Meningococcal disease among children who live in a large metropolitan area, 1981-1996

Secular trends in invasive meningococcal disease, Massachusetts, 1988–2011: what happened to invasive disease?

Invasive meningococcal disease (IMD) reported to the Massachusetts Department of Public Health from 1988 to 2011 was reviewed. The average annual incidence of IMD/100 000 decreased from 1·57 [95% confidence interval (CI) 1·42–1·73] for 1988–1991 to 0·22 (95% CI 0·17–0·29) for 2008–2011. The pattern of decreasing incidence over time differed by age group. There was a decrease in IMD/100 000 in the 0–4 years age group after 1991 from 10·92 (95% CI 8·08–14·70) in 1991 to 5·76 (95% CI 3·78–8·72) in 1992. Incidence in the 0–4 years age group remained below 5/100 000 per year on average thereafter. A substantial reduction in incidence in all age groups was observed between 2000 and 2009, which began before the introduction of conjugate meningococcal vaccine in 2005. Marked reductions in incidence of IMD in Massachusetts, and elsewhere, deserve further investigation with respect to potential factors that go beyond the introduction and deployment of improved meningococcal vaccines.

Invasive meningococcal infection: analysis of 110 cases from a tertiary care centre in North East India

OBJECTIVES

To report an outbreak of invasive meningococcal disease from Meghalaya, in the north east India, from January 2008 through June 2009.

METHODS

Retrospective review of case sheets was done. One hundred ten patients with invasive meningococcal disease were included for the study.

RESULTS

Of the total patients, 61.8 % were boys and 38.2 % were girls (boy to girl ratio = 1.62:1). The average age of presentation was 8.48 ± 5.09 y. Meningococcal meningitis was seen in 61.8 % of cases, meningococcemia in 20 % and 18.2 % had both. Fever was the most common manifestation (100 %) followed by meningeal signs (78.2 %), headache (56.4 %), vomiting (53.6 %), shock (38.2 %), low Glasgow coma scale (GCS) (25.5 %), purpura and rashes (23.6 %), seizures (9.1 %), abdominal symptoms (4.5 %), irritability and excessive crying (4.5 %) and bulging anterior fontanalle (23 %) in those below 18 mo of age. Raised intracranial pressure (ICP) was the most common complication (28.2 %) followed by coagulopathy (16.4 %), hepatopathy (10 %), herpes labialis (9.1 %), syndrome of inappropriate ADH secretion (SIADH) (8 %), pneumonia (7 %), arthritis (6 %), purpura fulminans, respiratory failure, sixth nerve palsy and diabetes insipidus in 4.5 % each, subdural empyema, optic neuritis, ARDS and ARF in 1.8 % each, cerebral salt wasting syndrome, third nerve palsy, cerebritis and hearing impairment in 0.9 % each. Culture was positive in 35.5 %. Patients were treated initially with ceftriaxone and dexamethasone but later on with chloramphenicol due to clinical drug resistance. Mortality was 6.4 %.

CONCLUSIONS

This is the first epidemic report of invasive meningococcal disease from the north east India. Chloramphenicol acts well in areas with penicillin or cephalosporin resistance. Mortality reduces significantly with early diagnosis and prompt intervention.

Review of meningococcal infection in children at a United Kingdom hospital

Sixty-nine children were identified and evaluable. Forty-one (60%) presented with hypotension and/or abnormal neurological signs. In 34 (49%) a petechial rash was present on admission. Of note, 13 (19%) had a non-petechial rash, and rash was absent in 19 (28%). Twenty-one (30%) presented with meningism or meningitis. In one child the illness was so mild that the child was discharged prior to making a diagnosis. Five children died (7%). Sixty-three cases (91%) were diagnosed by blood or cerebrospinal fluid culture; these investigations remain the mainstay of diagnosis.

Outcomes of meningococcal disease in adolescence: prospective, matched-cohort study

OBJECTIVE

We examined the physical, cognitive, educational, social, and psychological outcomes of invasive meningococcal disease in adolescence, as well as demographic and disease factors associated with outcomes.

METHODS

A population-based, matched-cohort study was performed. A total of 101 gender- and age-matched case-control pairs (15-19 years of age at the time of disease; 46% male) from 6 regions of England underwent follow-up evaluations 18 to 36 months after invasive meningococcal disease. Educational, social, and vocational function, mental health, social support, self-efficacy, and quality-of-life data were collected by using standardized questionnaires and neuropsychological tests.

RESULTS

Fifty-seven percent of case subjects (n = 58) had major physical sequelae. Survivors had greater depressive symptoms, greater fatigue, less social support, greater reduction in quality of life, and lower educational attainment compared with control subjects. Survivors with serogroup C disease had greater physical sequelae than did those with serogroup B disease. Greater cognitive deficits were associated with younger age at diagnosis. Only 53 of 101 case subjects reported any medical follow-up care after invasive meningococcal disease.

