Also known as meningococcal meningitis, meningococcemia.

Reporting Information

Class A

Report a case, suspected case, and/or positive laboratory result immediately via telephone to the local public health department in which the patient resides.  If patient residence is unknown, report immediately via telephone to the local public health department in which the reporting healthcare provider or laboratory is located.  Local public health departments should report immediately via telephone the case, suspected case, and/or a positive laboratory result to the Ohio Department of Health (ODH).

Reporting Form(s) and/or Mechanism

Immediate telephone reporting is required.

The local public health department should enter the case into the Ohio Disease Reporting System (ODRS) within 24 hours after the telephone report.

The Enhanced Meningococcal Disease Surveillance Worksheet (CDC) is required for completion by the local public health department when following up with cases.  Information collected from the form should be entered into ODRS where fields are available, and the form should be uploaded in the Administration section of ODRS.

Key Fields for ODRS Reporting

• Import status: whether the infection was travel-associated or Ohio-acquired.
• Date of illness onset.
• Types of infection: meningitis, primary bacteremia, etc.
• The reason not vaccinated or the vaccine information if previously vaccinated.

Agent

Neisseria meningitidis is a Gram-negative diplococcus bacterium with at least 13 serogroups known to cause invasive disease (e.g. A, B, C, W, X, Y).  Serogroups B, C, and Y are the most prevalent in Ohio.  Group A has historically been a major cause of disease in sub-Saharan Africa.

Case Definition

Clinical Criteria

Clinical purpura fulminans in the absence of a positive blood culture.

Laboratory Criteria for Diagnosis

• Gram-negative diplococci, not yet identified, isolated from a normally sterile body site (e.g., blood, cerebrospinal fluid [CSF]).
• Detection of N. meningitidis antigen in formalin-fixed tissue by immunohistochemistry (IHC) or in CSF by latex agglutination.
• Detection of N. meningitidis-specific nucleic acid in a specimen obtained from a normally sterile body site (e.g., blood, CSF) using a validated polymerase chain reaction (PCR) assay.
• Isolation of N. meningitidis
  • From a normally sterile body site (e.g., blood, CSF, or less commonly, synovial, pleural or pericardial fluid).
  • From purpuric lesions.

Case Classification

Suspected

A case that meets the clinical criteria or Gram-negative diplococci, not yet identified, isolated from a normally sterile body site (e.g., blood, CSF).

Probable

Detection of N. meningitidis antigen in formalin-fixed tissue by immunohistochemistry (IHC) or in CSF by latex agglutination.

Confirmed

A case that is laboratory confirmed by either culture or PCR.

Not a Case

This status will not generally be used when reporting a case, but may be used to reclassify a report if investigation revealed that it was not a case or if N. meningitidis was identified from a non-normally sterile site.

Comments

Defining meningococcal outbreaks can be challenging, and consultation with ODH's Bureau of Infectious Diseases (BID) is encouraged when an outbreak is suspected.  For information regarding specific criteria for institutional and community outbreaks, please see CDC's information on meningococcal outbreaks.

Signs and Symptoms

Invasive meningococcal infection usually results in meningococcemia and/or meningitis.  Onset is abrupt in meningococcemia with fever, chills, malaise, myalgia, limb pain, prostration, and a rash which can be macular, maculopapular, petechial, or purpuric.  The progression of disease is usually rapid.  In fulminant cases, purpura, limb ischemia, coagulopathy, pulmonary edema, shock, coma, and death can ensue within several hours despite appropriate therapy.

Meningococcal meningitis is indistinguishable from acute meningitis caused by other bacterial pathogens and presents with altered mental status, seizures in some patients, and meningeal irritation.  Individual symptoms vary widely from patient to patient; infants and small children may exhibit only fever and vomiting.  The classical symptoms of headache, stiff neck, and confusion occur in less than half of patients.

Invasive meningococcal infections may be complicated by arthritis, myocarditis, pericarditis, and endophthalmitis.  Less common manifestations of meningococcal disease include conjunctivitis, pneumonia, febrile occult bacteremia, septic arthritis, and chronic meningococcemia.  The overall case fatality rate is 10%, but is higher in adolescents.  Sequelae associated with meningococcal disease occur in 10-20% of survivors and include hearing loss, neurologic disability, digit or limb amputations, and skin scarring.

Diagnosis

A Gram-stained smear from a normally sterile body site showing Gram-negative diplococci raises suspicion of invasive meningococcal disease.  Diagnosis is confirmed by a culture of the blood and/or spinal fluid.

