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An update on meningococcal meningitis

Heavey, Elizabeth PhD, RN, CNM

doi: 10.1097/01.NURSE.0000388325.21511.7b
Department: COMBATING INFECTION
Free

Meningococcal meningitis

Elizabeth Heavey is assistant professor of nursing at the State University of New York in Brockport, N.Y.

MENINGITIS IS AN inflammation of the meninges, several connective tissue sheaths that loosely suspend and protect the brain and spinal cord. The inflammation generally involves not only the meninges but the subarachnoid space and brain parenchyma as well.1 It's usually caused by a bacterial, viral, or fungal infection. This article focuses on acute bacterial meningitis caused by Neisseria meningitidis, referred to as meningococcal meningitis.

Meningococcal meningitis is a highly contagious and severe disease that can progress to severe neurologic complications, vascular collapse, and death in less than 24 hours.2N. meningitidis accounts for 25% of all cases of bacterial meningitis.1

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Risk factors

People who haven't completed the full series of recommended childhood vaccines, including children under age 5, are at the greatest risk for developing bacterial meningitis.2 Before the development of effective vaccines, the incidence of bacterial meningitis was highest among young children. With widespread implementation of the childhood vaccination schedule, however, incidence has shifted; now the incidence of all types of bacterial meningitis is greater among preteens and young adults.2

In a large population-based study, mortality from bacterial meningitis caused by N. meningitidis was 10% to 15%.2 Teenagers and young adults ages 15 to 24 were six times more likely to die from the infection compared with those under age 15; however, the mortality was still highest among infants.3

Infection rates are highest for meningococcal meningitis in February and March, with a seasonal low in September.4

Meningococcal meningitis is highly contagious. People with compromised immune systems, those living in group settings (such as college dormitories or military units), people who are asplenic or who have spleen damage, and those attending group childcare facilities have a greater risk of acquiring the disease. Several genetic conditions also increase the risk, as does travel to areas where meningococcal meningitis is common.2 Smokers are at an increased risk for pharyngeal carriage of the bacteria and disease development.5

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Recognizing bacterial meningitis

The classic triad of symptoms—nuchal rigidity, headache, and sudden-onset high fever—usually appears within 3 to 7 days of exposure. Only about 25% of those infected with N. meningitidis will develop all of three of these symptoms, however, and infants may not display any of them. Many patients also develop photophobia, a rash, nausea and vomiting, and myalgia.2

Initially, the infection may be mistaken for influenza, but the disease quickly progresses to a more severe form. Later signs and symptoms may include seizures, confusion, loss of consciousness, and coma. Septicemia can develop, damaging blood vessels and producing internal hemorrhage. Death may occur within several hours.2

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Diagnosis and treatment

Patients with meningococcal meningitis should be admitted to a single room and droplet precautions instituted for at least 24 hours after the initiation of effective antibiotic treatment. To treat meningococcal meningitis, ensure adequate I.V. access and closely monitor the patient for seizure activity and signs of shock, such as hypotension. Initiate seizure precautions if indicated; endotracheal intubation may be necessary with signs of rising intracranial pressure.

All close contacts of the patient should be treated with appropriate antibiotics. Close contacts are those who had prolonged contact (8 hours or longer) while in close proximity (3 ft or less) to the patient during the week before symptom onset until 24 hours after initiation of treatment. Close contacts also include those who were directly exposed to the patient's oropharyngeal secretions through kissing, sharing beverages or cigarettes, endotracheal intubation, or endotracheal tube management.1,6 Vaccinations may be appropriate for close contacts as well.

Healthcare workers who are directly exposed to respiratory and oropharyngeal secretions due to unprotected intubation or suctioning should be given prophylactic antibiotic treatment within 12 hours through their facility's occupational health or infection control office.

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A new vaccine

Primary prevention for meningococcal meningitis includes completing the full course of recommended childhood vaccines, including the routine vaccination at age 11 to 18 with one dose of meningococcal conjugate vaccine. In addition to two vaccines already in use for meningococcal meningitis (Menomune and Menactra), the FDA licensed a new quadrivalent meningococcal conjugate vaccine, Meningococcal (Groups A, C, Y, and W-135) Oligosaccharide Diphtheria CRM197 Conjugate Vaccine (Menveo), in February 2010. It can be administered to patients ages 11 to 55.7

The Advisory Committee on Immunization Practices (ACIP) recommends a single dose of quadrivalent meningococcal conjugate vaccine (either Menactra or Menveo) for everyone ages 11 to 18 and those ages 11 to 55 with an increased risk of developing meningitis. Children ages 2 to 10 with an increased risk should also be vaccinated, but only with Menactra.2,7 Each vaccine provides protection against two common strains of N. meningitidis but not for all strains capable of causing the disease.

After reconstitution, Menveo is administered as a single I.M injection, preferably in the deltoid. The solution should appear clear and colorless, without particulate matter. Store it in the refrigerator and protect it from light.

Before the vaccine is administered, assess the patient for allergies. The vaccine is contraindicated if a patient is allergic to any of its components or has had an allergic reaction to diphtheria toxoid or another meningococcal vaccine. Other meningococcal vaccines have been associated with an increased risk of Guillain-Barré syndrome, but no current data exist to indicate whether this risk is present with Menveo.

The most common adverse reactions to the vaccine include pain at the injection site, headache, myalgia, malaise, and nausea. Menveo shouldn't be administered concomitantly with some pertussis vaccines because it can diminish the immune response.8

To encourage use of ACIP vaccine recommendations for preteens and adolescents, the CDC has developed the "It's Their Turn!" initiative, which includes free materials nurses can use for patient education and community advocacy. You can obtain these materials by contacting the Meningitis and Vaccine Preventable Disease Branch at 1–800-CDC-INFO or visiting http://www.cdc.gov/vaccines/spec-grps/preteens-adol/prof-matls/state-materials.htm.

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REFERENCES

1. Fauci AS, Braunwald E, Kasper DL, et al., eds. Harrison's Principles of Internal Medicine. 17th ed. New York, NY: McGraw-Hill Medical; 2008.
2. Centers for Disease Control and Prevention .
3. Kaplan SL, Schutze GE, Leake JA, et al. Multicenter surveillance of invasive meningococcal infections in children. Pediatrics. 2006;118(4): e979–e984.
4. Apicella M. Epidemiology of Neisseria meningitidis infection .
5. Coen PG, Tully J, Stuart JM, Ashby D, Viner RM, Booy R. Is it exposure to cigarette smoke or smokers which increases the risk of meningococcal disease in teenagers? Int J Epidemiol. 2006;35(2):330–336.
6. Tunkel A, Van De Beek D, Scheld WM. Acute Meningitis. In: Mandell G, Bennett J, Dolin R. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 7th ed. Philadelphia, PA: Churchill Livingstone Elsevier; 2009.
7. Centers for Disease Control and Prevention. Licensure of a meningococcal conjugate vaccine (Menveo) and guidance for use. MMWR Morb Mortal Wkly Rep. 2010; 59(9):273.
8. Novartis vaccines: meningitis vaccines .
© 2010 Lippincott Williams & Wilkins, Inc.