CONCLUSIONS

Survivors of invasive meningococcal disease in adolescence have a disturbing series of deficits, including poorer physical and mental health, quality of life, and educational achievement. Serogroup C is associated with poorer outcomes. Invasive meningococcal disease attributable to serogroup B disease remains a major cause of morbidity and death among adolescents. Medical care is poor after discharge from the hospital. Routine follow-up care of adolescent survivors may prevent or ameliorate physical and psychosocial morbidity after invasive meningococcal disease.

Effectiveness of vaccinating household contacts in addition to chemoprophylaxis after a case of meningococcal disease: a systematic review

SUMMARYWe performed a systematic review to estimate the effectiveness of vaccination, in addition to chemoprophylaxis, in preventing meningococcal disease among household contacts. Medline, EMBASE, EMGM, and EUIBIS were used for data collection. Studies reporting on at least 100 primary cases and on subsequent cases in household settings with follow-up of more than 2 weeks after onset of disease in the primary case were reviewed. A meta-analysis was used to calculate the average attack rate in household contacts given chemoprophylaxis 14-365 days after onset of disease in the primary case. In total, 652 studies were identified, five studies and one unpublished report met the inclusion criteria. The weighted average attack rate was 1.1/1000 household contacts (95% CI 0.7-1.7). This review supports vaccination of household contacts in addition to chemoprophylaxis to reduce the risk of meningococcal disease among household contacts of a case caused by a vaccine-preventable serogroup.

The evolving approach to the young child who has fever and no obvious source

Fever is a common complaint of young children who seek care in the emergency department. Recent advances, such as universal vaccination with the pneumococcal conjugate vaccine, require the review of traditional approaches to these patients. This article discusses newer strategies in the evaluation and management of the young child with fever, incorporating changes based on the shifting epidemiology of bacterial infection.

Multicenter surveillance of invasive meningococcal infections in children

OBJECTIVES

Meningococcal disease continues to result in substantial morbidity and mortality in children, but there is limited recent surveillance information regarding serogroup distribution and outcome in children in the United States. The objective of this study was to collect demographic, clinical, laboratory, and outcome information for infants and children who had Neisseria meningitidis infections of various serogroups and were cared for in 10 pediatric hospitals.

METHODS

Investigators at each of the participating hospitals identified children with meningococcal infections and collected demographic and clinical information using a standard data form. Meningococcal isolates were sent to a central laboratory for serogrouping by slide agglutination and penicillin susceptibility.

RESULTS

From January 1, 2001, through March 15, 2005, 159 episodes of systemic meningococcal infections were detected. The greatest numbers of children were younger than 12 months (n = 41) or were 12 to 24 months of age (n = 22). Meningitis was the most common clinical manifestation of disease accounting for 112 (70%) cases; 43 (27%) children had bacteremia only. Children who were younger than 5 years (17 of 102) were significantly less likely to require mechanical ventilation than children who were 5 to 10 years of age (12 of 24) or children who were older than 10 years (13 of 33). Overall, 55 (44%) isolates were serogroup B, 32 (26%) were serogroup C, and 27 (22%) were serogroup Y. All but 1 isolate (intermediate) were susceptible to penicillin. The overall mortality rate was 8% (13 of 159) but was greater for children who were > or = 11 years of age (7 [21.2%] of 33) than for children who were younger than 11 years (6 [4.8%] of 126). Unilateral or bilateral hearing loss occurred in 14 (12.5%) of 112 children with meningitis.

CONCLUSIONS

The morbidity and the mortality of meningococcal infections are substantial. With the recent licensure of meningococcal conjugate vaccines, our baseline trends in meningococcal disease can be compared with those seen after widespread vaccination to assess the success of routine immunization.

Fever without source in children 0 to 36 months of age

Although fever in the young child (0-36 months) is a common clinical problem, the evaluation and treatment of febrile children remain controversial. Furthermore, universal vaccination with the heptavalent pneumococcal conjugate vaccine (PCV7) has changed the epidemiology of invasive bacterial disease in young children. This article addresses the approach to febrile neonates (0-28 days old), young infants (1-3 months old), and older infants and toddlers (3-36 months old) in the PCV7 era.

Invasive meningococcal disease presenting as Henoch-Sch�nlein purpura

Henoch-Schonlein purpura (HSP) is an acute systemic form of vasculitis that has been associated with a number of viral and bacterial infections. Described here are the cases of two children with invasive meningococcal disease who presented with clinical and laboratory findings typical of HSP. Meningococcal infection may have been the trigger for the manifestation of HSP in these patients.

