Outbreak of meningococcal disease in Devon

Outbreaks of meningococcal meningitis in non-African countries over the last 50 years: a systematic review

Background

Meningococcal disease is caused by the bacteria Neisseria meningitidis, leading to substantial mortality and severe morbidity; with serogroups A, B, C, W135, X and Y most significant in causing disease. An outbreak is defined as multiple cases of the same serogroup occurring in a population over a short time-period. A systematic review was performed to gain insight into outbreaks of meningococcal disease and to describe the temporal pattern over the last 50 years in non-African countries.

Methods

PubMed and EMBASE were searched for English-language publications on outbreaks of meningococcal disease in non-African countries between January 1966 and July 2017, with an additional grey literature search. Articles and reports were considered eligible if they reported confirmed meningococcal outbreak cases, included the region, number of cases, and the start and end dates of the outbreak. Data on outbreaks was stratified by geographical region in accordance with the World Health Organization (WHO) regional classification, and case-fatality rates (CFRs) were calculated.

Results

Of the identified publications, 3067 were screened and 73 included, reporting data from 83 outbreaks. The majority of outbreaks were identified in the regions of the Americas (41/83 outbreaks), followed by the European region (30/83 outbreaks). In each of the Western Pacific, Eastern Mediterranean, and South-East Asian regions there were <10 outbreaks reported. The predominant serogroup in the majority of outbreaks was serogroup C (61%), followed by serogroup B (29%), serogroup A (5%) and serogroup W135 (4%). Outbreaks showed a peak in the colder months of both the Northern and Southern Hemispheres. Of the 54 outbreaks where CFR was calculable for all outbreak cases, it ranged from 0%-80%.

Conclusions

These data present a retrospective view of the patterns for meningococcal disease outbreaks in non-African countries, and provide valuable data for monitoring future changes in disease epidemiology and informing preventive measures.

An outbreak of serogroup B:15:P1.16 meningococcal disease, Frederiksborg County, Denmark, 1987-9

Epidemiological features of an outbreak of group B:15:P1.16 meningococcal disease (MD) in Frederiksborg county, Denmark, 1987-9, were investigated. The study comprised 149 cases notified during the outbreak and the two preceding years; 115 were confirmed by the isolation of Neisseria meningitidis. In 1989 the incidence had increased to 14.1 per 100,000 population. Among group B strains, B:15:P1.16 accounted for 80% (77/97). The overall mortality rate was 10% (15/149). Regarding cases due to group B:15:P1.16 strains a significant time-space clustering, which exclusively occurred within the 10-19 years age group, was demonstrated. The link between cases within clusters was indirect or unknown, except for ten patients with contact to one particular school. The prophylactic measures used included administration of rifampicin to household contacts. During the outbreak the proportion of secondary cases was high (6-15%). All secondary cases occurred outside the household indicating that the household had been protected.

Childhood acute bacterial meningitis in the Sudan: an epidemiological, clinical and laboratory study

The aims of the present study were to document the epidemiology, clinical features and complications of childhood acute bacterial meningitis (ABM) in The Sudan during both an inter-epidemic (endemic) period (1985-1986), and the 1988 serogroup A epidemic; and to examine the phenotypic and genetic similarities and differences of Neisseria meningitidis strains isolated in The Sudan and Sweden. A new enzyme immunoassay test (Pharmacia Meningitis EIA-Test) was evaluated as a potential rapid diagnostic method for the detection of Haemophilus influenzae (HI) type b, Neisseria meningitidis (MC) and Streptococcus pneumoniae (PNC). The test was found to have good sensitivity (0.86) and specificity (0.95) in the inter-epidemic period; and to be adaptable to the field work in The Sudan during the 1988 MC epidemic. During inter-epidemic (endemic) situations in The Sudan, greater than 90% of childhood ABM was caused by one of the three organisms, HI type b, MC and PNC. HI accounted for 57% of the cases. The peak incidence (76%) of HI cases was in infants (less than 12 months) similar to the situation in other African countries. The overall case fatality ratio was 18.6%. Prospective follow-up of survivors for 3-4 years revealed that an additional 43% either died or had permanent neurological complications, the most prevalent and persistent of which was sensorineural hearing loss recorded in 22% of long term survivors. Post-meningitic children were found to have significantly lower intelligence quotients (92.3 +/- 13.9) than their sibling controls (100.7 +/- 10.2, P = 0.029). Features of the large serogroup A sulphonamide resistant MC epidemic (February-August 1988) in Khartoum are described. An estimated annual incidence of 1,679/100,000 was recorded at the peak of the epidemic. The highest attack rate was in young children less than 5 years, as in many other African countries; nevertheless, a high morbidity was observed in adults (31% of the cases greater than or equal to 20 years). The clinical features, mortality (6.3%) and short term sequelae in Sudanese children were generally within the framework described for MC disease elsewhere. Detailed analysis of MC isolates from Sudan and Sweden by characterizing their electrophoretic enzyme types, DNA restriction endonuclease pattern and outer membrane proteins, revealed that serogroup A MC clone III-1 was responsible of The Sudan epidemic in 1988 and has been the dominant serogroup A organism in Sweden since 1973. The Sudanese strains isolated prior to the epidemic (1985) were clone IV-1.(ABSTRACT TRUNCATED AT 250 WORDS)

Epidemiology of meningococcal infections in the Federal Republic of Germany, 1966-1984

