MENINGITIS: The disease, the cure

Meningococcal meningitis, commonly referred to as cerebrospinal meningitis, is a serious infection of the meninges that affects the brain membrane. The country has been witnessing its outbreaks with the 2017 epidemic earmarked as one of the worst with high mortality. Recently the National Primary Health Care Development Agency (NPHCDA) alerted that about 26.7 million Nigerian children are at risk of contracting this disease. ISIOMA MADIKE, in this report, attempts to find out how this could be tamed from medical experts

 

  • Kissing, sneezing or living in close contacts with a carrier facilitates its spread –Medical experts

 

A Consultant Public Health Physician, Bayo Onajole, has disclosed that meningococcal meningitis, a bacterial form of meningitis, is a serious infection of the meninges that affects the brain membrane. According to the professor of Community Medicine, it can cause severe brain damage even as it is fatal in 50 per cent of cases if untreated. Several different bacteria, he said, can cause meningitis. But, Neisseria meningitidis, he further said, is the one with the potential to cause large epidemics.

“There are 12 serogroups of Neisseria meningitidis that have been identified, six of which (A, B, C, W, X and Y) can cause epidemics. Geographic distribution and epidemic potential differ according to serogroup,” the Consultant Public Health Physician at the College of Medicine, Uni-versity of Lagos / Lagos University Teaching Hospital (LUTH), said. Onajole said that the bacteria are transmitted from person-to-person through droplets of respiratory or throat secretions from carriers.

He said: “Close and prolonged contact – such as kissing, sneezing or coughing on someone, or living in close quarters (such as a dormitory, sharing eating or drinking utensils) with an infected person (a carrier) – facilitates the spread of the disease.

“The average incubation period is four days, but can range between two and 10 days. Neisseria meningitidis only infects humans; there is no animal reservoir. The bacteria can be carried in the throat and sometimes, for reasons not fully understood, can overwhelm the body’s defenses allowing infection to spread through the bloodstream to the brain.

“It is believed that 10 per cent to 20 per cent of the population carries Neisseria meningitidis in their throat at any given time. However, the carriage rate may be higher in epidemic situations.” Waheed Abayomi, another medical doctor and managing director of Crest Hospital, Egan-Igando, while agreeing with Onajole, said that the most common symptoms are a stiff neck, high fever, sensitivity to light, confusion, headaches and vomiting.

He said: “Even when the disease is diagnosed early and adequate treatment is started, five to 10 per cent of patients die, typically within 24 to 48 hours after the onset of symptoms. Bacterial meningitis may result in brain damage, hearing loss or a learning disability in 10 to 20 per cent of survivors.

“A less common but even more severe (often fatal) form of meningococcal disease is meningococcal septicaemia, which is characterised by a haemorrhagic rash and rapid circulatory collapse.” According to the doctor, initial diagnosis of meningococcal meningitis can be made by clinical examination followed by a lumbar puncture, showing a purulent spinal fluid. The bacteria, he said, can sometimes be seen in microscopic examinations of the spinal fluid.

“The diagnosis is supported or confirmed by growing the bacteria from specimens of spinal fluid or blood, by agglutination tests or by polymerase chain reaction (PCR). The identification of the serogroups and susceptibility testing to antibiotics are important to define control measures,” Abayomi said. For Onajole, meningococcal disease is potentially fatal and should always be viewed as a medical emergency. Admission to a hospital or health centre, he said, is necessary, although isolation of the patient, according to him, is not essential.

“Appropriate antibiotic treatment must be started as soon as possible, ideally after the lumbar puncture has been carried out, if such a puncture can be performed immediately. If treatment is started prior to the lumbar puncture it may be difficult to grow the bacteria from the spinal fluid and confirm the diagnosis.

“A range of antibiotics can treat the infection, including penicillin, ampicillin, chloramphenicol and ceftriaxone. Under epidemic conditions in Africa in areas with limited health infrastructure and resources, ceftriaxone is the drug of choice,” he said.

To prevent the disease, according to the consultant, three types of vaccines available. He however, said that polysaccharide vaccines have been available to prevent the disease for over 30 years. “Meningococcal polysaccharide vaccines are available in either bivalent (groups A and C), trivalent (groups A, C and W), or tetravalent (groups A, C, Y and W) forms to control the disease. “For group B, polysaccharide vaccines cannot be developed, due to antigenic mimicry with polysaccharide in human neurologic tissues.

