Meningococcal Disease

Narrative

Background

Healthcare-associated transmission of Neisseria meningitidis (N. meningitidis) is uncommon. In rare instances, N. meningitidis has been transmitted from patients to healthcare personnel (HCP) through contact with the respiratory secretions of patients with meningococcal disease and handling isolates of N. meningitidis.^1-4

Prevention of transmission of N. meningitidis in healthcare settings involves:

1. in addition to using Standard Precautions, placing patients with known or suspected meningococcal disease in Droplet Precautions⁵;
2. rapidly diagnosing and treating patients with clinical infection;
3. appropriately administering postexposure prophylaxis (PEP) to persons exposed to meningitidis; and
4. excluding potentially infectious HCP from work.^3,5,6

Guidelines for meningococcal vaccination of certain HCP (e.g., persons with known asplenia or persistent complement component deficiencies, personnel who are traveling to countries in which meningococcal disease is hyperendemic or epidemic) are maintained by the Advisory Committee of Immunization Practices (ACIP) and described in Immunization of Health-Care Personnel: Recommendations of the ACIP (https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6007a1.htm).^3,7 Vaccination is recommended for HCP who are employed as microbiologists who are exposed routinely to isolates of N. meningitidis.^3,8-10 Further information about meningococcal vaccines is provided on the CDC Meningococcal: Who Needs to Be Vaccinated website (https://www.cdc.gov/vaccines/vpd/mening/hcp/recommendations.html).⁹

Occupational Exposures

N. meningitidis can be transmitted person-to-person through unprotected direct contact with the respiratory secretions or saliva of a person with clinical disease, such as meningitis or bacteremia.^11,12 Exposures in healthcare may include mucous membrane contact with infectious secretions from close, face-to-face contact during activities such as mouth-to-mouth resuscitation, endotracheal tube placement or management, or open airway suctioning while not wearing or correctly using recommended personal protective equipment (PPE).^3,6,12,13

Brief, non-face-to-face contact, such as standing in the doorway of a patient’s room, cleaning a patient’s room, delivering a medication or food tray, starting an IV, or performing a routine physical exam, is generally not considered an exposure.¹⁴ Unprotected direct contact with the respiratory secretions or saliva of a person colonized with N. meningitidis, without clinical disease, is not considered an exposure.

Exposures to N. meningitidis in laboratory settings are described in Biosafety in Microbiological and Biomedical Laboratories (BMBL), 5^th Edition (https://www.cdc.gov/biosafety/publications/bmbl5/index.htm).¹⁰

Clinical Features

Meningococcal disease is a serious and potentially life-threatening infection. Common signs and symptoms of meningococcal disease include sudden onset of high fever, neck stiffness, confusion, nausea, vomiting, lethargy, and petechial or purpuric rash.¹² Without prompt and appropriate treatment, the infection can progress rapidly and result in death.¹²

Asymptomatic nasopharyngeal carriage of N. meningitidis is common, but few carriers develop invasive disease, and carriers without an exposure do not require treatment or chemoprophylaxis.^11-13  Persons who have close contact with persons with invasive disease are at substantially increased risk for acquiring carriage and disease.¹²

Patients infected with N. meningitidis may be contagious in the 7 days before symptom onset and are rendered noninfectious by 24 hours of effective antimicrobial therapy.^12,13 Cases occur in all age groups; however, children less than 2 years old, adolescents 16 through 23 years old, and adults 85 years of age or older have higher rates of disease than other age groups.¹¹ In addition, people with certain medical conditions, such as functional or anatomic asplenia; persistent complement component deficiencies (e.g., C3, C5-9, properdin, factor H, factor D or are taking eculizumab or ravulizumab); and HIV infection are at increased risk for meningococcal disease.^11,12,15

The incubation period of meningococcal disease is 3 to 4 days, with a range of 1 to 10 days.

Testing and Diagnosis

Diagnosis of meningococcal disease can pose challenges because its initial clinical manifestations are similar to more common, but less serious, illnesses.¹² Hence, laboratory testing is helpful in confirming the diagnosis. N. meningitidis is confirmed through culture or polymerase chain reaction (PCR) of fluid collected from a normally sterile site, such as blood or cerebrospinal fluid (CSF).¹⁶ Gram stain is still used for identification of N. meningitidis and continues to be a reliable and rapid method for presumptive identification, though it is not a confirmatory test.¹²

Additional information on laboratory testing for N. meningitidis is available on the CDC Laboratory Methods for the Diagnosis of Meningitis website (https://www.cdc.gov/streplab/index.html).¹⁷

Postexposure Prophylaxis

Chemoprophylaxis is administered as soon as possible after exposure, ideally less than 24 hours after identification of an index patient.¹³ Chemoprophylaxis administered more than 14 days after onset of illness in an index patient is probably of limited or no value.^12,13 In the event of an exposure involving a patient with possible meningococcal meningitis without microbiologic confirmation (e.g., culture negative, Gram stain negative, or lumbar puncture (LP) unable to be performed), decisions about use of PEP are made on a case-by-case basis considering the epidemiologic and clinical likelihood of N. meningitidis in the source patient.

