Meningococcal disease

Notification requirements for meningococcal disease

Meningococcal disease is an ‘urgent’ notifiable condition and must be notified by medical practitioners and pathology services immediately to the Department of Health by telephone on 1300 651 160 (24/7) upon initial diagnosis (suspected or confirmed). Pathology services must follow up with written notification within 5 days.

This is a Victorian statutory requirement.

Primary school and children’s service centres exclusion for meningococcal disease

Cases must be excluded from primary school and children’s service centres until 24 hours of appropriate antibiotic treatment have been completed.

Contacts must be excluded from primary school and children’s service centres until they are receiving clearance antibiotics. Contacts who do not receive clearance antibiotics must be excluded for 7 days following exposure to the case.

Infectious agent of meningococcal disease

Neisseria meningitidis (or meningococcus) is a Gram-negative diplococcus. It is also known as meningococcal bacteria or meningococcus.

There are 13 serogroups of N. meningitidis. Serogroups A, B, C, W, and Y account for the majority of cases of meningococcal disease worldwide. In Australia, serogroups B, W and Y account for most cases.

Identification of meningococcal disease

Clinical features

Meningococcal disease can present as a spectrum of clinical illness, including invasive infections (invasive meningococcal disease). Septicaemia and meningitis which are the most common presentations.

Symptoms of invasive meningococcal disease can include:

• fever
• headache
• neck stiffness
• photophobia
• nausea or vomiting
• diarrhoea
• petechial or purpuric rash
• fatigue or malaise
• arthralgia or myalgia
• pale or mottled skin
• cold extremities
• confusion
• altered consciousness.

Infants and young children may have non-specific symptoms which can include:

• irritability
• reduced feeding
• high-pitched crying
• grunting or moaning
• drowsiness
• difficulty waking
• convulsions.

The septicaemic form can have a fulminant and rapidly fatal course and initial symptoms may be non-specific, especially in children. This form can be difficult to diagnose before the onset of the characteristic petechial or purpuric rash that does not blanch under pressure.

Not all people with invasive meningococcal disease get a petechial or purpuric rash or it may occur late in the illness (median onset 13 to 22 hours). Sometimes in the early stages of illness there can be a maculopapular rash that blanches under pressure. This rash may progress to become a petechial or purpuric rash or may fade away.

Leg pain, cold extremities, and abnormal skin colour – described as pallor or mottling – are frequently reported in the first 12 hours of illness (median onset 7-12 hours), particularly in children and adolescents.

People with invasive meningococcal disease can become severely unwell very quickly. It can lead to death in 5 to 10 per cent of cases and long term complications in 10 to 20 per cent of cases. Complications can include skin scarring, limb amputation and neurological sequelae such as deafness, vision impairment, seizures, learning difficulties and other permanent brain damage.

Rarely, chronic meningococcal septicaemia can also occur, with febrile episodes, skin rashes and fleeting joint pains.

Other less common presentations of invasive meningococcal disease can include pneumonia, septic arthritis, pericarditis, epiglottitis, conjunctivitis and urethritis.

Diagnosis of meningococcal disease

Diagnosis is usually made on clinical grounds and confirmed by laboratory tests. Antibiotic treatment should be given immediately for people with suspected or confirmed meningococcal disease and never be delayed by the need to get laboratory specimens.

Laboratory tests to help confirm invasive meningococcal disease include:

• Polymerase chain reaction (PCR) of blood, cerebrospinal fluid (CSF) or other specimen from a normally sterile site
• Culture of blood, CSF or other specimen from a normally sterile site
• Microscopy of CSF or other specimen from a normally sterile site (detection of Gram-negative diplococci in Gram stain).

Meningococcal bacteria isolates are sent by primary pathology services to the Microbiological Diagnostic Unit at the Doherty Institute to monitor serogroups and for susceptibility testing.

Incubation period of meningococcal disease

The incubation period is usually 1 to 7 days, and rarely up to 10 days.

People who become asymptomatic carriers of meningococcal bacteria are unlikely to develop invasive meningococcal disease.

