Good Meningitis In U.K Case Study Example

A 63 old women was brought to the emergency unit, late night. Her partner was concerned that she is acting crazy. The patient has complained headache during the day time and was ill. She awakened at late night and was confused, repeating strange words that made no sense. No history of smoking, alcohol or illicit drug use noticed in the patient. The patient had no recent surgeries, or drug allergies.
On physical examination, pulse 106, BP-150/- respiration 19/minute and oxygen saturation 97% on room air. Temperature was 38.3C. The patient did not cooperate for physical examination and reacted briskly to light. No skin rashes were seen. Pupils were equal, 4mm and reacted to light stimuli. Stiifness in the neck was observed.

CT scan showed no intracranial abnormalities, and on lumbar puncture the fluid was cloudy.

Introduction: The membranous lining that surrounds and protects the brain and the spinal cord is called the meninges. It has three layers, the outermost duramater, the central arachnoid and the layer close to the brain or spinal cord is the piamater (Kneib, 2005). The inflammation of the meninges is called meningitis. It usually involves the leptomeninges (the side of the membrane facing the brain) and the underlying subarachnoid cerebrospinal fluid (Kneib, 2005). This disease is of national concern, and a notifiable disease in U.K (Nickerson, 2007). The death associated with meningitis is usually quick and most cases of bacterial meningitis don’t respond well to treatment. According to the latest census that is available, in 2012 alone, 2,357 meningitis cases were reported in U.K (Meningitis.org, 2015). In spite of the fact that the number of cases has been halved since 1989, it still remains a major burden to healthcare due to the high mortality rate associated with this condition.
Meningitis can occur due to viral, bacteria and fungal infection. Viral meningitis is comparatively less serious and very often self recovery is noticed in patients. It is also called sterile meningitis. Enterovirus, Herpesvirus, Mumps & Measles virus, Flavivirus and HIV are capable of causing viral meningitis (Nickerson, 2007). Fungal meningitis is rare. Candida albicans, Cryptococcus neoformes, Histoplasma are common causes of fungal meningitis (Nickerson, 2007). On the other hand bacteria causes the most serious, widespread and often fatal form of meningitis. A horde of bacteria are capable of causing meningitis of which, Meningococcus, Streptococcus pneumoniae, Haemophilus influenza type B (Hib), Group A Streptococcus, Group B Streptococcus, Mycobacterium tuberculosis, Escherichia coli (E.Coli) and Salmonella are the most regular ones (Nickerson,2007). Meningococcal meningitis accounts for 10-40% of endemic bacterial infection (Tiknomirov, Santamaria and Esteves, 2015). It is also the major cause of meningitis among children in England (Davidson, 2003). The organisim causes meningitis (15% of cases), septicemia (25% of cases) or both (60%) (Who.int, 2015). There are six common sero-groups in this bacterium, namely A, B, C, W, X & Y, of which B is the most predominant cause for meningitis (Who.int, 2015).
People of all age group can get meningitis, however babies and toddlers have a higher risk for bacterial meningitis than any other age group, because there immune system is not fully developed (Meningitis.org.nz,2015). Like wise immune-compromised individuals also have a higher chance of getting infected. The symptom of meningitis can vary with the kind of infectious agent; however the following signs are commonly noticed in the given order of presentation: fever and vomiting, severe headache, cold hands, shivering, rashes, stiff neck, dislike for bright light, very sleepy, dull, delirium and seizures. The success of treatment is favorable, when the patient is presented as early as possible. It is not necessary to wait treatment, till rashes appear and confirm meningitis. Babies often have bulging soft spot in their head. Very often, septicemia is seen associated with this condition and causing further complication. Teenagers are also at high risk of infection. (Klosterman,2007)
In order to confirm diagnosis, cerebrospinal fluid is taken from the spinal cord for testing. In a healthy condition, this fluid will be clear, however in meningitis, the fluid will appear cloudy. In order to identify the causative organism, cell culture or PCR techniques are employed (Nhs.uk,2015).
Epidemiological trends in meningitis: National Health Service hospitals across U.K, routinely report laboratory confirmed meningitis pathogens to Public Health England. As previously mentioned, meningitis is a notifiable diseases in U.K. The information for epidemiological data is obtained by i. notification based on clinical diagnosis, ii. laboratory confirmed reports, reporting with Meningococcal Reference Unit (MRU) and the death data from Office of National Statistics (ONS) (Meningitis.org, 2015). According to the Meningitis Research Foundation, U.K, the number of meningitis cases has halved from 1989 to 2014. The main reason for this is the introduction of vaccination for children against Hib, Men C and 13 strain of pneumo-meningitis. The incidence of disease fluctuates over time. Men B infections have been steadily declining since 2000. However in the absence of an effective vaccine, the diseases can easily turn back and increase in number. Ten percent of the populations are carriers for Meningococcus (also called Neisseria meningitis). The bacteria are present at the back of the mouth and throat as a harmless commensal. When the body is immune-compromised, the bacteria gain an upper hand and causes infection. Figure 1 gives the number of Meningococcal B and C infections during different epidemiological years. Table 1: indicates the number of people infected with meningitis in U.K and the causative bacteria in 2011-2012. From Table 1 we could understand that Meningococcus is the predominant cause of meningitis.(Meningitis.org, 2015)
(Meningitis.org, 2015)
(Meningitis.org, 2015)
Epidemiological trends in meningitis across the world: The Centre for diseases control and Prevention (CDC) reported 13,974 meningitis cases in U.S in year 1977 and 4,100 cases in year 2007. Nearly 80% of the infection was caused by three most common pathogens namely H. influenzae, N. meningitidis, and S. pneumonia. With introduction of H. influenzae type b conjugate vaccines in U.S, the number of cases reduced drastically. A heptavalent pneumococcal conjugate vaccine was introduced in 2000, after which there was a significant decline in Pneumococcal meningitis as well. A tetravalent meningococcal vaccine was introduced in 2005, however no epidemiological data about its effectiveness is available. Seventy percent of the meningitis cases happen in children. (Prevention, 2015)
In African countries with high rates of human immunodeficiency virus (HIV) infection, the majority of the meningitis cases was caused by S. pneumoniae, and are associated with high mortality rates. Sub-Saharan belt has the highest report of meningococcal infection, incidence rates of 101 cases per 100,000 populations in the period between 1981 to 1996 in Niger. The number of cases reported in Africa was more than epidemic outbreaks in countries like U.K and U.S.A (Figure: 2). Who.int, 2015
The epidemiological trends in Northwest, Southern Europe, Brazil, Israel, and Canada are similar to the United States. Vaccination has eliminated most of the H.influenza, and now the most common agents in adults and children are S. pneumoniae and N. meningitides. (Molesworth et al., 2002)