In the Federal Republic of Germany, the morbidity curve of meningococcal infections from 1966-1984 exhibited two maxima in 1970 and 1979 representing morbidity values of 2.9 and 2.3 per 100,000 of the population, and a small peak in 1974. The average morbidity of the 19 years was 2.1/10(5), the lowest morbidity 1.3/10(5) (1983/84). Meningitis occurred on an epidemic scale in 1970 in Bremen, in 1971 in Schleswig-Holstein and 1971-1977 in the Saarland. Most cases were notified during the first four four-week periods of the year, but in two years (1967, 1969), the late-summer peak exceeded the peak of winter/spring. 17.3% of the cases occurred in infants, 51.7% in the first five years of life. Morbidity was highest during the second quarter of the first year. The sex ratio (m:f) of the infections was 1.6:1, but in the aged, morbidity was about the same in both sexes (0.9:1). The case-fatality ratio varied between 7.1% (1977) and 12.1% (1971, 1982) and averaged at 9.7%. It was highest in the aged (37.1%) and second-highest in infants (18.7%). Differences of lethality due to sex could not be demonstrated. Of 1.685 meningococcal strains isolated from CSF and/or blood, 7.3% were of serogroup A, 74.4% of group B, 15% of group C, 1.5% of group Y and 1.1% of group W135. The proportion of group B infections was highest in infants, of group A infections in children (5-10 years), of group C infections in older children and adolescents (10-20 years). The sensitivity of N. meningitidis to sulfadiazine varied with serogroup and year of isolation. Since 1977, practically all group A strains, but only 13% of group B and 9% of group C strains proved to be resistant. Practically all strains were fully sensitive to rifampicin and minocycline; results of trials with spiramycin were not in support of the use of this compound as a chemoprophylactic agent.

An outbreak of meningococcal disease in Gloucestershire

Between October, 1981, and March, 1986, there were 65 cases of meningococcal infection, about five times the expected number, in Gloucester Health District. The cases, mainly in teenagers and young adults, were clustered in the Stroud district and in the southern part of Gloucester City, and most were caused by a sulphonamide-resistant group B type 15 meningococcus. 2 patients died. Only 57% of meningitis cases were formally notified. 7 (11%) patients had septicaemia without meningitis, not a notifiable disease. All meningococcal disease should be made notifiable and meningococci should be serotyped routinely so that the epidemiology of the disease can be monitored before the introduction of suitable vaccines.

Bacterial meningitis--ten years experience

Between January 1968 and December 1977, 635 cases of acute bacterial meningitis were admitted to hospitals in the Birmingham Area Health Authority. The epidemiology of these cases was analysed and compared with the 270 cases which were admitted to the regional infectious diseases unit at East Birmingham Hospital (E.B.H.). In children and young adults the meningococcus was the commonest causative organism while over the age of 25 pneumococcal meningitis predominated. Although Haemophilus influenzae was the second commonest infecting organism it was a rare cause of meningitis in school children and adults, only four cases presenting in these age groups in the Birmingham Area. A detailed analysis was made of the symptoms, signs, laboratory investigations and clinical course of the 270 cases treated at E.B.H. The mortality in the patients with pneumococcal meningitis was 30%. In the meningococcal group it was 3.5% and in the haemophilus groups 7.7%. An analysis of the various treatment regimes employed in the 270 E.B.H. patients supports the view that a single antibiotic is sufficient for the therapy of most forms of bacterial meningitis. Intrathecal antibiotic administration is unnecessary in pyogenic meningitis caused by meningococci, pneumococci or H. influenzae.

Mortality in meningococcal infections

Among 124 patients with meningococcal infections between 1966-1976, 108 had meningitis with a fatality rate of 7.4%, and 16 septicaemia with 18.8% fatality. High risk patients (more than 3 prognostically unfavourable characteristics) increased from 3.5% 1966-1970 to 15.6% 1971-1976, and the total mortality from 3.6 to 10.4%. The most unfavourable prognostic factor was low blood pressure at admission. High risk patients were more common among those who had meningococci with complete or partial sulfonamide resistance (25.7%) than among those having sensitive meningococci (11.9%). When the meningococci were at least partially sulfonamide-resistant, initial therapy with the combination of benzylpenicillin, sulfaisodimidine and chloramphenicol seemed to be more successful than benzylpenicillin alone in patients above 10 years. Ampicillin was used only in children, and these all survived.

Serotypes of group B meningococci

Strains of group B meningococci isolated from cases of sporadic infection, epidemic infection, and from patients unassociated with clinical meningococcal infection have been examined by a serological typing technique. The majority of group B meningococci from clinical infections in the UK have serotype 2 antigen. Such strains were relatively uncommon among carriers who had no association with meningococcal disease.

Fulminant meningococcal septicaemia. A hospital experience

In the first 5 months of 1975, 12 cases of meningococcal septicaemia were seen at a children's hospital where in previous years the condition was seen only sporadically. 3 of these children were dead on admission, 5 died shortly after admission, and 4 responded to treatment. Neisseria meningitidis was recovered from cerebrospinal fluid or blood or both in all cases, and the clinical illness was characterised by fever, prostration, and cutaneous purpura of abrupt onset. There were no significant previous illnesses, no recognisable prodromata, and, bacteriology apart, no pattern of laboratory results. There was a suggestion of centre-city clustering in the home background, although 2 of the patients came from rural areas. At necropsy gross adrenal haemorrhage was found in 6 of the 8 fatal cases, and upper gastrointestinal bleeds in the 5 deaths which were not sudden.

Meningococcal infections in Bolton, 1971-74

Between December 1970, and the end of June, 1974, there were 82 cases of meningococcal infection, including 14 deaths, in the metropolitan borough of Bolton. This outbreak, caused by a sulphonamide-sensitive group-B strain, was characterised by a high attack-rate in young children, reaching a peak of 184 per 100,000 per year in the 6-11-month age-group. All the deaths were in children under 3 years of age. Nasopharyngeal carriage of the epidemic strain was found in 34% of close family contacts investigated before receiving sulphonamide prophylaxis.