Clinical laboratories should send all N. meningitidis isolates from normally sterile sites to the ODH Laboratory for serogroup analysis.  Please fill out a WI VPD Specimen Submission Form when sending isolates to ODH Laboratory.  Presumptive evidence of invasive meningococcal disease can be obtained with PCR or antigen testing from a normally sterile body site.  Leftover CSF or blood from patients with negative culture results who were given antibiotics prior to specimen collection can be submitted for PCR testing.  Please contact the BID VPD Epidemiology Program at (614) 995-5599 to arrange for testing.

Positive antigen test results from urine or serum samples are unreliable for diagnosis of meningococcal disease.  These results should not be reported.  Further testing from a normally sterile site is necessary for diagnosis of invasive N. meningitidis.

Epidemiology

Source

The upper respiratory tract of humans.  Asymptomatic colonization is frequent and provides the focus from which the organism is spread.  It is estimated that 5-10% of people are asymptomatic carriers; less than 1% of carriers will progress to invasive disease.

Occurrence

Incidence peaks among persons in three age groups: infants and children <5 years, adolescents and young adults aged 16-21 years, and adults aged >65 years.

Child care centers, preschools, and military camps experience the majority of outbreaks.  Pre-teens, adolescents, college freshmen who live in dorms, and travelers to countries where meningococcal disease is endemic are at an increased risk.  The incidence is higher during the winter and spring in the United States.

Mode of Transmission

Person-to-person through droplets of infected respiratory secretions.

Period of Communicability

The exact period of communicability is unknown, but is probably throughout the duration of the presence of the organism in the upper respiratory tract of those with invasive disease and in contacts who have become asymptomatically colonized with meningococci.

Incubation Period

2-10 days, most commonly 3-4 days.

Public Health Management

Case

Treatment

Hospitalization is usually required for parenteral antibiotic treatment and vigorous supportive care.  Treatment for invasive disease does not eliminate nasopharyngeal carriage of the organism in the index case.  It is imperative that carriage of the organism be eradicated before the patient is discharged from the hospital by administering rifampin in the same dosage as noted below for Contacts.

Isolation

Ohio Administrative Code (OAC) 3701-3-13 (O) states:

"A person with meningococcal disease shall be isolated until twenty-four hours after the initiation of effective antimicrobial therapy."

This includes droplet precautions for 24 hours in hospitalization.

Contacts

Identification of contacts is important to determine those requiring chemoprophylaxis.

High-risk contacts for whom chemoprophylaxis is recommended include:

• Household contacts, especially young children less than 2 years old.
• Child care, nursery school, preschool, and babysitting contacts in the 7 days before onset of illness.
• Anyone who had direct contact with the case's oral secretions through kissing, sharing toothbrushes, or sharing eating utensils any time during 7 days before onset of illness.
• Anyone who performed mouth-to-mouth resuscitation on or was unprotected during oral intubation of the case any time during 7 days before onset of illness.
• Anyone who frequently sleeps or eats in the same dwelling as the case 7 days before onset of illness.
• Passengers seated directly next to the case during airline flights lasting more than 8 hours.

Low-risk contacts for whom chemoprophylaxis is not recommended include:

• Persons having only casual contact with the case and no direct contact with oral secretions (e.g., school or work mates).
• Persons who had contact only with a high-risk contact (i.e., no direct contact with the case).
• Healthcare personnel who did not have contact with the case's oral secretions.

Prophylaxis

All household and child care or preschool contacts should receive prophylaxis, preferably within 24 hours of diagnosis of the index case.  Prophylaxis of high-risk contacts should not be delayed for confirmation of N. meningitidis in the index case; it can several days for the organism to grow in culture.  Nasopharyngeal cultures are not recommended for screening contacts.  They are of no value in making decisions related to prophylaxis.

Rifampin, ceftriaxone, and ciprofloxacin are equally effective for prophylaxis.  The drug of choice for most children is rifampin.  Another appropriate drug is azithromycin:

• Rifampin is administered twice daily for two days: adults 600 mg per dose, children >1 month of age 10 mg/kg (maximum 600 mg), and children <1 month of age 5 mg/kg.  Rifampin is not recommended for pregnant women.
• Ceftriaxone is administered IM in a single dose: adults 250 mg, children <15 years of age 125 mg.
• Ciprofloxacin given to adults in a single oral dose of 500 mg is also effective in eradicating meningococcal carriage.  Presently, ciprofloxacin is not recommended for persons younger than 18 years of age or for pregnant women.
• Azithromycin (not routinely recommended) 10mg/kg (maximum 500 mg).

Prophylaxis is not completely effective, and exposed contacts should remain under medical supervision for one month.

