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Abstract
Meningitis is an inflammatory disease of the meninges covering the brain. Bacteria, viruses, fungi,
chemicals or inflammatory conditions are some of the potential causes of meningitis. In this article, we
discuss prevention of the three most common bacterial causes of meningitis: Streptococcus pneumoniae,
Neisseria meningitidis and Haemophilus influenzae.
BACTERIAL MENINGITIS
Bacterial meningitis develops when the virulence of the causative pathogen overcomes the hosts defense mechanisms.
The virulent bacteria are able to colonise the hosts mucosal
epithelium, invade the blood stream, cross the blood brain
barrier and multiply within the CSF.3 The host then initiates an
intense inflammatory response. The inflammatory response
activates other processes which ultimately cause damage to
the subarachnoid space, resulting in neuronal injury. 4
Bacterial meningitis is a medical emergency.5 Despite appropriate
medical therapy, case fatality rates have been reported as follows:
For meningitis caused by Haemophilus influenzae 2% to
5%.6
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Presentation
Although the clinical manifestations of bacterial meningitis are
variable and nonspecific, most patients present with fever and
signs of meningeal irritation such as nausea, vomiting, irritability, anorexia, headache, confusion, back pain and the inability
to flex the head forward.5
The clinical presentation of bacterial meningitis depends partly
on the duration of the illness, the hosts response to the infection and the age of the patient.
In adults, a triad of neck stiffness, headache and photophobia occurs in 44% of patients.5
The manifestations seen in older children include fever,
headache, photophobia, nausea, vomiting, confusion, lethargy and irritability.5
In infants, bacterial meningitis may manifest as fever, hypothermia, lethargy, respiratory distress, jaundice, poor feeding, vomiting, diarrhoea, seizures, restlessness, irritability
and /or bulging fontanelle.5
Causative agents
Neisseria meningitidis, Streptococcus pneumoniae and Haemophilus influenzae are the most common causes of bacterial
meningitis after the neonatal period. Since the introduction of
H. influenzae type b (Hib) conjugate vaccines, N. meningitidis
and S. pneumoniae have become the most common causes of
bacterial meningitis in the world.1
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MENINGOCOCCAL MENINGITIS9
Thirteen serogroups of N. meningitidis have been identified, five of
which are recognised to cause epidemics, namely serogroups A,
B, C, W-135 and Y. In South Africa, sporadic cases of meningococcal disease are seen throughout the year with a seasonal increase
in winter and early spring. Occasionally, small clusters of cases occur.9 About 400500 cases of meningococcal disease are reported
in South Africa annually. Serogroup W-135 is dominant in Gauteng
while serogroup B is dominant in the Western Cape.9
Meningitis belt
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disease is antibiotic chemoprophylaxis given to close contacts of the infected patient.8 The chemoprophylaxis reduces
nasopharyngeal carriage of N. meningitides.8
Close contacts of a patient with meningococcal meningitis are
defined as:9,12
Those living in the same household
Those who share eating utensils
Those who share a bathroom and or bedroom in a hostel
Those exposed to the respiratory secretions of the patient e.g.
intimate boy or girlfriends, mouth kissing contacts, medical staff
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Vaccination8,9
There are two vaccines available in South Africa against
meningococcal meningitis namely Menomune and
Mencevax. Both vaccines are polysaccharide vaccines and
are protective against the serogroups A, C, W-135 and Y.
There is no vaccine available against the B serogroup.
Polysaccharide vaccines are of limited benefit in children under
two years of age.
Vaccines are given to prevent future infection. They are not
indicated for post-exposure prophylaxis after a single case of
meningococcal meningitis. However, they are indicated in a
confirmed outbreak situation.9
Vaccination against meningococcal meningitis is not routinely
performed in South Africa. However, it is recommended in
certain circumstances such as8,9:
Long term travellers to the meningitis belt
Pilgrims going to Hajj or Umrah
Individuals with functional or actual asplenia
Individuals with terminal common complement pathway
deficiencies
Laboratory staff working with N. meningitidis
A confirmed outbreak setting
Prevention
Pneumococcal meningitis can be prevented by vaccination.
Routine vaccination
Children under two years of age, and adults over 65 years of age
are at increased risk of invasive pneumococcal disease and it is
recommended that these age groups be routinely vaccinated.17
In South Africa there are four pneumococcal vaccines available:15
a. A conjugated-7-valent pneumococcal vaccine (PCV7) called
Prevenar for use in all infants and young children. Prevenar
was introduced into the South African market in 200515 and was
incorporated into the EPI in 2009.16 Prevenar is registered to
be given at 6, 10 and 14 weeks of age and a booster dose in
the second year of life.18 In the EPI however, it is given at 6 and
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H. influenzae type b (Hib) was the leading cause of bacterial meningitis among children younger than five years of age
before an effective vaccine against Hib was developed.6 It was
responsible for 5065% of all cases of meningitis in the prevaccination era.6 Nearly all Hib infections occurred among children
younger than five years of age, and approximately two-thirds
of all cases occurred among children younger than 18 months
of age.6 Diseases caused by Hib are not commonly seen in
patients over five years of age.6 Hib is transmitted from personto-person via infected respiratory secretions.4,6
Close contacts of a patient with invasive Hib disease who receives antibiotic chemoprophylaxis soon after the index patient
is diagnosed, will remove pharyngeal carriage of Hib. This will
a. reduce the risk of developing invasive disease if they are
not immune and
b. prevent further spread of the disease.27
Prevention
Vaccination
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Children under two years of age do not develop an adequate immune response to Hib invasive disease and therefore still need
to either start vaccination or continue vaccination against Hib
once they have been discharged from hospital.28 It is expected
that children over two years of age will develop protective immunity after infection and do not need vaccination against Hib.27
Drug of choice27,29
Rifampicin is recommended to eliminate pharyngeal carriage
of Hib. Over one month of age the dose is 20 mg/kg (up to a
maximum dose of 600 mg) per day for four days. Under one
month of age a dose of 10 mg/kg per day for four days is used.
In conclusion
Bacterial meningitis is a potentially life threatening disease. In
patients who survive, there is a risk of permanent sequelae.
Meningitis caused by Haemophilus influenzae has been dramatically reduced in countries where routine vaccination has been
implemented including South Africa. Invasive pneumococcal
disease can be prevented by routine vaccination of PCV7 for
young children and by vaccinating high-risk individuals with
PPV23. The spread of sporadic cases of meningococcal meningitis is prevented by administration of chemoprophylaxis to close
contacts of the patient. Vaccination and chemoprophylaxis play
a key role in the prevention of the three most common causes of
bacterial meningitis namely Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae.r
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