The first vaccine against NmB, made from a combination of four protein components, was released in 2014. “Since 1999, meningococcal conjugate vaccines against group C have been available and widely used. Tetravalent A, C, Y and W conjugate vaccines have also been licensed since 2005 for use in children and adults in some countries like Canada, the United States of America, and Europe,” he further said. Abayomi however, said that Cerebrospinal Meningitis (CSM) is a disease characterised by inflammation of the meninges (protective membrane covering the brain and the spinal cord).

He said it can be caused by a variety of microbial pathogens including viral and bacterial organisms, noting that the main etiological agents in bacterial meningitis are Neisseria meningitidis, Streptococcus pneumoniae and Haemophilus Influenzae. Just like Onajole, Abayomi agreed that Neisseria meningitidis (Meningococcus) is a leading cause of bacterial meningitis. According to the World Health Organisation (WHO), Meningococcal meningitis occurs in small clusters throughout the world with seasonal variation, and accounts for a variable proportion of epidemic bacterial meningitis.

The largest burden of meningococcal disease, the world health body said, occurs in an area of sub-Saharan Africa known as the meningitis belt, which stretches from Senegal in the west to Ethiopia in the east. WHO further said that during the dry season between December to June, dust winds, cold nights and upper respiratory tract infections combine to damage the nasopharyngeal mucosa, increasing the risk of meningococcal disease. At the same time, transmission of Neisseria meningitidis, it also said, may be facilitated by overcrowded housing and by large population displacements at the regional level due to pilgrimages and traditional markets. WHO said: “This combination of factors explains the large epidemics which occur during the dry season in the meningitis belt. Following the successful roll-out of the MenA conjugate vaccine, epidemics due to Neisseria meningitidis serogroup A are disappearing, but other meningococcal serogroups such as NmW, NmX and NmC still cause epidemics albeit at a lower frequency and smaller size.”

The experts are in agreement with WHO when they noted that Meningococcal meningitis occurs in small clusters but stated that the outbreaks can occur in any part of the world, the largest of these usually occur mainly in the semi-arid areas of sub-Saharan Africa, designated the ‘African meningitis belt’.

Nigeria, according to them, is one of the countries situated within the meningitis belt with almost entire northern sphere of the country embedded in the belt geographically. This, they said, might be the reason the country has been witnessing outbreaks of meningitis, with the 2017 outbreak earmarked as one of the worst with high mortality.

Several guideline documents exist globally, which address specific compoinnents of meningitis response but there is none that is specific to the Nigerian context, leading to response efforts being uncoordinated and unstructured.

The Nigeria Centre for Disease Control (NCDC) which is a parastatal of the Federal Ministry of Health (FMoH) has the responsibility of protecting the health of Nigerians through prevention, detection, and control of communicable and non-communicable diseases. Consequently, the NCDC developed a document as a “National Preparedness and Response Guideline for Cerebrospinal Meningitis Outbreak” in response to the growing need by stakeholders to streamline coordination efforts to prevent and respond to outbreaks of meningitis in Nigeria.

The purpose of the practical guideline was to provide guidance on the prevention, detection and response to cerebrospinal meningitis outbreaks in Nigeria through specific measures. These include prevention, early detection of suspected cases and prompt reporting of these cases from health facilities to higher levels, activation of response coordination structures at national and sub-national levels during outbreaks. It is equally saddled with the responsibility to strengthening surveillance and laboratory confirmation data at all levels and use of such information for immediate public health control response.

The document is the first of its kind in Nigeria that integrates all aspects of control such as Prevention, Surveillance, and Laboratory diagnosis. Others are Case Management, Risk Communication with Social Mobilisation, Vaccines/Logistics and Incident ForewordF8 Management Coordination for meningitis outbreaks with sample details of some useful practical annexes. Compliance with this guideline will improve the country’s response capacity in any subsequent outbreak of meningitis in Nigeria. Little wonder, the National Primary Health Care Development Agency (NPHCDA), a few weeks ago alerted the nation that about 26.7 million Nigerian children between ages one to seven years are at risk of contracting meningitis.

