MENINGITIS IN CHILDREN

UNDER FIVE YEAR OF

AGE.

Dr Farrukh Iqbal Roll number 06

Definition
 Meningitis is inflammation of the protective membranes covering
the brain and spinal cord, known collectively as the meninges. [1]
It is an acute communicable disease caused by various
organisms among which

 Escherichia coli are more common among children between 0-2

months of age.

 Haemophilus influenzae is more common among children

between 2month-2years of age.

 Neisseria meningitis and streptococcus pneumoniae is more

common among children between 02yrs to 21 yrs of age of age.
[2].
 In Pakistan a vaccination with the name of Hib have been included
in EPI Vertical program against Haemophilus influenzae but no
focus have been made on the Neisseria meningitis which is the
main cause of meningitis in children and young adults and it is
important because of its potential to cause epidemic.

Historical Context
Meningococcal disease was first described in 1805 when an out
break swept through Geneva, Switzerland. The causative agent
Neisseria meningitis was identified in 1887. [3]
 Geographic Distribution

 Distribution world wide

occurring sporadically
and in small out breaks
in most part of the world.
The zone lying between
5and 15 degree north of
the equator in tropical
Africa is called meningitis
belt because of the frequent
epidemic waves
Cases of meningococcal meningitis are also reported in Pakistan
as sporadic cases or small cluster 45-100/100,000 in children
suffers from meningitis. Incidence (adjusted of) suspected
meningitis/10,000 new cases are given in the following table
province vice. Out breaks reported but now lab confirmed include
those near Peshawar in April and November, 2000 and in
Rawalpindi March, 2001
Following bar chart shows the total number of lab
confirmed meningitis cases among the total suspected
cases admitted in children hospital (PIMS) in Islamabad in
2005-06-07
Case definitions
 Suspected cases:
Any person with acute illness that demonstrate sudden on
set of fever (>38.05 C0 rectal or 38C0 axiliary) and one or more
of the following neck stiffness, altered conscious other meningial
sign.
In patient under one year of age when fever is accompanied
with bulging fontanel
 Probably cases:
A suspected case of meningococcal meningitis with turbid
CSF or link to a confirmed case.
 Confirmed Cases.
A suspected or probably case with positive CSF antigen
cases: detection for Neisseria meningitis.
A positive culture result from CSF or blood sample with
identification of Neisseria meningitis.
 Aim:
 Reduction of mortality and morbidity among
children due meningitis in Pakistan.

Objectives:
 To reduce mortality due to meningococcal
meningitis up to 80 per cent in children under
five in Pakistan with in three years.
 To strengthen the existing bacterial meningitis
surveillance mechanisms in Pakistan.
 Epidemiological feature
 Agent The causative agent Neisseria meningitis is a gram
negative diplococcic several serotypes have been
identified groups A,B,C,D,X,Y, 29 E,W135 etc. Group A&C
who are lesser extent group B Meningococcal are capable
of causing major epidemic the incidence of infection by
group Y and W 135 strange are increasing in some
countries

Source of infection:
 The organism is found in the naso pharynx of cases and
carriers carriers are most important source of infection.
The mean duration of temporary carrier is about 10
months. During epidemics carrier rate may go even up to
70-80%.
Period of communicability:
 Until meningococcal are no longer present and discharge
from nose and throat. Cases rapidly loose their
infectioness with in 24 hrs of specific treatment.
Age & Sex:
 This is predominantly is a disease of children and young
adults of both sexes.
Immunity:
 All ages are susceptible. Younger age groups are more
susceptible than older group as their antibodies are
lower. Immunity is acquired by sub clinical infection
mostly, clinical disease or vaccination. Infant derived
immunity comes from the mother.
Environmental Factors:
 The seasonal variation of the disease is well established out
breaks occur more frequently in dry and cold months of the year.
Over crowding as occurs in schools, refugee, and other camps is
an important pre disposing factor the incidence is also greater in
the low socio economics groups living in the poor housing
conditions.
Mode of Transmission:
 The disease spreads mainly by droplet infection. The portal of
entry is the nasopharynx.
Incubation Period:
 Usually 3 to 4 days, but may vary from 2 to 10 days.
 Existing Strategies:

 There are three existing BM Surveillance System in

Pakistan. These are Health Management and Information
System (HMIS), Disease Early Warning System (DEWS)
and Laboratory based Bacterial Meningitis Surveillance
(BMS) programs

 In HMIS from the different heath care facilities i.e. basic

health units and rural health centers data on meningitis is
collected via HMIS and after sending to the respective
Edo’s Health then it is sent to the provincial HMIS cell and
after this then is sent to the National HMIS cell of Ministry
of Health.
 The BMS exists only in provincial head quarters and
federal capital viz. Islamabad. In the BMS consists of
data collection centers in PIMS Islamabad, Children
Hospital Lahore, NICH Karachi, Mayo Hospital Lahore,
HMC Peshawar and BMCH Quetta and from there
data and reports are being sent to NIH Islamabad and
further disseminated to WHO EMRO on monthly basis.
Prevention and Control Strategies:

 Basically we should have two pronged strategy at national level:

epidemic preparedness and epidemic response. Preparedness
will focus on surveillance, from case detection and investigation
and laboratory confirmation. This implies strengthening of
surveillance and laboratory capacity for early detection of
epidemics, the establishment of national and sub-regional stocks
of vaccine, ant the development or updating of national plans for
epidemic management (preparedness, contingency and
response).

