Risk of secondary meningococcal disease in health-care workers

Evaluation of antibody responses in healthcare workers before & after meningococcal vaccine and determination of meningococcal carriage rates

The rates of nasopharyngeal meningococcal carriage in healthcare workers are unknown. Meningococcal vaccine is recommended for risk groups but healthcare workers are not included in risk groups for many countries. Herein, we aimed to investigate the nasopharyngeal meningococcal carriage rates, basal and after one dose of Men-ACWY-DT vaccine response on the 30th day by evaluating meningococcus IgG antibody levels and decolonization at month six after vaccination among the detected carriers. Nasopharyngeal swab samples were taken before vaccination to evaluate meningococcal carriage in healthcare workers. All participants received a single dose of Men-ACWY-DT vaccine. Serum samples were collected immediately before vaccination and again on day 30 post-vaccination. Antibodies in the stored sera were analyzed using the ELISA method. Participants who were determined to carry meningococci at the initial visit underwent another round of nasopharyngeal swab tests six months post-vaccination to check for decolonization. Between November 2020 and May 2021, we evaluated samples from 100 physicians [52 % females, 28.28 ± 4.45 (min: 24, max: 49)]. The majority of the physicians worked in the emergency department (45 %), followed by the infectious diseases clinic (14 %). Fifty-eight physicians had a history of at least one contact with a meningococcus-infected patient, and 53 (91.4 %) had used prophylactic antibiotics at least once due to this exposure. None of the study group nasopharyngeal swab cultures were positive for Neisseria meningitidis. Before the Men-ACWY-DT vaccine, anti-meningococcus IgG positivity was detected in the serum samples of only 3 (3 %) participants. By day 30 after vaccination, 48 % of participants showed positive for antibodies. As we didn't detect nasopharyngeal carriage in any participants, we didn't evaluate decolonization among carriers six months post-vaccination. Notably, detection of antibodies was evident in about half of the participants on day 30 after receiving a single dose of the Men-ACWY-DT vaccine.

Pharyngeal carriage rates of Neisseria meningitidis in health care professionals at a tertiary university pediatric hospital

Pharyngeal carriage is the reservoir for Neisseria meningitidis in the population and the first step in disease transmission. Especially in young infants and adolescents, N. meningitidis can cause serious invasive infection with high fatality rates and high rates of long-term sequelae among survivors. The aim of this study was to determine N. meningitidis colonization rates in asymptomatic health care professionals at a tertiary university pediatric hospital and to identify risk factors for carriage. This cross-sectional meningococcal carriage survey was conducted between April and October 2018 at the Medical University of Vienna. Individuals working as nurses, pediatricians, or medical students were enrolled. Oropharyngeal swabs were directly plated onto selective agar plates and conventional culture was used for bacterial identification. Meningococcal isolates were further characterized using whole-genome sequencing. A total of 437 oropharyngeal specimens were collected. Overall, meningococcal carriage prevalence was 1.14% (5/437), with 0.7% (3/437) for capsular genotype B, and 0.5% (2/437) for capsular genotype W. Mean age of carriers was significantly lower than of non-carriers (24.2 vs. 35.8; p = 0.004). The highest carriage rate of 4.4% (4/91) was found in the age group 18–25. Carriage was negatively associated with age and timespan working in pediatrics. This is the first study evaluating the prevalence of Neisseria meningitidis carriage in health care professionals working in Pediatrics and Adolescent Medicine. Carriage was in general lower than expected for all age groups, implicating a low risk of meningococcal transmission via this population.

Managing the risk of bacterial meningitis among healthcare workers

BACKGROUND

Meningococcal disease is generally caused by A, B, C, W and Y subgroups of Neisseria meningitidis. In 2015, the Italian mass media focused on this disease due to the death of two nurses. This generated alarm in the general population, especially in healthcare workers (HCWs). The Occupational Medicine department of the Foundation PTV Polyclinic Tor Vergata (PTV) offered free MenACWY vaccine to HCWs and to students of the University of Rome Tor Vergata.

AIMS

To analyse the prevalence of N. meningitidis in PTV, a large teaching hospital, and to evaluate preventive measures offered to individuals at risk (i.e. HCWs and students).

METHODS

The Hospital Informatic Service provided data about patients admitted to PTV from January 2012 to December 2016. Hospital Discharge Registers were analysed and all cases of meningitis were selected. MenACWY vaccine administered to HCWs and students of PTV in 2017 was analysed.

RESULTS

There was just one case of meningococcal disease in 2016. Of the 117 MenACWY vaccines administered, 42% were given to students, 32% to doctors, 8% to nurses, 2% to clerks and 16% to other healthcare professionals.

CONCLUSIONS

International guidelines recommend MenACWY vaccine for microbiologists exposed to N. meningitidis isolates. The Italian Legislative Decree 81/2008, however, states that occupational physicians can adopt special protective measures such as vaccination programmes for HCWs. The response rate highlights how perceived risk may influence behaviour even in populations with a higher background knowledge than the general population.