Public health significance and occurrence of meningococcal disease

In Australia, the incidence of invasive meningococcal disease is low, partly due to widespread vaccination. Most cases occur sporadically and outbreaks are uncommon. Young children and adolescents are most commonly affected. There is characteristically a seasonal pattern, with incidence peaking in the winter and spring months. There is evidence that respiratory tract infections, such as influenza or Mycoplasma pneumoniae infections, may be risk factors for invasive meningococcal disease and that closer personal contact or lack of ventilation may facilitate transmission. When cases occur, they frequently cause public concern and receive a high level of media attention.

Most cases of invasive meningococcal disease in Australia are caused by serogroups B, W and Y. According to the National Notifiable Diseases Surveillance System, notification rates peaked at 4.3 cases per 100,000 people in 2002 and declined to 0.4 cases per 100,000 people in 2013. Between 2015 to 2017, notification rates increased again particularly among older age groups, with a rise in serogroups W and Y. However, after the implementation of immunisation programs with Meningococcal ACWY vaccine from 2017 onwards, cases have subsequently declined. In 2022, there were 15 cases notified in Victoria, which represented 12 per cent of the national total for 2022. All Victorian cases were serogroup B, with this serogroup being responsible for 86 per cent of cases nationally that year.

Globally, different serogroups predominate in different regions. The ‘meningitis belt’ in sub-Saharan Africa stretching from Senegal in the west to Ethiopia in the east has the highest rates of meningococcal disease and experiences large outbreaks and epidemics, particularly during the dry season. Large epidemics have occurred in 7 to 14 year intervals in the region. Prior to mass immunisation campaigns that commenced in 2010, meningococcal disease from serogroup A accounted for most cases. Since then, the rates of meningococcal disease and the proportion of serogroup A have declined. Recent outbreaks in the region have primarily been caused by serogroups C and W and serogroup X outbreaks have also been reported.

The Hajj pilgrimage to Saudi Arabia has also been associated with outbreaks of meningococcal disease among returning travellers and their contacts. In 2000, there was a large Hajj-associated outbreak caused by serogroups A and W. The Saudi Arabian government now requires travellers participating in the Hajj pilgrimage to be vaccinated against meningococcal disease.

Reservoir for meningococcus

Humans are the only natural host of meningococcal bacteria.

Mode of transmission of meningococcal bacteria

Meningococcal bacteria can be transmitted from person-to-person through respiratory droplets shed from the nose and throat. Transmission can occur from close, prolonged or intimate contact.

The bacteria colonise the mucosa of the upper respiratory tract and dies quickly outside the human host. It is estimated that between 5 to 25 per cent of the population are carriers. Most cases of invasive meningococcal disease are sporadic with transmission likely to have occurred from an asymptomatic carrier in the network of close contacts.

Meningococcal bacteria are not easily spread by sharing drinks, food or cigarettes. Saliva has been shown to inhibit the growth of meningococcal bacteria.

Period of communicability for meningococcal disease

People with invasive meningococcal disease are considered infectious from the onset of acute illness until they have received 24 hours of appropriate antibiotic treatment.

After 24 hours of appropriate antibiotic treatment, meningococcal bacteria are usually no longer present in discharges shed from the nose and throat.

Susceptibility and resistance of meningococcal disease

Invasive meningococcal disease is uncommon. It most commonly affects children aged under 5 years with a secondary peak in adolescents and young adults aged 15 to 19 years.

Other risk factors for invasive meningococcal disease include:

• not being fully immunised against meningococcal disease
• congenital or acquired immunoglobulin deficiencies and complement deficiencies
• anatomic or functional asplenia
• exposure to cigarette smoke
• concurrent respiratory tract infections
• crowded living conditions or recreation spaces
• close contacts of someone with meningococcal disease, such as household members and intimate partners
• travel to or residence in regions with high rates of meningococcal disease
• laboratory personnel who work with or may be exposed to meningococcal bacteria.

Aboriginal and Torres Strait Islander people are at significantly increased risk of invasive meningococcal disease compared with the non-Indigenous population.

There is no maternal immunity for invasive meningococcal disease.

Control measures for meningococcal disease

Preventive measures

Vaccines are available to protect against common disease-causing meningococcal bacteria serogroups:

• Meningococcal ACWY vaccine protects against serogroups A, C, W and Y
• Meningococcal B vaccine protects against serogroup B.