Prevention and Control

Vaccination

Two quadrivalent (A, C, W, and Y) and two serogroup B vaccine formulations are currently available in the United States.  Vaccine is indicated to control outbreaks of disease proven to be caused by one of the serogroups represented in the vaccine.  In an outbreak, the serogroup should be determined and the population at risk delineated by neighborhood, school, dormitory, or other reasonable boundary.  Although endemic disease is very uncommon, older children, adolescents, and young adults constitute a higher proportion of cases during outbreaks and may warrant vaccination during an outbreak.  Contact the ODH Bureau of Infectious Diseases at (614) 995-5599 if an outbreak of meningococcal disease is suspected.

Meningococcal vaccination (serogroups A, C, W, and Y) is recommended for the following groups:

• Routine vaccination of adolescents aged 11-18 years (a single dose administered at age 11 or 12 with a booster dose at age 16 for those who received the first dose before age 16).
• Routine vaccination of persons >2 months of age at increased risk for meningococcal disease including:
  • Persons with complement component deficiency (C3, C5-9, properdin, factor D, and factor H, or who are taking eculizumab [Soliris]).
  • Persons with anatomical or functional asplenia (including sickle cell disease).
  • Microbiologists routinely exposed to isolates of Neisseria meningitidis.
  • Persons identified as at increased risk because of a serogroup A, C, W, or Y meningococcal disease outbreak.
  • Unvaccinated or incompletely vaccinated first-year college students living in residence halls.
  • Unvaccinated or incompletely vaccinated military recruits.
  • Persons who travel to or reside in countries where meningococcal disease is hyperendemic.

Two serogroup B meningococcal vaccines are currently licensed by the Food and Drug Administration (FDA).  In February 2015, the Advisory Committee on Immunization Practices (ACIP) recommended the routine use of the meningococcal B vaccines for persons >10 years who are at increased risk for serogroup B meningococcal disease.  The recommendations do not apply to children <10 years, first-year college students living in residence halls, military recruits, travelers, or all adolescents.

Meningococcal vaccination (serogroup B) is recommended for the following groups:

• Persons with persistent complement component deficiencies (C3, C5-9, properdin, factor D, and factor H, or who are taking eculizumab [Soliris].
• Persons with anatomic or functional asplenia (including sickle cell disease).
• Microbiologists routinely exposed to isolates of Neisseria meningitidis.
• Persons identified as at increased risk because of a serogroup B meningococcal disease outbreak.

In June 2015, the ACIP also recommended that a MenB vaccine series may be administered to adolescents and young adults aged 16-23 years to provide short term protection against most strains of serogroup B meningococcal disease.  The preferred age for MenB vaccination is 16-18 years (recommendation category B; for individual clinical decision making).

The four meningococcal vaccines available in the United States are:

• Meningococcal Conjugate Vaccine (MenACWY-D) was licensed in 2005 and is a quadrivalent conjugate vaccine protecting against serogroups A, C, W, and Y.  It is approved for use in persons aged 9 months-55 years.
• Meningococcal Conjugate Vaccine (MenACWY-CRM) was licensed in 2010 and is a quadrivalent conjugate vaccine protecting against serogroups A, C, W, and Y.  It is approved for use in persons aged 2 months-55 years.
• Meningococcal Recombinant (MenB-4C) was licensed in 2015 and is a recombinant vaccine protecting against serogroup B.  It is approved for use in persons aged 10-25 years.
• Meningococcal Recombinant (MenB-FHbP) was licensed in 2014 and is a recombinant vaccine protecting against serogroup B.  It is approved for use in persons aged 10-25 years.

Please refer to the most current ACIP recommendations for meningococcal vaccination.

Ohio School Requirement: Beginning with the start of the 2016-2017 school year, all students entering the 7th and 12th grade are required to be vaccinated against meningococcal disease.  One dose of meningococcal (serogroups A, C, W, and Y) vaccine is required prior to entry in the 7th grade.  A second dose of meningococcal (serogroups A, C, W, and Y) vaccine is required prior to entry into the 12th grade.  This is a progressive requirement.

Ohio College Requirement: The Ohio Revised Code (ORC) 1713.55 states that beginning with the academic year that commences on or after July 1, 2005, an institution of higher education shall not permit a student to reside in on-campus housing unless the student (or the student's parent if the student is younger than 18 years of age) discloses whether the student has been vaccinated against meningococcal disease and hepatitis B by submitting a meningitis and hepatitis B vaccination status statement.  The student is NOT required to have the vaccinations, just disclose whether they have or not.