Meningococcal meningitis C in Tamil Nadu, public health perspectives.

Meningococcal meningitis has rarely been reported in Tamil Nadu. We report here two children diagnosed with meningococcal meningitis in Vellore, Tamil Nadu, on May 2014. The causative strain was Neisseria meningitidis serotype C. The role of the primary care physician in early diagnosis, appropriate referral, and preventive measures of this disease to the immediate family and community is stressed.

Introduction

Meningococcal disease is an acute bacterial disease caused by Neisseria meningitides which is a gram negative capsulated coffee-bean-shaped bacteria seen in pairs. Thirteen serogroups of N. meningitidis have been identified based on capsular polysaccharide antigen and of these; four sera groups namely A, B, C, and W135 are known to cause epidemics.[1] Meningococcal disease is seen mainly in the northern part of the country. Multiple outbreaks have occurred in 1966, 1985–86, 2005, 2007, and 2009. The largest outbreak of 6133 cases was in Delhi in the year 1985–1986.[2] An outbreak of meningococcal disease was reported in three districts of Andhra Pradesh namely, Vishakhapatnam, Vijayanagram, and Srikakulam in 2005–2006. A total of 475 cases were reported in the state accounting for 108 deaths. The etiological agent was again found to be of the sera group A.[2] There are no other cases reported from other parts of south India. We are reporting two cases of Meningococcal meningitis from an urban health centre from Vellore, Tamil Nadu.

Case Report

Two male children, 12 years and 7 years, presented to the casualty of the urban health centre within 2-week interval. They came from the same community and lived half a kilometre of each other. The first child presented with history of fever, headache, neck pain, and vomiting for 4 days. The second child had these symptoms for one day and approached the urban health centre within 1 day. There was no history of immunosuppressive diseases. The past history, immunization history, and developmental history were normal for both children.

On examination both children were drowsy, febrile with a Glasgow Coma Scale (GCS) of 13/15 for first child and 15/15 for the second child. Both children had significant neck stiffness. The examination of other systems was normal. They were both admitted and underwent lumbar puncture for cerebrospinal fluid (CSF) analysis. At lumbar puncture both the CSF was turbid. The investigation results [Table 1] were as follows:

Table 1

Results of cerebrospinal fluid analysis for both children

Both children had predominant leucocytosis and increased neutrophil predominance in the blood investigation. The children were referred to the tertiary centre for further treatment and management due to deterioration in the sensorium. The Latex agglutination was positive for meningococcal meningitis. The blood culture had grown Neisseria meningitis sensitive to cefotaxime for both patients. The polymerase chain reaction (PCR) test revealed the causative strain to be Neisseria meningitis serotype C. Both children were administered injection cefotaxime by parenteral route for two weeks and were well at discharge.

Once the diagnosis was established, we initiated preventive measures to the health-care providers, immediate family, and the community. Health education about the signs and symptoms of this disease was given to the community and the health volunteers after the admission of the first child. Chemoprophylaxis was given to the immediate family members and the health-care providers. The second child was brought to the health centre within a day of the symptoms because of the intervention of local health volunteers. After the diagnosis of the second child, further health education was planned and done to the surrounding urban community. We provided chemoprophylaxis for 19 adults and 12 children who were close contacts. As schools were closed for the summer vacation, chemoprophylaxis was not given to the school children. Volunteers and health workers did intensive monitoring for 3 weeks consecutively after the diagnosis of the first case. These two cases were reported to the government officials.

Discussion

Limited data available on the epidemiology of meningococcal infection in India reveal a low background incidence of disease. There are occasional large epidemics mostly distributed in the drier Northern states.[3] Sero group A meningococcus is the most common causative agent in India. Reports of occurrence of sera group B and C disease are rare.[2] The disease is characterized by fever, headache, and vomiting, and neck stiffness. If not detected early it can run a fulminating course leading to septicaemia and death. Residual neurological squeal are seen in 10–15% of the cases.[2]

The age group mostly affected are children and young adults as observed in our case report. Human beings are reservoirs for this bacterium and 10–15% of healthy subjects harbour it in the upper respiratory tract. The transmission of disease is by droplet infection from nose and throat of patients and carriers. The incubation period is 2–10 days and outbreaks are more common in spring and winter months.[2] The geographic distance between our two cases was around half a kilometre. The second child was brought to the centre early due to increased awareness initiated by the volunteers and health care workers after diagnosis of the first child. The management of suspected meningococcal disease includes admission to a health centre for lumbar puncture and CSF examination. Antimicrobial therapy should be initiated only after collection of CSF in clinical suspect cases. Appropriate antimicrobial and supportive therapy are crucial in preventing neurological squeal.

As primary care physicians are also responsible for the health of the community, the management of cases also involves prevention of secondary cases. Chemoprophylaxis is recommended to prevent secondary cases. It should be initiated within 48 h of diagnosis of cases to all identified persons who had close contact with the case within 7 days of onset of the disease. The recommended drugs with dosage for chemoprophylaxis are listed in the Table 2.[4]

Table 2

Drugs with dosage recommended for chemoprophylaxis in meningococcal disease

Two different types of meningococcal conjugate vaccine (MCV) are available in India. One is a quadrivalent (A, C, W135, Y) MCV and the other is a monovalent serogroup A vaccine. The Indian Academy of Paediatrics (IAP) state that routine use of MCVs in India is not justified because of low incidence of disease. IAP recommends MCV for persons with high risk immunosuppressive conditions and for international travellers.[5] Mass vaccination is recommended during outbreaks (defined as more than 10 cases per 100,000 populations).[4] There were no further cases reported from the area.