Meningitis

Overview

Generalities

Agents

Several agents:

1) Bacteria:
- Neisseria meningitides (meningococcus): the serotypes responsible of invasive infection are A, B, C, W135, Y, X
- Haemophilus influenza: there are 6 serotypes from (a) to (f). The serotype (b) is responsible of invasive infection
- Streptococcus pneumonia (pneumococcus): there are more than 90 serotypes
- Other bacterial agents: listeria, staphylococcus, enteric bacteria, group B streptococci, tuberculosis …

2) Virus:
- Mumps
- Measles
- West Nile virus: a flavivirus
- Enterovirus: including Coxsackieviruses A (1-11, 14, 16-18, 22, 24), Coxsackieviruses B (1-6), Echoviruses (1-7, 9-23, 25, 27, 30-33), Enterovirus 71, Poliovirus (1-3)
- Herpes Simplex virus: with 2 types 1 and 2
- Varicella / Chicken-pox: Human (alpha) herpesvirus 3 (varicella-zoster) from the group Herpesvirus
- Adenovirus: Adenovirus, several types (1, 2, 3, 4, 5 and 7), genus Mastadenovirus, family Adenoviridae,
- Lymphocytic choriomeningitis: lymphocytic choriomeningitis virus (arenavirus)
- Sandfly fever viruses: genus phlebovirus, family Bunyaviridae. They include more than 60 antigenically distinct virus serotypes. Two main groups are identified: the sandfly fever group including the Naples serocomplex (Karimabad virus, Arabia virus, Massilia virus, Punique virus, Tehran virus, Toscana virus …) and Sicilian serocomplex; and the Uukuniemi group.

-Other virus: arboviruses…

3) Parasites and fungi:
- Leptospirosis: Spirochetes, Leptospira interrogans (25 serogroups)
- Other: Candida albicans, cryptococcal, syphilis …

Incubation

The incubation varies with the agent.

Agent	Incubation
Bacteria
Neisseria meningitidis	3-4 days (2-10 days)
Haemophilus influenza	2-4 days
Streptococcus pneumoniae	1-4 days
Listeria monocytogenes	3-70 days (median of 3 weeks)
Virus
West Nile virus	3-12 days
Enterovirus	7-14 days (2-35 days)
Herpes	2-12 days
Varicella / Chicken-pox	2-3 weeks
Lymphocytic choriomeningitis virus	8-13 days (15-21 days for meningitis)
Adenovirus	1-10 days
Sandfly fever viruses	3-4 days (up to 6 days)
Parasites and Mycoses
Leptospira	2-30 days (10 days)

Period of communicability

The period of communicability varies with the agent.

Agent	Period of communicability
Bacteria
Neisseria meningitidis	From onset and up to 24 hours after starting antibiotherapy that has effective concentrations in nasopharynx.
Haemophilus influenza	From onset and up to 24-48 hours of starting effective antibiotherapy.
Streptococcus pneumoniae	As long as the bacteria is present in the upper respiratory tract.
Listeria monocytogenes	- Mothers of infected newborns can shed the bacteria in vaginal discharges and urine 7-0 days after delivery - Infected patients can shed the bacteria in stool for several months
Virus
West Nile virus	No person-to-person transmission.
Enterovirus	- Virus excreted in stools for several weeks - Virus excreted in pharynx for the first 2 weeks post infection
Herpes	2-7 weeks after skin lesions onset.
Varicella / Chicken-pox	2 days before until the skin lesions are crusted (5 days).
Lymphocytic choriomeningitis virus	No person to person transmission.
Adenovirus	Shortly prior to and for the duration of the active disease
Sandfly fever viruses	Virus present in blood of infected patients 1 day before and 1 day after onset of illness.
Parasites and Mycoses
Leptospira	Excreted in urine for 1 month

Reservoir

The reservoir varies with the agent.

Agent	Reservoir
Bacteria
Neisseria meningitidis	Humans
Haemophilus influenza	Humans
Streptococcus pneumoniae	Humans, possible carriage.
Listeria monocytogenes	Soil, forage, water, mud and silage.
Virus
West Nile virus	Birds
Enterovirus	Humans
Herpes	Humans
Varicella / Chicken-pox	Humans
Lymphocytic choriomeningitis virus	House mouse (Mus musculus), hamster colonies. The mouse excretes the virus in saliva, feces and urine.
Adenovirus	Humans
Sandfly fever viruses	Humans, rodents.
Parasites and Mycoses
Leptospira	Wild and domestic animals

Modes of transmission

The modes of transmission vary with the agent.

