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Meningitis: the fears - and the facts

Cathy Taylor
RGN DipN BSc CHS MSc
Tutor
Health Visiting
University of Wales Swansea

There are approximately 3,500-4,000 reported cases of meningitis per year in the UK.(1) In the mid-1990s, the incidence of meningococcal disease increased, with fatalities often emphasised by media attention and coverage. As a result, despite an increase in public awareness, it has become the disease most feared by parents. In infants, this may be due to its sudden onset, as in reality its actual incidence (especially in relation to neonatal meningitis) over the years has not significantly altered. However, what has improved is the mortality rate that is often associated with the disease.(2) This may partly be due to the advances in early diagnosis and treatment as well as the proactive nature of immunisation programmes that over the years have had significant effects. The new Department of Health (DH) report Preventing Meningitis continues to highlight information regarding the disease, its symptoms, and the campaigns that have helped in the fight against it.(1)
 
Prevalence
Although meningitis can affect people of all ages, the disease appears to be most prevalent in babies during their first year,(3) children under five years and young people.(4) It can occur at any time of the year, but some forms of the disease are more significant in certain seasonal peaks - meningococcal meningitis appears to be more prevalent between December and February, whereas viral meningitis tends to occur most in the summer months.(5)
Meningococcal disease occurs when the meninges (the membranous tissues that surround the brain and spinal cord) become inflamed and infected. The disease can be viral, bacterial or fungal in origin, but surprisingly viruses tend to be the most common cause of the disease. Viral meningitis appears to be less severe and, although it often resolves normally without treatment, can be extremely debilitating. Viral meningitis (if reported) appears to be more prevalent in adults (although it can occur in infants and children), normally lasting between four and 10 days with nonspecific symptoms.(4)
In comparison, bacterial meningitis is much rarer but is renowned because of its links with fatality. There are three main strains of bacteria that usually cause meningitis - Neisseria meningitidis (the meningococcus), Streptococcus pneumoniae (the pneumococcus) and Haemophilus influenzae type B (Hib).(6) The meningococcal bacteria is subdivided by laboratory testing into serogroups, of which 13 are currently recognised - A, B, C, D, E, H, I, K, L, W135, X, Y and Z. However, in the UK, serogroups B and C are the most common.(7) Serogroup B disease reached it highest recorded level in 2001 and now accounts for some 80% of confirmed meningococcal cases in UK,(1) whereas cases of serogroup C have fallen dramatically since the introduction of the conjugate meningitis C vaccine in November 1999.(5)

Transmission of meningitis
Approximately 10% of the well population carry the meningococci organism at the back of the nose and throat,(4) but the majority of these carriers are symptom-free and unaware that they may be carrying the disease. Outside the human body the organism is fragile and cannot survive for long, so transmission occurs from close person-to-person contact. This occurs via the transmission of secretions from the upper respiratory tract, mainly from coughing, sneezing and kissing. If the individual has come into contact with the organism and contracted the disease, primary symptoms will tend to occur between two and 10 days.(8)

Signs and symptoms
Meningococcal disease has two main clinical presentations - meningitis and septicaemia, which often appear together.(9) In the early stages the vague nonspecific symptoms often make the disease difficult to diagnose, especially in babies and young children (see Table 1).(10)  However, the disease may develop extremely quickly and result in serious consequences if not treated.
This can be difficult for primary care practitioners, especially as rapid diagnosis and treatment is essential. If diagnosis is in doubt, parents should be encouraged to remain vigilant and be provided with information regarding the signs and symptoms of the disease. Health education factsheets and symptom cards are available from organisations such as the Meningitis Trust and are a useful aid for parents.
The most serious form of the disease is when the patient presents with meningococcal septicaemia. A purplish-red rash appears due to blood leaking out of the tiny blood vessels onto the surface of the skin. This is recognised by the fact that the rash does not blanche/fade when pressed under a glass/tumbler (more commonly known as "The Glass Test"). This is the hallmark of meningococcal septicaemia and is an indication that urgent treatment is required, but it is not evident in all cases. Patients tend to have higher mortality rates if septicaemia is present. In some severe cases the bacteria multiply so quickly in the blood that massive damage occurs to the body, with shock and death a possibility from cardiovascular failure.(11)
If diagnosis is confirmed, intravenous antibiotics should be administered immediately by the GP and arrangements for transfer into secondary care made without delay. Intravenous benzylpenicillin is the drug of choice for suspected meningococcal infection, apart from those cases where the patient has a history of penicillin anaphylaxis. On arrival at hospital, intensive management is necessary, with laboratory diagnosis required for identification of the causative organism. This can be obtained via cerebrospinal fluid (via lumbar puncture), blood cultures and throat swabs.