Rifampin, ciprofloxacin, and ceftriaxone are 90%-95% effective in reducing nasopharyngeal carriage of N. meningitidis and are all acceptable antimicrobial agents for chemoprophylaxis.^13,18 Azithromycin is not routinely recommended, nor is it a first-line agent for PEP, but it may be used as chemoprophylaxis in situations such as sustained ciprofloxacin-resistant strains of N. meningitidis in a community.^12,19,20 Detailed information regarding dosage and administration of PEP for N. meningitidis is available in the Manual for the Surveillance of Vaccine-Preventable Diseases (https://www.cdc.gov/vaccines/pubs/surv-manual/chpt08-mening.html).¹²

Outbreaks

In the setting of a healthcare facility meningococcal disease outbreak, meningococcal vaccination or use of chemoprophylaxis in a wider group than exposed HCP may be considered in consultation with public health officials. Additional guidance regarding meningococcal disease outbreaks is described in Guidance for the Evaluation and Public Health Management of Suspected Outbreaks of Meningococcal Disease [PDF – 16 Pages] (https://www.cdc.gov/meningococcal/downloads/meningococcal-outbreak-guidance.pdf).¹⁶

References

1. Centers for Disease Control and Prevention. Laboratory-acquired meningococcemia–California and Massachusetts. MMWR Morb Mortal Wkly Rep. 1991;40(3):46-47, 55.
2. Centers for Disease Control. Nosocomial meningococcemia – Wisconsin. MMWR Morb Mortal Wkly Rep. 1978;27:358-363.
3. Centers for Disease Control and Prevention. Immunization of health-care personnel: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2011;60(Rr-7):1-45.
4. Rose HD, Lenz IE, Sheth NK. Meningococcal pneumonia. A source of nosocomial infection. Arch Intern Med. 1981;141(5):575-577.
5. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Siegel JD, Rhinehart E, Jackson M, Chiarello L, the Healthcare Infection Control Practices Advisory Committee. 2007; (https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html). Accessed August 7, 2019.
6. Centers for Disease Control and Prevention. Occupational transmission of Neisseria meningitidis — California, 2009. MMWR Morb Mortal Wkly Rep. 2010;59(45):1480-1483.
7. MacNeil JR, Rubin LG, Patton M, Ortega-Sanchez IR, Martin SW. Recommendations for Use of Meningococcal Conjugate Vaccines in HIV-Infected Persons – Advisory Committee on Immunization Practices, 2016. MMWR Morb Mortal Wkly Rep. 2016;65(43):1189-1194.
8. Patton ME, Stephens D, Moore K, MacNeil JR. Updated Recommendations for Use of MenB-FHbp Serogroup B Meningococcal Vaccine – Advisory Committee on Immunization Practices, 2016. MMWR Morb Mortal Wkly Rep. 2017;66(19):509-513.
9. Vaccines and Preventable Diseases, Meningococcal: Who Needs to Be Vaccinated? Centers for Disease Control and Prevention; National Center for Immunization and Respiratory Diseases. 2019; (https://www.cdc.gov/vaccines/vpd/mening/hcp/recommendations.html). Accessed August 12, 2019.
10. Centers for Disease Control and Prevention; National Insitutes of Health. Biosafety in Microbiological and Biomedical Laboratories, 5th Edition. US Department of Health and Human Services; 2009.
11. Meningococcal Disease: Technical and Clinical Information. Centers for Disease Control and Prevention; National Center for Immunization and Respiratory Diseases. 2017; (https://www.cdc.gov/meningococcal/clinical-info.html). Accessed December 9, 2019.
12. MacNeil J, Patton M. Chapter 8: Meningococcal Disease. In: Roush S, Baldy L, eds. Manual for the Surveillance of Vaccine-Preventable Diseases. 5 ed. Atlanta, GA: Centers for Disease Control and Prevention; 2018.
13. Centers for Disease Control and Prevention. Chapter 14: Meningococcal Disease. In: Hamborsky J, Kroger A, Wolfe S, eds. Epidemiology and Prevention of Vaccine-Preventable Diseases. 13 ed. Washington, DC: Public Health Foundation; 2015.
14. Cohen MS, Steere AC, Baltimore R, von Graevenitz A, Pantelick E, Camp B, et al. Possible nosocomial transmission of group Y Neisseria meningitidis among oncology patients. Ann Intern Med. 1979;91(1):7-12.
15. Meningococcal Disease: What People Living with HIV Need to Know. Centers for Disease Control and Prevention; National Center for Immunization and Respiratory Diseases. 2017; (https://www.cdc.gov/meningococcal/downloads/17-275138B-MeningococcalDis-HIV-FS.pdf [PDF – 2 Pages]). Accessed December 9, 2019.
16. Guidance for the Evaluation and Public Health Management of Suspected Outbreaks of Meningococcal Disease. Centers for Disease Control and Prevention. 2017; (https://www.cdc.gov/meningococcal/downloads/meningococcal-outbreak-guidance.pdf [PDF – 16 Pages]). Accessed December 9, 2019.
17. Centers for Disease Control and Prevention; National Center for Immunization and Respiratory Diseases; Division of Bacterial Diseases. Laboratory Methods for the Diagnosis of Meningitis caused by Neisseria meningitidis, Streptococcus pneumoniae, and Haemophilus influenzae. 2nd ed: World Health Organization; 2011. (https://www.cdc.gov/streplab/index.html)
18. Cohn AC, MacNeil JR, Clark TA, Ortega-Sanchez IR, Briere EZ, Meissner HC, et al. Prevention and control of meningococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2013;62(Rr-2):1-28.
19. Centers for Disease Control and Prevention. Emergence of fluoroquinolone-resistant Neisseria meningitidis–Minnesota and North Dakota, 2007-2008. MMWR Morb Mortal Wkly Rep. 2008;57(7):173-175.
20. Wu HM, Harcourt BH, Hatcher CP, Wei SC, Novak RT, Wang X, et al. Emergence of ciprofloxacin-resistant Neisseria meningitidis in North America. N Engl J Med. 2009;360(9):886-892.