General Measures:
 It is very important to create the awareness in people about the
manifestations of disease, its early detection and also about the
preventive measures from the meningitis via mass media like
newspapers, radio, televisions, printing materials and walking
campaigns.
Surveillance:

 We should improve surveillance system , HMIS through

capacity enhancement of human and logistic resources,
integration of secondary and tertiary health care facility into
HMIS, DEWS: through capacity enhancement of human and
logistic resources. Laboratory based BMS (bacterial
meningitis surveillance program) expansion of sentinel sites
country wide, strengthening the existing sentinels labs.

 we should develop a national surveillance system and merge

all vertical programs and develop and extend public health
laboratory networks.
Immunization:

 Effective vaccine prepared from purified group A, C, Y and

or W135 meningococcal polysaccharide are now available.
They may be monovalent or polyvalent. Recent field trials
have indicated that immunity lasts for about three years and
boosters every three years would be reasonable. High risk
population should be identified and vaccinated. Vaccine use
is not recommended in children under two years of age.
The vaccine is contraindicated in pregnant women.

Mass Chemoprophylaxis:

 This is in fact mass medication of the total population some

of which are not infected. It is recommended that mass
chemoprophylaxis be restricted to close and medically
supervise communities.
 Cases:
 Treatment with antibiotics can save the lives
of 95 per cent of patients provided that it is
started during the first two days of the illness.
Penicillin is the drug of choice. In penicillin
allergic patients, choloramphenicol should be
substituted . Isolation of cases is of limited
usefulness in controlling epidemics because
the carriers outnumber cases
Carriers:
Treatment with penicillin does not eradicate the carrier
state; more powerful anti-biotic such as rifampicin is
needed to eradicate the carrier state.

Contacts:
Close contacts of the person with confirmed
meningococcal disease are at an increased risk of
developing meningococcal illness (about 1000 times the
general populations). Nearly one third of secondary cases
occur in the first four days. Chemoprophylaxis has been
suggested for close contacts. Current recommendations of
close contacts are early institution of rifampicin 600 mg BD
for two days.
Implementation (with cost estimate) and Evaluation

 Total Expenditure i.e. Capital Cost of the Project on

Meningococcal meningitis is 300 millions rupees for the three
years. There should be quarterly financial target release and
expenditure evaluation.

 The annual budget is prepared with unit cost estimate and the
major components of the budget will be for: Vaccination, mass
chemoprophylaxis, Treatment, Monitoring/ Evaluation, Training
and Salaries, Health Education Campaign, Data Surveillance,
Office equipments (infrastructure). The provincial depart. Be
provided with separate budgetary allocations. The
performances of provincial departments be done on quarterly
basis to do the cost estimate and cost benefit analysis,
nevertheless there must be an ongoing supervision and
monitoring of these provincial and other districts level
institutions.
 The evaluation of the program can be done
by frequent meetings arrange after every six
months in which all the stake holder are
invited. There will be regular monthly visits of
the health team (under provincial
Government) to every district to supervise the
surveillance system.
 Process :
 Total number of walks arranged in a year to create awareness among people.
 Number of suspected cases of meningococcal meningitis reported in a year.
 Number of Lab conformed cases of meningococcal meningitis reported in a year in
children less than five year of age.
 Number of children vaccinated for meningococcal meningitis in a year in children
under five year of age.
 Number of children mass chemoprophylaxis done for meningococcal meningitis in
a year in children under five year of age.
 Number of physician per hundred thousand populations under five year of age.
 The proportion of the people who have awareness about Meningococcal
meningitis and its effects.
 Number of institutes having adequate availability of medicines.

Outcome Indicators:
 Number of cases treated for meningococcal meningitis reported in a year in
children less than five year of age.
 Number of deaths due to meningococcal meningitis reported in a year in children
less than five year of age.
 REFERANCES:

 ^ Sáez-Llorens X, McCracken GH (June 2005). "Bacterial meningitis in

children".Lancet 361: 2139–48.
 Khan.P.A, “Meningitis”, Basic of pediatrics, Pub: Carvan. 6th edit. pp:
264.
 http://www.who.int/topics/meningitis/en/30-09-2009.
 WHO (2005). The work of WHO. 2003-2004.
 WHO, Global Health situation and projections, 1992.
 Ansari. J.A., Kazi.B.M. et al. Public health laboratory division NIH
Islamabad, CDC Atlanta. USAID. 2008.
 WHO. DEWS, Case definitions management and prevention of infectious
disease. Meningococcal meningitis.pp:30, Sept2006.
 WHO (2006). Tech. Resp. Ser. No 658.
 Cujetanovic. B et al (2007) Bull WHO 56 (Supplement No .1):81.
 WHO (2006) Wkly Epi. Rec; 56(27)211.
 Wahdon M.H. et al. (1973) Bull WHO 48:667-673
 Wahdon M.H. et al. (1973) Bull WHO 55:645-651.