Meningitis Dr Farrukh

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MENINGITIS IN CHILDREN UNDER FIVE YEAR OF AGE.

Dr Farrukh Iqbal Roll number 06

Definition 

Meningitis is inflammation of the protective membranes covering the brain and spinal cord, known collectively as the meninges. [1] It is an acute communicable disease caused by various organisms among which



Escherichia coli are more common among children between 0-2 months of age.



Haemophilus influenzae is more common among children between 2month-2years of age.



Neisseria meningitis and streptococcus pneumoniae is more common among children between 02yrs to 21 yrs of age of age. [2].



In Pakistan a vaccination with the name of Hib have been included in EPI Vertical program against Haemophilus influenzae but no focus have been made on the Neisseria meningitis which is the main cause of meningitis in children and young adults and it is important because of its potential to cause epidemic.

Historical Context Meningococcal disease was first described in 1805 when an out break swept through Geneva, Switzerland. The causative agent Neisseria meningitis was identified in 1887. [3]

Geographic Distribution 

Distribution world wide occurring sporadically and in small out breaks in most part of the world. The zone lying between 5and 15 degree north of the equator in tropical Africa is called meningitis belt because of the frequent epidemic waves

Cases of meningococcal meningitis are also reported in Pakistan as sporadic cases or small cluster 45-100/100,000 in children suffers from meningitis. Incidence (adjusted of) suspected meningitis/10,000 new cases are given in the following table province vice. Out breaks reported but now lab confirmed include those near Peshawar in April and November, 2000 and in Rawalpindi March, 2001

Following bar chart shows the total number of lab confirmed meningitis cases among the total suspected cases admitted in children hospital (PIMS) in Islamabad in 2005-06-07

Case definitions 





Suspected cases: Any person with acute illness that demonstrate sudden on set of fever (>38.05 C0 rectal or 38C0 axiliary) and one or more of the following neck stiffness, altered conscious other meningial sign. In patient under one year of age when fever is accompanied with bulging fontanel Probably cases: A suspected case of meningococcal meningitis with turbid CSF or link to a confirmed case. Confirmed Cases. A suspected or probably case with positive CSF antigen cases: detection for Neisseria meningitis. A positive culture result from CSF or blood sample with identification of Neisseria meningitis.







Aim: Reduction of mortality and morbidity among children due meningitis in Pakistan. Objectives: To reduce mortality due to meningococcal meningitis up to 80 per cent in children under five in Pakistan with in three years. To strengthen the existing bacterial meningitis surveillance mechanisms in Pakistan.

Epidemiological feature 



Agent The causative agent Neisseria meningitis is a gram negative diplococcic several serotypes have been identified groups A,B,C,D,X,Y, 29 E,W135 etc. Group A&C who are lesser extent group B Meningococcal are capable of causing major epidemic the incidence of infection by group Y and W 135 strange are increasing in some countries Source of infection: The organism is found in the naso pharynx of cases and carriers carriers are most important source of infection. The mean duration of temporary carrier is about 10 months. During epidemics carrier rate may go even up to 70-80%.

Period of communicability:  Until meningococcal are no longer present and discharge from nose and throat. Cases rapidly loose their infectioness with in 24 hrs of specific treatment. Age & Sex:  This is predominantly is a disease of children and young adults of both sexes. Immunity:  All ages are susceptible. Younger age groups are more susceptible than older group as their antibodies are lower. Immunity is acquired by sub clinical infection mostly, clinical disease or vaccination. Infant derived immunity comes from the mother.

Environmental Factors:  The seasonal variation of the disease is well established out breaks occur more frequently in dry and cold months of the year. Over crowding as occurs in schools, refugee, and other camps is an important pre disposing factor the incidence is also greater in the low socio economics groups living in the poor housing conditions. Mode of Transmission:  The disease spreads mainly by droplet infection. The portal of entry is the nasopharynx. Incubation Period:  Usually 3 to 4 days, but may vary from 2 to 10 days.

Existing Strategies: 

There are three existing BM Surveillance System in Pakistan. These are Health Management and Information System (HMIS), Disease Early Warning System (DEWS) and Laboratory based Bacterial Meningitis Surveillance (BMS) programs



In HMIS from the different heath care facilities i.e. basic health units and rural health centers data on meningitis is collected via HMIS and after sending to the respective Edo’s Health then it is sent to the provincial HMIS cell and after this then is sent to the National HMIS cell of Ministry of Health.



The BMS exists only in provincial head quarters and federal capital viz. Islamabad. In the BMS consists of data collection centers in PIMS Islamabad, Children Hospital Lahore, NICH Karachi, Mayo Hospital Lahore, HMC Peshawar and BMCH Quetta and from there data and reports are being sent to NIH Islamabad and further disseminated to WHO EMRO on monthly basis.