Who.int, 2015

Environmental and Socio-Economic Risk Factor for Meningitis: Infection of meningitis is rarely a primary infection. Most often it is secondary to infection is other part of the body, most commonly the respiratory tract. Once the infectious agent enters the blood stream and gains access to the central nervous system, they survive well, because of the low immune response in this region. Immunosupression is an important reason for the spread of infection from the primary site to the meninges. Immunosupression is noticed in alcoholics, autoimmune-disorders, HIV/AID, cancer, diabetes, immunosuppressive drugs therapy (e.g.corticosteroids, chemotherapy), intravenous drug abuse, removal of spleen and smoking; thus predisposing individuals with these condition to meningitis. (Meningitis.org, 2015)
Infants and children under the age of four are also at high risk of infection. The immune systems in the children are not fully developed and thus become immune-susceptible to infection. People above 60 years of age are also susceptible for the same reason. Vaccination can go a long way in preventing meningitis in infants. Infection rate is very high among non-vaccinated children.
The incidence of diseases is high among the black and socio-economically backward class. Overcrowding, unsanitary and unhygienic conditions can predispose to meningitis. Thus people leaving in large groups like; military bases, child care facilities, school dormitories and boarding school can get infection easily. Prolonged contact with infectious agent like, Meningococcus, is required to get infected, thus activities like kissing and any other close contact can result in disease. Dairy farmers and pregnant women are at high risk of getting meningitis associated with listeriosis. Mothers who smoking during pregnancy increase the risk of meningitis for their baby. Passive smoking put children at risk for meningococcal meningitis. Patients with head injury and brain surgery are also at high risk for meningitis.(Feigin and Bennett, 2007)
Meningococcus is the main cause of endemic meningococcus in Asia and Africa. Internal and external factors like, strain virulence, carriers, humoral immunity, co-infection, low humidity, drought, population movement and crowding predisposes for epidemic (Tiknomirov, Santamaria and Esteves,2015).
Transmission, host & vector cycle: No vector had been suspected in bacterial causes of meningitis. Meningitis can also result from zoonotic infection e.g. Leptospirosis, where the infection is usually contacted from infected rat or raccoon. Malaria is one vector born diseases that causes fatal meningitis. It is transmitted by mosquitoes, and is rare in U.K. Prolonged and close contact with the infectious agent may be required for getting meningococcal meningitis. The possible ways by which bacteria can spread is by sneezing, coughing, sharing utensils, sharing personal possessions like tooth brush, cigarette, etc (Prevention,2015). Smoke and dust also favor the spread of the infectious agent.
Prevention: Since meningitis can be caused by many agents, the method to prevent it also varies. Vaccination is the best method to prevent bacterial and viral meningitis. However presently, vaccination is not available for all meningitis causing agents (Sullivan,2005). Meningococcal conjugate vaccine and meningococcal polysaccharide vaccines are available and can be taken by people at risk, like travelers, those living in dormitory, military base, laboratory workers who come in close contact with the infectious agent, etc. Meningitis vaccines are available for routine immunization schedule for children in U.K. These vaccines protect against Hib, MenC and Pneumococcus. Antibiotic prophylaxis can reduce immediate risk of infection, but does not give any future protection. Rifampicin, ciprofloxacin or ceftriaxone are antibiotics used in prophylaxis. (Prevention,2015)
Economics of Meningitis: The major factors that contribute to the cost of meningitis management include physician visits, hospital admissions, emergency room visits, medications, procedure such as lumbar puncture, CT scan, re-hospitalization and follow up physician visit. Indirect cost are incurred in terms of school days or work days missed or restriction in daily activities. Interventions like vaccination that prevents the diseases, early diagnosis, or effective drugs to treat the diseases can help cut down the cost associated with meningitis. Affordable vaccine cost can favor more people to opt for vaccination. (Maimaiti et al., 20120
Conclusion: Meningitis is the infection of the meninges. It is a notifiable disease in U.K. In U.K, 2350 cases were reported in 2011-12. Latest census is not available; however the numbers of new cases are showing decreasing trends than the previous years. In U.S there are approximately 4,100 cases each year. Africa reported the highest number of meningitis cases in the world. Of all the infectious agents, bacterial meningitis is more prevalent and serious. The condition is often life threatening and prevention is always better than treatment. Immune-suppression makes a person susceptible to this condition. Other factors that favor the spread are over crowding, unsanitary conditions and close contact with infectious agent. Vaccination is important in protecting against meningitis.