Agent	Modes of transmission
Bacteria
Neisseria meningitidis	Person to person transmission: direct contact with droplet, nasal and throat discharge
Haemophilus influenza	Person to person transmission: direct contact with respiratory, nasal and throat discharge.
Streptococcus pneumoniae	Person to person transmission: direct contact with respiratory discharge
Listeria monocytogenes	- Food-borne: ingestion of raw or contaminated milk, soft cheese vegetables and ready-to-eat meats (Pate) - Direct contact with infectious material - Neonatal: from mother to fetus or from mother to newborn (through the infected birth canal) - Nosocomial transmission in nursery: via contaminated equipment or material
Virus
West Nile virus	Bite by infected mosquitoes (Culex sp, or Anophele sp)
Enterovirus	- Person-to-person: - Fecal-oral - Contact with respiratory secretions - Contact with conjunctival secretions - Contaminated water / swimming pools - Flies
Herpes	- Person-to-person: - Contact with saliva - Sexual contact - Soiled hands - Neonatal (infected birth canal)
Varicella / Chicken-pox	- Person-to-person: - Contact with droplets - Contact with vesicle fluid - Indirect contact - Airborne
Lymphocytic choriomeningitis virus	- Airborne: contaminated dust - Food-borne: ingestion of contaminated food - Direct contact: skin contamination or cuts
Adenovirus	- Person-to-person: - Fecal-oral route - Respiratory transmission - Inoculation with conjunctival secretions - Nosocomial - Contaminated water and swimming pools
Sandfly fever viruses	Bite of infective phlebotomine (Phlebotomus papatasi, P. perfiliewi , P. perniciosus, P. major sensu lato )
Parasites and Mycoses
Leptospira	- Contact with abraded skin or mucous membranes with soil, vegetation, contaminated with urine of infected animals or contaminated water - Direct contact with urine or tissues of infected animals - Ingestion of food or water contaminated with urine of infected animals

Clinical

The symptoms vary with the agent.

Agent	Clinical picture
Bacteria
Neisseria meningitidis	Meningitis, septicaemia
Haemophilus influenza	Meningitis, epiglottitis, pneumonia …
Streptococcus pneumoniae	Meningitis, pneumonia, septicaemia
Listeria monocytogenes
Virus
West Nile virus	- Usually asymptomatic. - Complication: meningitis and encephalitis
Enterovirus	- Asymptomatic, - Gastro-enteritis, flu-like illness, aseptic meningitis, paralysis
Herpes	- Gingivostomatitis (type1), genital infection (type 2) - Complications: meningoencephalitis - Reactivation is possible
Varicella / Chicken-pox	- Skin eruption: first maculo-papular then vesicular. - Complications: pneumonia, hemorrhage, meningoencephalitis
Lymphocytic choriomeningitis virus	- Influenza-like illness. - Complications: meningitis, parotiditis, arthritis, myocarditis…
Adenovirus	- Epidemic herato-conjunctivitis, gastro-enteritis, pharyngo-conjunctival fever, acute respiratory infection - Complications: meningoencephalitis
Sandfly fever viruses	- Usually self-limited disease: fever, myalgia, headache, photophobia … - Complications: Aseptic meningitis and meningoencephalitis (Toscana),
Parasites and Mycoses
Leptospira	Rash, hemolytic anemia, hemorrhage, hepato-renal failure, mental confusion, myocarditis…

Worldwide

Agent	Profil
Bacteria
Neisseria meningitidis	Endemic in the African meninigitis belt (from Senegal to Ethiopa)
Haemophilus influenza	Worldwide under 5 years
Streptococcus pneumoniae	Worldwide
Listeria monocytogenes	Worldwide
Virus
West Nile virus	Widespread in Africa, Middle East, North America, India.
Enterovirus	Worldwide
Herpes	Worldwide
Varicella / Chicken-pox	Worldwide
Lymphocytic choriomeningitis virus	America, Europe.
Adenovirus	Worldwide
Sandfly fever viruses	In Mediterranean counties, Europe and Middle East
Parasites and Mycoses
Leptospirose	Worldwide

Lebanon

The annual average of reported cases of meningitis is 192.
Among them, meningitis due to Neisseria meningitis occurs with 6 (2-12) cases per year.
Among them, meningitis due to Haemophilus influenza occurs with 1 (0-2) cases per year.
Among them, meningitis due to Streptococcus pneumoniae occurs with 19 (16-21) cases per year.

