ohio 2000
Northern CA 2001
X
Northern CA 2000
Northern CA 1995
California 2000
Missouri 1995
X
X
X
X
XX
X
X
X
Southern CA
1995
XX
XX
X
X
Arizona 1997
New Hampshire 1995
1999
X
Massachusetts 1995, 1997, 1998
X
Connecticut 1997, 2001
XXXX
Pennsylvania 1995, 2001
X
X
X
Pennsylvania 2001, 2000
X X X
X
Maryland 1997
XX
X
Virginia 1995, 1996
X X
Virginia 1996, 1999, 2000
X
North Carolina 1997
North Carolina 1996
North Carolina 1995
X
X
X
X
Missouri 1997
Missouri 2002
NW New Mexico 1995
XX X
South Carolina 1996
X
Louisiana
2001
Arkansas 1999
Colorado 1997
Illinois 1996
Central Texas 1994
South Central Texas 2001
Community outbreak
X Organization-based outbreak
Florida 1996
East Texas 1994
East Texas 1995 NE Texas 1996
East Texas 2001 NE Texas 2002
East Texas 2001
East Texas 2001
IDEAS
Vermont 1995
Georgia 1995, 1997
Tennessee 1996, 1997, 1997
Florida 1998
Florida 1997
Central Florida 1995
Central Florida 1997
South Florida 1995
*Woods, IDSA 2003
Meningococcal meningitis
(disease)
Meningococcal meningitis is caused by
Neisseria meningitidis
most severe form of bacterial meningitis
10-15% of infected persons will die,
often within hours of onset
May result in blindness, deafness,
amputations, permanent brain damage
IDEAS
IDEAS
• 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
IDEAS
Transition Slide
IDEAS
IDEAS
IDEAS
IDEAS
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
IDEAS
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)
IDEAS
Prophylaxis of close contacts:
Antibiotics are recommended to
prevent MD disease
observation of household, day care, and
other intimate contacts for early signs of
the illness
Cases should also be vaccinated
against MD
IDEAS
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
rates
It is not clear why colonized persons
become ill.
IDEAS
IDEAS
Right anterior leg lesion
R anterior leg lesion-postoperative debridement
R anterior leg lesion-postoperative debridement
IDEAS
Right lateral-superior
leg lesion
IDEAS
R lateral-superior leg lesion--postoperative debridement
IDEAS
IDEAS
IDEAS
IDEAS
Control Measures
IDEAS
IDEAS
IDEAS
IDEAS
Prevention:
Don’t share eating or drinking utensils,
toothbrushes, or anything else that
would include saliva exchange
Cover your mouth when you cough or
sneeze
Wash your hands frequently especially
after coughing or sneezing or use an
ETOH-based hand sanitizer
IDEAS
Vaccines
IDEAS
IDEAS
Pneumococcal Vaccines
Polysaccharide (Pneumovax®)
23/90 serotypes (85% +disease)
Over 64
2+ w chronic disease at risk for pneumo.
disease
2+ immunocompromised at risk for
infection
2+ w functional or anatomic asplenia
IDEAS
Pneumococcal Vaccines
Conjugate (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
IDEAS
Meningococcal Vaccines
Polysaccharide (Menomune®)
MPSV4
Covers serogroups A, C, Y, and W-135
Does not protect against serogroup B
disease
Protective antibody levels are usually
achieved within 7-10 days of
vaccination
Routine vaccination is not
recommended
IDEAS
College freshman, lab, military
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)
IDEAS
Isolation Precautions
Are they necessary??
Isolation for 24 hours is recommended
with droplet precautions
Standard precautions always
Droplet/airborne may be indicated for
specific situations
IDEAS
Reporting:
If meningococcal disease is
suspected, report immediately to the
DSHS
If bacterial or viral meningitis is
suspected, report within one week to
TDH
Texas Health and Safety Code,
Chapters 81, 84, and 87
Texas Administrative Code,
IDEAS
Chapter7, Title 25
Resources
http://www.nlm.nih.gov/medlineplus/encyclop
edia.html
http://www.dshs.state.tx.us/idcu/disease/meni
ngitis/
http://www.cdc.gov/health/diseases.htm
http://www.cdc.gov/nip/publications/aciplist.htm
IDCU-Neil 512 458-7111 x2358
[email protected]
IDEAS