Prevention and Control Strategies: 

Basically we should have two pronged strategy at national level: epidemic preparedness and epidemic response. Preparedness will focus on surveillance, from case detection and investigation and laboratory confirmation. This implies strengthening of surveillance and laboratory capacity for early detection of epidemics, the establishment of national and sub-regional stocks of vaccine, ant the development or updating of national plans for epidemic management (preparedness, contingency and response).

General Measures:  It is very important to create the awareness in people about the manifestations of disease, its early detection and also about the preventive measures from the meningitis via mass media like newspapers, radio, televisions, printing materials and walking campaigns.

Surveillance: 

We should improve surveillance system , HMIS through capacity enhancement of human and logistic resources, integration of secondary and tertiary health care facility into HMIS, DEWS: through capacity enhancement of human and logistic resources. Laboratory based BMS (bacterial meningitis surveillance program) expansion of sentinel sites country wide, strengthening the existing sentinels labs.



we should develop a national surveillance system and merge all vertical programs and develop and extend public health laboratory networks.

Immunization: 

Effective vaccine prepared from purified group A, C, Y and or W135 meningococcal polysaccharide are now available. They may be monovalent or polyvalent. Recent field trials have indicated that immunity lasts for about three years and boosters every three years would be reasonable. High risk population should be identified and vaccinated. Vaccine use is not recommended in children under two years of age. The vaccine is contraindicated in pregnant women.

Mass Chemoprophylaxis: 

This is in fact mass medication of the total population some of which are not infected. It is recommended that mass chemoprophylaxis be restricted to close and medically supervise communities.

Cases:  Treatment with antibiotics can save the lives of 95 per cent of patients provided that it is started during the first two days of the illness. Penicillin is the drug of choice. In penicillin allergic patients, choloramphenicol should be substituted . Isolation of cases is of limited usefulness in controlling epidemics because the carriers outnumber cases

Carriers: Treatment with penicillin does not eradicate the carrier state; more powerful anti-biotic such as rifampicin is needed to eradicate the carrier state. Contacts: Close contacts of the person with confirmed meningococcal disease are at an increased risk of developing meningococcal illness (about 1000 times the general populations). Nearly one third of secondary cases occur in the first four days. Chemoprophylaxis has been suggested for close contacts. Current recommendations of close contacts are early institution of rifampicin 600 mg BD for two days.

Implementation (with cost estimate) and Evaluation 

Total Expenditure i.e. Capital Cost of the Project on Meningococcal meningitis is 300 millions rupees for the three years. There should be quarterly financial target release and expenditure evaluation.



The annual budget is prepared with unit cost estimate and the major components of the budget will be for: Vaccination, mass chemoprophylaxis, Treatment, Monitoring/ Evaluation, Training and Salaries, Health Education Campaign, Data Surveillance, Office equipments (infrastructure). The provincial depart. Be provided with separate budgetary allocations. The performances of provincial departments be done on quarterly basis to do the cost estimate and cost benefit analysis, nevertheless there must be an ongoing supervision and monitoring of these provincial and other districts level institutions.

 The

evaluation of the program can be done by frequent meetings arrange after every six months in which all the stake holder are invited. There will be regular monthly visits of the health team (under provincial Government) to every district to supervise the surveillance system.

Process :        

Total number of walks arranged in a year to create awareness among people. Number of suspected cases of meningococcal meningitis reported in a year. Number of Lab conformed cases of meningococcal meningitis reported in a year in children less than five year of age. Number of children vaccinated for meningococcal meningitis in a year in children under five year of age. Number of children mass chemoprophylaxis done for meningococcal meningitis in a year in children under five year of age. Number of physician per hundred thousand populations under five year of age. The proportion of the people who have awareness about Meningococcal meningitis and its effects. Number of institutes having adequate availability of medicines.

Outcome Indicators:  

Number of cases treated for meningococcal meningitis reported in a year in children less than five year of age. Number of deaths due to meningococcal meningitis reported in a year in children less than five year of age.

REFERANCES:            

^ Sáez-Llorens X, McCracken GH (June 2005). "Bacterial meningitis in children".Lancet 361: 2139–48. Khan.P.A, “Meningitis”, Basic of pediatrics, Pub: Carvan. 6th edit. pp: 264. http://www.who.int/topics/meningitis/en/30-09-2009. WHO (2005). The work of WHO. 2003-2004. WHO, Global Health situation and projections, 1992. Ansari. J.A., Kazi.B.M. et al. Public health laboratory division NIH Islamabad, CDC Atlanta. USAID. 2008. WHO. DEWS, Case definitions management and prevention of infectious disease. Meningococcal meningitis.pp:30, Sept2006. WHO (2006). Tech. Resp. Ser. No 658. Cujetanovic. B et al (2007) Bull WHO 56 (Supplement No .1):81. WHO (2006) Wkly Epi. Rec; 56(27)211. Wahdon M.H. et al. (1973) Bull WHO 48:667-673 Wahdon M.H. et al. (1973) Bull WHO 55:645-651.

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