Meningococcal vaccines are recommended for:

• infants from 6 weeks, children, adolescents and young adults who want to reduce their risk of meningococcal disease
• special risk groups, including Aboriginal and Torres Strait Islander people
• people with medical conditions that increase their risk of invasive meningococcal disease
• laboratory workers who frequently handle meningococcal bacteria
• people who travel to regions where invasive meningococcal disease is more common or who travel to mass gatherings
• young adults who live in close quarters or who are current smokers.

Meningococcal ACWY vaccine

Free quadrivalent meningococcal ACWY vaccine is available for eligible people under the National Immunisation Program (NIP) schedule for:

• children at 12 months
• adolescents at Year 10 (or age equivalent) through the secondary school-based vaccination program
• people with asplenia, hyposplenia, complement deficiency, or receiving treatment with eculizumab.

Free catch-up meningococcal ACWY vaccine is available under the NIP for young people under the age of 20 years.

Meningococcal B vaccine

Free recombinant meningococcal B vaccine is available for eligible people under the NIP schedule for:

• Aboriginal and Torres Strait Islander children aged 2 months (from 6 weeks), 4 months, 6 months (certain medical conditions) and 12 months
• people with asplenia, hyposplenia, complement deficiency, or receiving treatment with eculizumab.

Free catch-up meningococcal B vaccine is available under the NIP for Aboriginal and Torres Strait Islander children up to the age of 2 years.

Meningococcal vaccines are also available via private prescription for people who do not meet NIP eligibility, seeking to protect themselves or their family against meningococcal disease.

For further information on meningococcal vaccination refer to the Australian Immunisation Handbook.

Control of case

People with invasive meningococcal disease can become severely unwell very quickly. Early diagnosis and treatment are very important.

Treatment is the responsibility of the treating doctor. Antibiotic treatment should be commenced as soon as possible once a clinical diagnosis is made and should never be delayed by the need to get laboratory samples or confirmation of the diagnosis.

For antibiotic treatment recommendations, refer to the current edition of the Therapeutic Guidelines: Antibiotic or an infectious diseases specialist. Some antibiotics, including penicillin, do not reliably clear nasopharyngeal carriage of meningococcal bacteria, so appropriate clearance antibiotics should also be given.

Most cases require treatment in hospital. Cases should be managed under standard and droplet precautions until they have received 24 hours of appropriate antibiotic treatment.

Control of contacts

Cases are likely to have acquired meningococcal bacteria from an asymptomatic carrier who either lives in the same household (or similar setting) or is an intimate partner of the case. Children tend to acquire meningococcal bacteria from adults in the same household, whereas teenagers and adults are more likely to acquire it from their close social network.

Clearance antibiotics

Clearance antibiotics are only recommended for people who are at higher risk of either being the source of infection for the case or acquiring the infection from the case. These include the following people who have had close contact with the case from 7 days before the onset of the case's symptoms until the case has completed 24 hours of appropriate antibiotic treatment:

• Household or household-like contacts who lived in the same house (or dormitory-type room) as the case or were having an equivalent degree of contact with the case in the 7 days before the onset of the case’s symptoms until completion of 24 hours of appropriate antibiotic treatment.
• Intimate kissing or sexual contacts in the 7 days before the onset of the case’s symptoms until completion of 24 hours of appropriate antibiotic treatment.
• Childcare contacts: Children and staff in childcare should have an equivalent degree of contact with the case as a household contact. As a guide, this should mean at least 4 hours/day on average, or 20 hours in total, in the 7 days before the onset of the case’s illness. Childcare includes any situation where children under 5 years of age are cared for with other children away from home. This setting includes kindergartens, preschools (pre-primary) and primary schools.
• Passengers seated immediately next to the case during long-distance travel (>8 hours duration) by aeroplane, train, bus or other vehicle.
• Healthcare workers are rarely at risk. Only those who have come into direct contact with the nasopharyngeal secretions of a case (before the case receiving 24 hours of therapeutic antibiotics) during a procedure, such as intubation without wearing a surgical mask or mouth-to-mouth resuscitation, should be regarded as higher-risk contacts.

The aim of clearance antibiotics is to prevent further transmission of meningococcal bacteria. Where clearance antibiotics are recommended, they should be given as soon as possible and within 4 weeks from the last exposure to an infectious case. Wider use of clearance antibiotics is not recommended as the harms such as medication side-effects, development of antimicrobial resistance and elimination of protective flora outweigh the potential benefits.