The evolving epidemiology of invasive meningococcal disease: a two-year prospective, population-based study in children in the area of Athens

In response to an increase in the incidence in invasive meningococcal disease (IMD) due to Neisseria meningitidis, a system of hospital- and laboratory-based surveillance was used in a prospective epidemiological and clinical assessment of IMD in children 0-13 years of age hospitalized in the Athens area between 1 January 1999 and 31 December 2000. The annual incidence of laboratory-confirmed disease was 10.2/100,000. Serogroup B strains were predominant. There was a sharp decrease in serogroup C from 19% of cases in 1999 to 3% in 2000 (P=0.013). Of note was the emergence of serogroup A responsible for 7% of the cases. The overall case fatality rate was 4.5%, but 2.8% for microbiologically confirmed cases. A remarkable decrease in disease severity assessed by admissions to intensive care units was noted during the second study year. Polymerase chain reaction-based methods for detection of meningococcal DNA were the sole positive laboratory test in 45% of the cases and the only test on which serogroup determination was based in 52% of groupable cases. The epidemiological and clinical profile of meningococcal disease appears to be rapidly evolving and close monitoring is required particularly for input into decisions regarding use of meningococcal vaccines.

Extremity pain and refusal to walk in children with invasive meningococcal disease

OBJECTIVE

Early recognition of invasive meningococcal disease in children may be difficult. Extremity pain and refusal to walk (extremity symptoms) are uncommonly mentioned as clinical findings in children who present with this disease. We sought to determine 1) the frequency of extremity symptoms as part of the clinical presentation in children with invasive meningococcal disease and 2) whether these symptoms help identify children with otherwise unsuspected meningococcal disease.

METHODS

We reviewed the medical records of patients who were younger than 20 years and had invasive meningococcal disease from 1985 to 1996 at 3 pediatric referral centers. Children with extremity symptoms were identified and described. We compared clinical and laboratory findings and frequency of adverse outcomes between these children and those with invasive meningococcal disease without extremity symptoms.

RESULTS

We identified 274 children with invasive meningococcal disease, 45 (16%) of whom had either history or physical examination evidence of extremity pain (31) or refusal to walk (14) as part of their clinical presentations. Five of the 45 patients had arthritis at the time of presentation. Patients with extremity symptoms at presentation were significantly older (77.9 +/- 62.2 vs 44.0 +/- 56.9 months), had lower temperatures (38.8 +/- 1.2 degrees C vs 39.2 +/- 1.2 degrees C), and had higher band counts (28.2 +/- 15.2% vs 18.1 +/- 12.4%) than did patients without extremity symptoms. There were no significant differences, however, between groups with regard to rash, white blood cell counts, coagulation parameters, prevalence of meningitis, or adverse outcomes. Seventy-three (27%) of the 274 patients had unsuspected disease, and 5 (7%) of these had extremity symptoms at the time of diagnosis.

CONCLUSIONS

Sixteen percent of children with invasive meningococcal disease have extremity symptoms at the time of diagnosis. These symptoms may help to identify some patients with otherwise unsuspected invasive meningococcal disease.

Meningococcal infections in children from Arkansas

BACKGROUND

Infections with Neisseria meningitidis are an important cause of morbidity and mortality in children of all ages. With wide-spread use of the heptavalent pneumococcal conjugate vaccine, this organism might become the prominent pathogen for invasive disease in children.

METHODS

Retrospective reviews of medical and microbiologic records from Arkansas Children's Hospital were done to identify patients with invasive N. meningitidis infections from January, 1988, through December, 2000. Basic demographic and clinical data were gathered and reviewed. Data on invasive meningococcal infections were obtained from the Arkansas Department of Health.

RESULTS

Three hundred ninety-four cases of invasive meningococcal infection were reported to the Arkansas Department of Health during the study period. Two hundred ninety-six cases were in patients <21 years of age. The estimated annual incidence of meningococcal disease for the State of Arkansas was calculated to be 1.2-cases/100000 population during the study period. The annual incidence of meningococcal disease in patients <21 years of age was estimated at 2.9 and 21.7 cases/100000 population for children < 1 year of age. One hundred fifty patients (51%) <21 years of age with 151 episodes of invasive meningococcal infections were treated at our institution. Eighty percent of the patients were Caucasian, 55% were male, 31% live in a rural area and the median age at presentation was 30 months (range, 2 weeks to 21 years). The most common signs and symptoms at admission included fever (95%), petechial/purpuric rash (62%), nuchal rigidity (41%) and hypotension (41%). Thirty-eight patients (26%) required both inotropic support and mechanical ventilation during hospitalization, 15 patients died and 18 patients had long term sequelae. Eighty-three of the isolates were serogrouped and included the following: A (2); B (38); C (33); and Y (10). Eighty-four of the index cases were treated with parenteral cephalosporin therapy alone and did not receive additional chemoprophylaxis.

CONCLUSIONS

Many infections in the general pediatric population are a result of N. meningitidis. Although most patients do well and recover without sequelae, there are a significant number who experience major morbidity and mortality as a result of this infection.