Control objective

Control

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ATC	Name	B/G	Ingredients	Dosage	Form	Price
D06AA04	TETRACYCLINE OINTMENT	G	Tetracycline HCl - 3%	3%	Ointment	107,507 L.L
J01AA04	TETRALYSAL	B	Lymecycline - 300mg	300mg	Capsule	796,899 L.L
J01AA07	TETRAN	G	Tetracycline HCl - 250mg	250mg	Capsule	168,940 L.L
J07CA02	TETRAXIM (Vaccin Diphterique, tetanique, coquelucheux acellulaire et Poliomyelitique inactivé adsorbé)	B	Diphteria toxoid purified - ?30IU, Tetanus toxoid purified - ?40IU, Poliomyelitis virus type 1 inactivated - 40D.U., Poliomyelitis virus type 2 inactivated - 8D.U., Poliomyelitis virus type 3 inactivated - 32D.U., Bordetella Pertussis Antigens: toxoid - 25mcg, Bordetella Pertussis Antigens: filamentous haemagglutinin - 25mcg		Injectable suspension	1,628,737 L.L
L04AX02	THALIDOMIDE BMS	B	Thalidomide - 50mg	50mg	Capsule	27,387,764 L.L
L04AX02	THALIDOMIDE CELGENE	B	Thalidomide - 50mg	50mg	Capsule	27,387,764 L.L
R03DA04	THEODEX	G	Theophylline - 80mg/15ml	80mg/15ml	Elixir	156,142 L.L
R03DA04	THEOSOL ELIXIR	G	Théophylline - 25mg/5ml	25mg/5ml	Elixir	312,283 L.L
N01AF03	THIOPENTAL PANPHARMA	G	Thiopental - 500mg	500mg	Injectable powder for solution	8,446,717 L.L
B01AC04	THROMBO	G	Clopidogrel - 75mg	75mg	Tablet, film coated	764,646 L.L
L04AA04	THYMOGLOBULINE 5mg/ml	BioTech	Rabbit anti-human thymocyte immunoglobulin - 25mg/5ml	25mg/5ml	Injectable powder for solution	L.L
L04AA04	THYMOGLOBULINE 5mg/ml	BioTech	Rabbit anti-human thymocyte immunoglobulin - 25mg/5ml	25mg/5ml	Injectable powder for solution	21,928,334 L.L
H01AB01	THYROGEN	BioHuman	Thyrotropin alfa - 0.9mg	0.9mg	Injectable lyophilised powder for solution+diluent	65,558,997 L.L
H03BB02	THYROZOL	B	Methimazole (Thiamazole) - 5mg	5mg	Tablet, film coated	233,829 L.L
H03BB02	THYROZOL	B	Methimazole (Thiamazole) - 10mg	10mg	Tablet, film coated	326,554 L.L
R01AD08	TICANASE	G	Fluticasone propionate - 50mcg/actuation	12g/Bottle	Spray, suspension	405,840 L.L
J01AA12	TIGECYCLINE /ANFARM	G	Tigecycline - 50mg	50mg	Injectable powder for solution	15,214,166 L.L
B03AA07	TIMOFEROL	G	Iron bivalent (as dried ferrous sulfate) - 50mg (172.73mg), Ascorbic acid - 30mg		Capsule	678,787 L.L
N06AB10	TIOPRAM	G	Escitalopram (oxalate) - 10mg	10mg	Tablet, film coated	671,921 L.L
R03BB04	TIOVA-T	G	Tiotropium bromide monohydrate - 18mcg	18mcg	Rotacaps	384,339 L.L
B01AC17	TIROPREST	G	Tirofiban - 12.5mg/50ml	12.5mg/50ml	Injectable concentrate for solution	18,279,605 L.L
B02BC30-V03AK	TISSEEL LYO	B	Fibrinogen, human (clottable protein) (I) - 91mg/ml, Aprotinin, synthetic (I) - 3000KIU/ml, Thrombin, Human (II) - 500IU/ml, Calcium chloride (II) - 40?mol/ml		Injectable powder for solution + solution	53,437,592 L.L
B02BC30-V03AK	TISSEEL LYO	B	Fibrinogen, human (clottable protein) (I) - 91mg/ml, Aprotinin, synthetic (I) - 3000KIU/ml, Thrombin, Human (II) - 500IU/ml, Calcium chloride (II) - 40?mol/ml		Injectable powder for solution + solution	24,369,850 L.L
B02BC30-V03AK	TISSEEL LYO	B	Fibrinogen, human (clottable protein) (I) - 91mg/ml, Aprotinin, synthetic (I) - 3000KIU/ml, Thrombin, Human (II) - 500IU/ml, Calcium chloride (II) - 40?mol/ml		Injectable powder for solution + solution	13,394,024 L.L
J05AX12	TIVICAY	B	Dolutegravir - 50mg	50mg	Tablet, film coated	54,508,037 L.L
J05AX12	TIVICAY	B	Dolutegravir - 50mg	50mg	Tablet, film coated	54,508,037 L.L
S01AA12	TOBRACIN	G	Tobramycin - 0.3%	0.3%	Drops	322,522 L.L
S01AA12	TOBRACIN	G	Tobramycin - 0.3%	0.3%	Ointment	280,863 L.L
S01AA12	TOBRASTILL	G	Tobramycin - 0.3%	0.3%	Drops solution	255,330 L.L
S01AA12	TOBRIN	G	Tobramycin - 0.3%	0.3%	Drops	169,324 L.L

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