Autopsy Biosafety: Recommendations for Prevention of Meningococcal Disease

Introduction

As invasive meningococcal disease progresses rapidly, often affects youth, and has a fairly high mortality rate, such cases are likely to fall under medical examiner/coroner (ME/C) jurisdiction. Morgue personnel may be at risk of contracting secondary meningococcal disease. We review the current scientific literature regarding Neisseria meningitidis infection and provide recommendations for the prevention of meningococcal disease at autopsy.

Methods

A PubMed search utilizing applicable medical subject heading terms was performed retrieving articles for review from the preceding two decades. Pertinent current guidelines from multiple national organizations were also retrieved.

Results

Invasive meningococcal disease is transmitted by direct contact with large respiratory droplets or oral secretions. While a surgical mask would normally provide adequate protection from large droplet spread, it does not prevent inhalation of smaller aerosolized particles such as those generated at autopsy. Prosectors are advised to routinely wear N-95 respirator masks or powered respirator hoods. All published cases of secondary meningococcal disease transmission to healthcare workers invariably arose in scenarios in which face masks/respirators were not employed; none of these cases involved meningococcal disease transmission to ME/C or other morgue staff.

Discussion

In the event that no mask-or inadequate coverage such as a surgical mask-is employed during autopsy of a decedent suspected/confirmed to have invasive meningococcal disease, antibiotic prophylaxis is advisable. Assuming appropriate personal protective equipment is utilized, chemoprophylaxis is unnecessary. Routine meningococcal vaccination is not recommended, except for ME/C with specified immunocompromising conditions or traveling to hyperendemic/endemic meningococcal regions. Acad Forensic Pathol. 2018 8(2): 328-339.

Invasive Meningococcal Disease on the Workplaces: a systematic review

Background and aims of the work: Invasive Meningococcal Disease (IMD) represents a global health threat, and occupational settings have the potential to contribute to its spreading. Therefore, here we present the available evidences on the epidemiology of IMD on the workplaces.

METHODS

The following key words were used to explore PubMed: Neisseria meningitidis, meningococcus, meningococcal, invasive meningococcal disease, epidemiology, outbreaks, profession(al), occupation(al).

RESULTS

We identified a total of 12 IMD cases among healthcare workers (HCW), 44 involving biological laboratory workers (BLW), 8 among school personnel, and eventually 27 from other settings, including 3 large industrial working populations. Eventual prognosis of BLW, particularly the case/fatality ratio, was dismal. As clustered in time and space, data about school cases as well as industrial cases seem to reflect community rather than occupational outbreaks. In general, we identified a common pattern for HCW and BLW, i.e. the exposure to droplets or aerosol containing N meningitidis in absence of appropriate personal protective equipment (PPE) and/or microbiological safety devices (MSD) (e.g. cabinets). Post-exposure chemoprophylaxis (PEC) was rarely reported by HCW (16.7%) workers, and never by BLW. Data regarding vaccination status were available only for a case, who had failed requested boosters.

CONCLUSIONS

The risk for occupational transmission of IMD appears relatively low, possibly as a consequence of significant reporting bias, with the exception of HCW and BLW. Improved preventive measures should be implemented in these occupational groups, in order to improve the strict use of PPE and MSD, and the appropriate implementation of PEC.

The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults

Bacterial meningitis and meningococcal sepsis are rare conditions with high case fatality rates. Early recognition and prompt treatment saves lives. In 1999 the British Infection Society produced a consensus statement for the management of immunocompetent adults with meningitis and meningococcal sepsis. Since 1999 there have been many changes. We therefore set out to produce revised guidelines which provide a standardised evidence-based approach to the management of acute community acquired meningitis and meningococcal sepsis in adults. A working party consisting of infectious diseases physicians, neurologists, acute physicians, intensivists, microbiologists, public health experts and patient group representatives was formed. Key questions were identified and the literature reviewed. All recommendations were graded and agreed upon by the working party. The guidelines, which for the first time include viral meningitis, are written in accordance with the AGREE 2 tool and recommendations graded according to the GRADE system. Main changes from the original statement include the indications for pre-hospital antibiotics, timing of the lumbar puncture and the indications for neuroimaging. The list of investigations has been updated and more emphasis is placed on molecular diagnosis. Approaches to both antibiotic and steroid therapy have been revised. Several recommendations have been given regarding the follow-up of patients.

[Vaccination recommendations for health care workers in Austria]

In Austria the vaccination coverage among health care workers (HCW) - particularly among hospital personnel - is not sufficient. This is of specific concern, because not only the individual protection but also the prevention of disease transmission of vaccine preventable diseases between HCW and patients needs to be guaranteed. Particularly immunosuppressed patients, who are at higher risk for morbidity and mortality due to certain infections, but cannot be vaccination themselves, must be able to rely on herd protection, i.e. not being infected by surrounding/caring persons. The following publication provides for the first time detailed guidelines for vaccination programs for HCWs in Austria, including personnel within hospitals, medical institutions and laboratories, as well as Medical Universities including students. Moreover, these guidelines are also recommended to medical personnel in outpatient clinics, social service institutions and medical practices. Additionally to the vaccination schedules this publication also includes a chapter on ethical as well as legal background underlying these recommendations.