The Executive Director, NPHCDA, Dr Faisal Shuaib, revealed this recently in Calabar, according to the News Agency of Nigeria (NAN),in a message during the introduction of “Men A” vaccine into routine immunisation in Cross River. In the signed message, made available to journalists at the occasion, Shuaib said that Nigeria had 25 states and the FCT that fell within the meningitis belt. He said that the use of vaccines was the only way to prevent meningitis for now. Shuaib said: “The introduction of “MenA” vaccine into the EPI schedule will provide protection against Neisseria Meningitis Serotype A.” In his speech, Professor Ivara Esu, Deputy Governor of Cross River, said the state had trained hundreds of health workers to ensure the success of the exercise.

Esu said that since Cross River was among the 25 states that fell within the belt, the government would do everything possible to ensure that every eligible child was immunised. “Immunisation remains the protection against meningitis. Meningitis is a devastating disease that affects children. We will ensure that every eligible child in the state is immunised,” he said, while urging the women to take their children within 15 months of birth to the nearest government health facility for immunisation.

He expressed appreciation to all the partners in the fight against meningitis, including the WHO, United Nation’s Children Education Fund and the NPHCDA. Also, Rilwan Raji, the State Coordinator of WHO in Cross River, appealed to the state government to ensure the vaccines were well protected. Raji said there was a need for periodic review of routine immunisation in the state. He appealed to traditional rulers, religious and opinion leaders to sensitise their subjects and followers on the need to take advantage of the exercise to immunize their children. NPHCDA however, had earlier introduced meningitis vaccine into the national routine immunisation schedule to tackle this menace, according to reports. With the support of development partners, the Agency in August, 2019, introduced the meningitis A (MenA) vaccine into Nigeria’s routine immunisation (RI) programme.

The introduction of MenA vaccine into the RI schedule was effective nationwide as it provided protection against Neisseria meningitidis Serotype A, the microorganism responsible for meningitis A. This update was obtained from a thread of tweets from NPHCDA’s official twitter account @NphcdaNG. The MenA vaccine was administered free of charge as a single dose injection to children nine months of age, alongside measles and yellow fever vaccines. NPHCDA assured the public of the safety, potency and efficacy of the MenA vaccine and all other vaccines administered under national RI schedule.

WHO is said to be providing supportive guidance to intensify routine immunisation (RI) strategies in lowperforming Local Government Areas in selected priority states in Nigeria. One of such supportive guidance is the engagements with local government area teams during the Optimised Integrated Routine Immunisation Sessions (OIRIS). During these engagements, the local government area teams were taken through problem solving tools to identify root causes and develop strategies to resolving the problems.

In addition, there were face-to-face sessions where the local government area teams were able to share sensitive details about barriers to implementation of their plans for which national interventions are required. The Routine Immunisation Lots Quality Assurance Sampling (RILQAS), which started in the fourth quarter of 2017, has also been adopted by the country to assess the quality of RI service at the local government level. Meningitis is an inflammation of the membranes (meninges) surrounding the brain and spinal cord.

The swelling from meningitis typically triggers symptoms such sudden high fever, stiff neck, severe headache that seems different than normal, headache with nausea or vomiting, confusion or difficulty concentrating, seizures, sleepiness or difficulty waking, sensitivity to light, no appetite or thirst, skin rash (sometimes, such as in meningococcal meningitis). For the newborns and infants, the signs are high fever, constant crying, excessive sleepiness or irritability, inactivity or sluggishness, poor feeding, a bulge in the soft spot on top of a baby’s head (fontanel) and stiffness in a baby’s body and neck. However, early meningitis symptoms may mimic the flu (influenza) and may develop over several hours or over a few days and the infectious agent is virus while risk factors are alcoholism, diabetes, and Human Immuno Virus and Acquired Immune Deficiency Syndrome (HIV/AIDS).

Most cases of meningitis are caused by a viral infection, but bacterial, parasitic and fungal infections are other causes. Some cases of meningitis improve without treatment in a few weeks while others can be life-threatening and require emergency antibiotic treatment. Suspected persons with these sign are advised to see a doctor and seek immediate medical care.

Initial diagnosis of meningococcal meningitis can be made by clinical examination followed by a lumbar puncture showing a purulent spinal fluid. The bacteria can sometimes be seen in microscopic examinations of the spinal fluid. The diagnosis is supported or confirmed by growing the bacteria from specimens of spinal fluid or blood, by agglutination tests or by polymerase chain reaction (PCR). The identification of the serogroups and susceptibility testing to antibiotics are important to define control measures.

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