REFERENCES

Davison, K. (2003). The epidemiology of acute meningitis in children in England and Wales. Archives of Disease in Childhood, 88(8), pp.662-664.
Edmond, K., Clark, A., Korczak, V., Sanderson, C., Griffiths, U. and Rudan, I. (2010). Global and regional risk of disabling sequelae from bacterial meningitis: a systematic review and meta-analysis. The Lancet Infectious Diseases, 10(5), pp.317-328.
Feigin, V. and Bennett, D. (2007). Handbook of Clinical Neuroepidemeology. Newyork: Nova science publishers, pp.342-343.
GJINI, A., STUART, J., LAWLOR, D., CARTWRIGHT, K., CHRISTENSEN, H., RAMSAY, M. and HEYDERMAN, R. (2005). Changing epidemiology of bacterial meningitis among adults in England and Wales 1991–2002. Epidemiol. Infect., 134(03), p.567.
GJINI, A., STUART, J., LAWLOR, D., CARTWRIGHT, K., CHRISTENSEN, H., RAMSAY, M. and HEYDERMAN, R. (2005). Changing epidemiology of bacterial meningitis among adults in England and Wales 1991–2002. Epidemiol. Infect., 134(03), p.567.
Gov.uk, (2014). Meningococcal disease: guidance, data and analysis - GOV.UK. [online] Available at: https://www.gov.uk/government/collections/meningococcal-disease-guidance-data-and-analysis [Accessed 29 Jan. 2015].
Klosterman, L. (2007). Meningitis. New York: Marshall Cavendish Benchmark, p.17.
Kneib, M. (2005). Meningitis. New York: Rosen Pub. Group.
Maimaiti, N., Zafar, A., Amrizal, M., Zaleha, M., Saperi, S. and Aljunid, S. (2012). Estimating clinical and economic burden of pneumococcal meningitis in Malaysia using Casemix data. BMC Health Services Research, 12(Suppl 1), p.O4.
Meningitis.org, (2015). Meningitis and septicaemia: UK facts and figures. [online] Available at: http://www.meningitis.org/facts [Accessed 1 Feb. 2015].
Meningitis.org.nz, (2015). The Meningitis Foundation | About Meningitis Symptoms | Who it Affects. [online] Available at: http://www.meningitis.org.nz/who_does_meningitis_affect [Accessed 1 Feb. 2015].
Molesworth, A., Thomson, M., Connor, S., Cresswell, M., Morse, A., Shears, P., Hart, C. and Cuevas, L. (2002). Where is the meningitis belt? Defining an area at risk of epidemic meningitis in Africa. Transactions of the Royal Society of Tropical Medicine and Hygiene, 96(3), pp.242-249.
Nhs.uk, (2015). Meningitis - Diagnosis - NHS Choices. [online] Available at: http://www.nhs.uk/Conditions/Meningitis/Pages/Diagnosis.aspx [Accessed 1 Feb. 2015].
Nickerson, E. (2007). Infectious diseases. Edinburgh: Mosby/Elsevier, pp.77-90.
Prevention, C. (2015). Meningitis | Lab Manual | Epidemiology | CDC. [online] Cdc.gov. Available at: http://www.cdc.gov/meningitis/lab-manual/chpt02-epi.html [Accessed 1 Feb. 2015].
Prevention, C. (2015). Meningococcal | Causes and Transmission | CDC. [online] Cdc.gov. Available at: http://www.cdc.gov/meningococcal/about/causes-transmission.html [Accessed 1 Feb. 2015].
Sullivan, M. (2005). Increased Meningitis Risk Revealed. Pediatric News, 39(8), p.41.
Tiknomirov, E., Santamria, M. and Esteves, K. (2015). Meningococcal disease: public health burden and control. World Health Statistics Quaterly, 50(3-4), pp.170-177.
Who.int, (2015). WHO | Epidemiological information. [online] Available at: http://www.who.int/csr/disease/meningococcal/epidemiological/en/ [Accessed 1 Feb. 2015].
Who.int, (2015). WHO | Meningococcal meningitis. [online] Available at: http://www.who.int/mediacentre/factsheets/fs141/en/ [Accessed 1 Feb. 2015].