Infection control and postexposure prophylaxis for the pregnant healthcare worker

Pregnant health care workers (HCW) may be exposed to pathogens during routine patient care duties. Although they do not seem to be at higher risk for infection compared with nonpregnant HCW, certain infections can be associated with increased maternal morbidity, mortality, and adverse perinatal outcomes. Primary prevention through vaccination is crucial. Medical providers must know which vaccines are safe during pregnancy and which should be postponed until after delivery. Pregnancy should not be a contraindication for certain postexposure prophylaxis regimens after an occupational exposure. Pregnant HCW need to be educated about specific occupational risks and the recommended infection control precautions.

Evidence for indirect nosocomial transmission of Neisseria meningitidis resulting in two cases of invasive meningococcal disease

Nosocomial transmission of Neisseria meningitidis has only rarely been reported. Here, we present a significant spatiotemporal association of two cases of invasive meningococcal disease identified by retrospective cluster analysis with the program SaTScan. The most likely epidemiological link was simultaneous hospitalization, resulting in indirect nosocomial transmission.

Diagnosing meningococcemia as a cause of sepsis

OBJECTIVE

In 2004, a consensus meeting of critical care and infectious disease experts was organized to review and make recommendations on current definitions of infections, sepsis, and organ failure for neonates and children and for the predisposing conditions leading to these diseases. Among the infections leading to sepsis, meningococcemia is so distinguishable that a separate article on its diagnosis and management was thought to be warranted.

DESIGN AND METHODS

The process included a modified Delphi method, a consensus conference, subsequent smaller meetings of subgroups and key individuals, and electronic-based discussion among subgroups. A systematic review of the literature was undertaken.

CONCLUSIONS

Early recognition and treatment of likely meningococcal sepsis has led to decreased mortality. Since the start of vaccination against serogroup C, the prevalence of this disease has decreased. Not only the possible presence of a meningococcal sepsis is important, but also the assessment of the shock state and the severity of disease and the possible presence of meningoencephalitis. There are also a number of genetic predispositions determining the severity of disease. The only three randomized trials in this disease have led to the conclusion that mortality is not a stable end point. Improvement in organ function, morbidity (including amputations), and functional outcome are better outcome measures.

Risk and prevention of meningococcal disease among education workers: A review

The aims of the present study were to review the risk of invasive meningococcal disease (IMD) among education workers, particularly pregnant women, and to evaluate preventive measures, in a context of endemicity, outbreak or epidemic as observed in the province of Quebec. The literature was reviewed and persons in charge of IMD surveillance in France, Quebec, the United Kingdom and the United States were interviewed. Surveys of asymptomatic carriage of Neisseria meningitidis show that transmission among students is higher than transmission between students and teachers. IMD incidence among education workers was analyzed in Cheshire (United Kingdom) in the period from 1997 to 1999, and the results indicated a risk six times higher than that in the general population. Overestimation of the magnitude of the risk is possible because the analysis focused on a cluster. None of the population-based studies of IMD mentioned a risk of secondary cases among education workers. Six IMD cases in education workers were identified in five clusters in schools in the United Kingdom, but not in the other countries. There is no epidemiological study on IMD risk among pregnant women, and this factor was not mentioned in any published review of IMD. Immunization of education workers at the beginning of their employment, using serogroup C glycoconjugate vaccine or a combined A, C, W-135, and Y conjugate vaccine (still under development), could reduce IMD risk, but the cost effectiveness of this measure should be evaluated. The societal benefit of excluding pregnant women from the work place during an outbreak seems to be very low, even if disease risk could be decreased for this specific group. When chemoprophylaxis is indicated for the control of an outbreak in an educational setting, treatment should be offered both to students and teachers in the group at risk.

Opportunities for Control of Meningococcal Disease in the United States

The United States currently has relatively low rates of meningococcal disease caused by Neisseria meningitidis. Serogroups Y, C, and B are most common. Although most cases are sporadic, a minority are associated with outbreaks. Pediatric populations have disproportionately higher rates of disease, but nearly two thirds of all cases occur in persons aged 15 years and older. The major challenge to control of domestic meningococcal disease is the absence of a vaccine to prevent sporadic cases spanning many age groups. The quadrivalent A/C/Y/W-135 meningococcal polysaccharide vaccine is licensed in the United States, but because of its limited efficacy in children under two years of age, it is recommended for high-risk groups and outbreak response rather than routine childhood immunization. New conjugate meningococcal vaccines have successfully reduced endemic disease in the United Kingdom, and similar vaccines promise to have a dramatic impact on the burden of meningococcal disease in the United States.

Risk of laboratory-acquired meningococcal disease

Five probable secondary cases of meningococcal disease were identified in microbiology laboratory workers in England and Wales during a 15-year period. All cases had prepared suspensions of Neisseria meningitidis outside a safety cabinet upto seven days before onset of illness. Relative risk in laboratory workers compared with the background adult population was 184 (95% CI 60-431). In view of the potentially serious outcome from this infection, a safety cabinet should always be used when preparing or working with suspensions of meningococci. Vaccination policy for microbiology laboratory workers should be reviewed.