While the overall risk to contacts is low, household contacts have the highest risk of meningococcal disease, particularly during the first 7 days after exposure to an infectious case. Beyond this period the risk of meningococcal disease in household contacts declines and after 30 days of exposure approaches background population levels. However, delayed secondary cases have been reported. The absolute risk of a household contact developing invasive meningococcal disease within 1 to 30 days after an index case if clearance antibiotics are not given is about 1 in 300.

Contacts in childcare, school and university have a modest increased risk, but less compared to contacts who are household members or intimate partners. Similarly, healthcare workers who have had unprotected close airway exposure to large particle respiratory droplets (for example, during airway management) from a case are at increased risk of meningococcal disease in the 10 days after exposure. However, the absolute risk is very low, estimated at 8 in 1,000,000.

For recommendations on clearance antibiotics, refer to the current edition of the Therapeutic Guidelines: Antibiotic or an infectious diseases specialist.

Outlined in Table 1. below is guidance on clearance antibiotics from the current edition of the Communicable Diseases Network of Australia (CDNA): Invasive meningococcal disease – CDNA National Guidelines for Public Health Units.

Table 1. Clearance antibiotics guidance

Note if you are using a mobile phone: Swipe to the left to view the rest of the table.

Vaccination

Meningococcal vaccination may be offered to higher-risk contacts, including among persons who did not receive clearance antibiotics, to further reduce the small risk of secondary cases.

In addition to clearance antibiotics, vaccination with an appropriate vaccine is recommended for unimmunised household-like contacts of cases.

Depending on their age, further doses may be required to have long term protection against meningococcal disease. For further information on meningococcal vaccination refer to the Australian Immunisation Handbook.

Control of environment

Cases should be managed under standard and droplet precautions until they have received 24 hours of appropriate antibiotic treatment.

There should be concurrent disinfection of articles soiled with discharges from the nose or throat. Articles used by the patient should be terminally cleaned.

Outbreak measures for meningococcal disease

The Communicable Diseases Network Australia has determined the following outbreak definitions and considerations for invasive meningococcal disease.

Organisation-based outbreak

Two or more probable or confirmed (where the available microbiological characterisation of the organisms is the same) cases with onset in a 4-week interval, among people who have a common organisation-based affiliation (such as attending the same high school) but no close contact with each other, in a grouping that makes epidemiological sense.

Clearance antibiotics should be considered for a wider group than household-like contacts, even though the evidence for preventing further cases is not strong. Co-primary or secondary cases should not be counted when determining whether criteria for provision of organisation-based clearance antibiotics have been met.

If cases have occurred in a household-like setting, then this may not meet criteria for an organisational outbreak.

Community outbreak

Three or more confirmed or probable cases of invasive meningococcal disease, where there is no direct epidemiologic link between the cases, with onset in a 3-month interval among persons residing in the same area who are not close contacts of each other, and the primary attack rate is at least 10 per 100 000. Rate calculations should not be annualised. This is not an absolute threshold and should be considered in the context of other factors – for example, completeness of case reporting, whether there is continuing occurrence of cases after recognition of a suspected outbreak and population vaccination coverage, where relevant.

These outbreaks are difficult to define and manage. Assess carefully all available epidemiological information, including:

• both confirmed and probable cases
• serotyping and/or genotyping data
• dates of onset
• direct and indirect links between cases
• the size of the population or identifiable subpopulation containing the cases
• Meningococcal ACWY and B vaccination coverage rates (where relevant).

Vaccination of the population at risk should be considered if an outbreak of a vaccine preventable serogroup is identified. Community-wide clearance antibiotics should not be used.

Aboriginal and Torres Strait Islander communities

Based on outbreaks reported in the 1980s and early 1990s, the risk of sustained transmission of invasive meningococcal disease in Aboriginal and Torres Strait Islander communities, especially remote communities, is probably higher than in the general community. For this reason, a low threshold should be used to determine the necessity for disease control measures. Action targeted to all community members should be considered (depending on community size and serogroup) if there are two or more cases in a remote Aboriginal or Torres Strait Islander community within a 4-week period and where available characterisation indicates they are the same strain.

Meningococcal conjunctivitis

Primary meningococcal conjunctivitis may also precede invasive disease in a case or in a close contact. Hence, it is recommended that contacts of individuals with meningococcal conjunctivitis receive information and antibiotic prophylaxis, as for contacts of invasive meningococcal disease cases.

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