[[NIP30_table1_83]]

Role of primary healthcare practitioners
Meningitis is a "notable infection", and all cases should be reported to the Consultant for Communicable Disease Control (CCDC). Upon notification, the CCDC will have the responsibility for deciding on the correct course of action to be taken. Parents may be asked to draw up lists of close contacts if prophylaxis is necessary. They can then be traced and contacted. This may be difficult and cause additional anxiety for surrounding family, friends, schools and the extended local community. Primary care practitioners are often the first point of contact and can be instrumental in providing education and information in relation to lowering the risk of secondary transmission and disease. It is essential that primary care nurses are able to offer advice, support and correct, up-to-date information to help people cope, enabling a degree of understanding and awareness to be achieved.

Consequences and implications
The effects of meningitis can have serious consequences, especially if contracted in infancy. Bedford et al discuss various health and developmental problems in children who had contracted meningitis at an early age.(3) Ongoing complications ranged from learning and motor disabilities to seizures, hearing and visual disorders. Other long-term and less specific consequences included speech, language and behavioural problems. This demonstrates that children and parents continue to need ongoing support long after the initial disease has manifested. Primary healthcare practitioners are well placed to provide long-term support and help for these families alongside other agencies such as school and voluntary organisations.
From this year, the Chief Medical Officer within the Department of Health has announced changes that will be made to the routine childhood immunisation programme. This will include the introduction of a new pneumococcal vaccine, with additional respacing of the meningitis C and Hib vaccinations (see Table 2). It is hoped that this will lower the rates of pneumococcal disease, therefore offering further protection against this serious disease and its complications. Previously the introduction of new vaccines has been extremely successful, with both Hib and meningitis C being dramatically reduced within the UK.(5)

[[NIP30_table2_84]]
 
Primary healthcare practitioners have been instrumental in their implementation and will undoubtedly be a part of its ongoing success in relation to these future changes.

Conclusion
Though meningitis is relatively infrequent in the UK, when considered on a global scale its effects can still be devastating. Professionals working in primary care are essential to providing ongoing awareness, information and support on the disease to individuals, families and communities. This will hopefully help to dispel the myths surrounding meningitis, alleviating some of the panic and fear that can occur within the public domain.

References

  1. Department of Health. Preventing meningitis. London: DH; 2006.
  2. Holt DE, Halket S, de Louvois J,Harvey D. Neonatal meningitis in England & Wales 10 years on. Arch Dis Child Foetal Neonatal Ed 2001;84:85-9.
  3. Bedford H, de Louvois J, Halket S, Peckham C, Hurley R, Harvey D. Meningitis in infancy in England and Wales: follow up at age 5 years.BMJ 2001;323:533-7.
  4. Bowler S. Meningococcal disease. Nurs Stand 1998;13(5):49-52.
  5. Health Protection Agency. Protecting the health of the nation's children: the benefit of vaccines. First national report on the current status of the universal vaccine programmes from the Centre for Infections. London: HPA Centre for Infections; 2005.
  6. Betts S. Is meningitis a disease of the past? Pract Nurs 2001;12:144-7.
  7. Booker S, Hart B. Meningococcal disease: the facts. Nurs Times 2002;98(38):54.
  8. Boyne L. Meningococcal infection. Primary Health Care 2001;11(3):43-9.
  9. Peate I. An overview of meningitis: signs, symptoms, treatment and support. Br J Nurs 2004;13:796-801.
  10. El Bashir H, Laundy M, Booy R. Diagnosis and treatment of bacterial meningitis. Arch Dis Child 2003;88:615-20.
  11. Peate I. Meningitis: causes, symptoms and signs and nursing management. Br J Nurs 1999;8:1290-8.

Resources
Meningitis Trust
W:www.meningitis-trust.org
T:0800 028 1828
 (24-hour nurse-led helpline)
T:01453 768 000
Meningitis Research Foundation
W:www.meningitis.org